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MANUAL OF INFECTION CONTROL

PROCEDURES
2nd Edition
To my wife Laila, and my children Numair and Namiz for
their abiding love, understanding and encouragement
MANUAL OF INFECTION CONTROL
PROCEDURES
2nd Edition
Dr N. N. DAMANI
MSc (Lond.), MBBS, FRCPath, FRCPI
Clinical Director Pathology & Laboratory Services
Consultant Microbiologist & Infection Control Doctor
Craigavon Area Hospital Group Trust, Portadown, UK
Honorary Lecturer
Department of Medical Microbiology
Queens University, Belfast, UK
Treasurer, International Federation of Infection Control
Foreword by
Professor A. M. Emmerson
OBE, FRCP, FRCPath, FMedSci, DipHIC
Emeritus Professor of Microbiology
Division of Microbiology and Infectious Diseases
University Hospital
Queen’s Medical Centre
Nottingham, UK
LONDON ! SAN FRANCISCO

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without the written permission of Cambridge University Press.
First published in print format 2004
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ISBN-13 978-1-841-10107-1 paperback

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guarantee that any content on such websites is, or will remain, accurate or appropriate.
What, will these hands ne’er be clean?
WILLIAM SHAKESPEARE
Macbeth
Foreword to the Second
Edition
W hen Professor Graham Ayliffe wrote the foreword to the first edition of this
manual in 1997, he said ‘this manual contains a wealth of practical advice, a
number of useful tables, diagrams, definitions and essential references.’ He also said that
the policies were detailed enough and provided enough instruction to allow health
care workers (HCWs) to carry out individual procedures. In this respect, the second
edition of this manual fulfils these requirements and will appeal to both medical and
nursing practitioners in infection control and to nurse educators whose job it is to
provide first-hand practical advice to those responsible for the provision of a safe
environment for patients and staff alike.
This second edition has been revised and updated and the reader eager to find out
what is new and different from the first edition will be pleasantly surprised. New
sections include the Principles of Infection Control, Design and Management of Health
Care Facilities, Surveillance and Outbreak Control, Epidemiology and Biostatistics and
not least a section on Infection Control Information Resources. This latter section,
together with the updated and easily accessible reading lists which are highlighted at
strategic points in the text and at the end of each section provides a wealth of infor-
mation for the inquisitive reader. In this respect, as much evidence-based informa-
tion as there is available has been presented.
Infection control is a quality improvement activity that focuses on improving
the care of patients and protecting the health of staff, and yet, despite advances in
modern medicine and surgery, 5–10% of patients admitted to hospital subsequently
acquire an infection of varying degrees of severity. Because of the need to discharge
patients to the community with the shortest possible length of stay in hospital, some
patients may not manifest their hospital-acquired infection (HAI) until some time
later. Post-discharge surveillance is still in its infancy but some record of its occur-
rence will need to be taken into account before the true cost of HAIs can be meas-
ured. Unfortunately, the incidence of HAI is as high today as it has been for many
years, but there are many reasons for this. Improvements in supportive care have led
to more aggressive medical and surgical therapy and seriously ill patients with several
underlying risk factors are often highly susceptible to infection.
vii
Manual of Infection Control Procedures
This manual addresses the need for patient care and recognises that the factors
involved in HAI are complex and that cost-effective measures to combat them are
needed which are based on evidence-based guidelines. Reliable comparisons of
infection rates between units, hospitals and countries are difficult without ongoing
monitoring with risk factor adjustment and benchmarking. The new section on
Epidemiology and Biostatistics will facilitate worthwhile comparison and make
benchmarking a challenge, not a threat.
The control of infection in hospitals has greatly improved in recent years; we have
many more professional staff, who are better trained, and more resources are being
set aside for infection control since the acknowledgement by management that infec-
tion control is part of the quality improvement process required of health care ser-
vices. However, the free movement of patients between hospitals and the community,
by breaking down invisible barriers, will always remain a challenge for HCWs. We
still lack sufficient isolation facilities to contain the major problems of patients with
antibiotic-resistant strains of bacteria such as multi-drug resistant tuberculosis
(MDR-TB), methicillin-resistant Staphylococcus aureus (MRSA) and gylcopeptide
resistant enterococci (GRE). A combined approach of prudent antibiotic prescribing,
effective surveillance and good infection control practices is essential if antibiotic
resistance is to be contained. This is a worldwide problem, and the spread of infec-
tion is a major problem in the developed world, but the principles of effective
control are the same throughout the world.
In the developed world, people are having longer and more ‘adventurous’ surgery
and transplantation is being carried out in hospitals in the face of emerging new
diseases and newly-identified micro-organisms which are difficult to treat. There is a
sharp increase in the use of minimally invasive surgery, with the widespread use of
expensive, heat-labile equipment like endoscopes, which require a high quality
system for decontamination. This manual contains most of the procedures necessary
to carry out such a service, but the author has not forgotten that basic hand washing
is generally considered to be the most important single measure in the control of
hospital infection and is dealt with in detail in this manual.
I have enjoyed reading this manual and commend it to all health care workers
involved in the prevention and control of infection.
M. Emmerson
London
November, 2002
viii
Foreword to the First
Edition
H ospital-acquired (nosocomial) infection is a major problem in the hospitals of

most countries and despite improvements in control methods, the prevalence
of infection remains at 5–10%. Infections are mainly of surgical wounds, the respira-
tory and urinary tracts, and the skin. The important risk factors for the acquisition
of infection are invasive procedures which include operative surgery, intravascular
and urinary catheterization and mechanical ventilation of the respiratory tract.
Other risk factors include traumatic injuries, burns, age (elderly and neonates),
immunosuppression and existing disease.
Many infections are endogenous (i.e. acquired from the patient’s own microbial
flora) and are not necessarily preventable, although infection can be kept to a min-
imum by good aseptic techniques. The spread of infection from patient to patient is
often difficult to prevent, particularly in overcrowded hospitals with staff shortages
and limited facilities. The prevention of cross-infection with highly antibiotic-resistant
organisms, such as epidemic methicillin-resistant Staphylococcus aureus (MRSA)
can be difficult and often requires considerable resources. Vancomycin-resistant
enterococcal infections may be untreatable with currently available antibiotics and
Gram-negative bacilli resistant to the quinolones and the third generation
cephalosporins frequently cause therapeutic problems. Cross-infection can be con-
siderably reduced by a few basic measures, for example handwashing or disinfection
correctly performed at the right time. Handwashing is generally considered to be the
most important single measure in infection control and is dealt with in detail in this
manual. Although prevention of transmission is of major importance, the rational
use of antibiotics and restriction of certain agents is necessary to achieve a long-term
effect. Other organisms which have emerged in hospitals in recent years include
Clostridium difficile, causing outbreaks in the elderly, and legionella associated with
cooling towers and contaminated water supplies. Food poisoning is mainly a prob-
lem in the community, but epidemics occur in hospitals. Escherichia coli 0157:H7 has
recently been responsible for large outbreaks of severe gastroenteritis and occasional
deaths from renal failure.
ix
The potential hazards of blood-borne viruses (hepatitis B (HBV) and C (HCV) and
human immunodeficiency virus (HIV)), particularly from injuries due to sharp
instruments, cause considerable anxiety to staff. Policies for the safe disposal of clin-
ical waste, especially needles, must be correctly implemented. Spread of these blood-
borne infections to patients from contaminated medical equipment is also a
potential hazard and the production of safe decontamination policies is a major
responsibility of infection control teams. Although decontamination of equipment
by heat is the optimal method, many items are heat-labile and chemical disinfection
is required. Flexible endoscopes fall into this category and are difficult to clean and
disinfect. The nature of surgery is also changing and minimal access surgery is often
replacing conventional surgery, but the equipment is often heat-labile and difficult to
clean. All of these problems have been well addressed in this manual.
Litigation for negligence is becoming increasingly common and often involves pos-
sible deficiences in control of infection procedures. This further emphasises the
importance of having well-defined procedures and ensuring that they are imple-
mented by training of staff and audit.
The prevention of infection is one of the requirements for good quality of care of
patients and is relevant to all members of staff. Protection of staff from infection is
now a major consideration and is backed by health and safety legislation. Hospitals
should have an infection control organization which includes an infection control
doctor, usually the medical microbiologist in the UK, and one or more infection con-
trol nurses, depending on the size of the hospital and the type of patient. These are
members of the team who should meet daily or at least several times a week. The
infection control committee is an expansion of the team and meets less frequently. It
is important for approving policies and programmes, and for making recommenda-
tions which have a major financial implication to the Chief Executive. Collaboration
with the community is also necessary and the Consultant in Communicable Disease
Control (CCDC) should be a member of the infection control committee.
It is obviously necessary, in view of the problems described, for every hospital to have
an infection control manual. To produce such a manual is a major task and it is time
wasting for every hospital to produce it’s own. This manual, originally produced by
Dr. Damani and his colleagues for Craigavon hospital, covers all the main policies
required in a hospital. It has been expanded to include basic information on the vari-
ous topics and is now generally applicable to other hospitals in the UK and many
other countries. It will be particularly useful in countries or hospitals which are set-
ting up new infection control programmes. However, although national and hospital
guidelines are important, individual departments differ and the final decisions
should be made by local infection control staff.
This manual contains a wealth of practical advice, a number of useful tables, dia-
grams, definitions and essential references. The policies are detailed and provide suf-
ficient instructions to carry out individual procedures. Infection control staff will
x
Foreword to the First Edition
find this manual useful for producing shorter manuals for individual wards. These
should be introduced as part of an ongoing educational programme to ensure the
manuals are not only read but are followed by nursing and medical staff and admin-
istrators. The manual should also be useful in preparing audit programmes. I con-
gratulate Dr. Damani on producing a comprehensive and useful manual of
procedures.
G. A. J. Ayliffe
1997
xi
Preface to the Second
Edition
A fundamental activity in health care establishments is to continually improve the

quality of care and provide a safe working environment. Central to this activity
is an effective infection control strategy, which prevents the acquisition of infection
within the health care environment.
The second edition of this book has been thoroughly revised and rearranged. Four
new chapters Principles of infection control, Design and maintenance of health care
facilities, Epidemiology and biostatistics, and Infection control information resources
have been added as I have found that these subjects are especially useful to infection
control practitioners.
While revising the book I have made changes that are in keeping with current guid-
ance and the recommendations made by various professional and statutory bodies
with an overall intention to provide advice based on current evidence and the
fundamental principles of infection control.
The scope of this book is intentionally broad and, whilst it does not attempt to cover
all aspects of infection control in detail, it aims to serve as a practical manual on
infection control procedures and provide essential information on the most import-
ant issues relating to infection control on a day-to-day basis.
Nizam N. Damani
November, 2002
xiii
Preface to the First
Edition
…by forseeing in a distance, which is only done by men of talents, the

evils which arise from them are soon cured; but when, from want of
foresight, they are suffered to increase to such a height that they are
perceptible to everyone, there is no remedy.
NICCOLÒ MACHIAVELLI
P revention of infection acquired in the health care setting remains a major goal for
all health care personnel because of increased morbidity and mortality for
patients. In addition, it utilizes resources that could be used elsewhere in health care.
Studies in the UK, Europe and North America indicate that approximately 10% of
patients develop infection whilst in hospital. Evidence in the US suggests that one
third of hospital-acquired (nosocomial) infections could be prevented. Therefore
financial benefit to the health care provider could be substantial by prevention of
such infections.
Although in recent years there have been an increased allocation of resources directed to
the problem on infection control services, the resources allocated have been constrained.
This is because in the recent years the very nature of the hospital has changed. With the
reduction in numbers of beds, the sickest patients have been concentrated in hospital
and the throughput of patients has increased. Patients are often subjected to more
aggressive diagnostic and therapeutic procedures and a greater number of health care
workers (HCWs) are involved in the patient’s management. In addition, newer varieties
of the microorganisms are responsible for a wider spectrum of nosocomial infection,
and bacterial isolates are becoming more resistant to the standard antibiotic therapies.
Although hospital-acquired infection has been worrying health care professionals for
many years, more recently it is worrying patients and the public as well. This is due
to emerging new pathogens coupled with heightened public awareness caused by
AIDS, blood-borne hepatitis (B&C), methicillin-resistant Staph. aureus (MRSA), and
more recently by Clostridium difficile, multidrug resistant tuberculosis (MDR-TB),
xv
vancomycin resistant enterococci (VRE) and E. coli 0157 making their control more
problematic and challenging for infection control personnel world wide.
Until the 1960s, recommendations on the control of infection were subjective, based
on personal observations and anecdotes. The art beginning to emerge but the science
was lacking. It is only in the past two decades that infection control has been taken
as a serious issue although there are still areas where practice is still ritualist and con-
troversial. An attempt has been made in this book to provide practical advice to the
HCW on the control of infection based on current scientific knowledge and recom-
mendation from various bodies on prevention and control of infection in the health
care setting.
Nizam N. Damani
1997
xvi
Acknowledgements
I
would like to thank the following people who have made the production of this
book possible:
• Dr. Christopher Armstrong, MRCPath, Consultant Microbiologist and

Jemima Keyes, Infection Control Nurse, Craigavon Area Hospital for read-
ing the manuscript and making helpful comments.
• Dr. Conall McCaughey, FRCPath, Consultant Virologist, The Royal Hospital
Group, Belfast for reviewing Chapter 10 Blood-borne hepatitis and HIV
infections and Chapter 11 Protection for health care workers.
• Dr. John Yarnell, MD, FFPHM, Senior Lecturer in Epidemiology and Public
Health, Queen’s University, Belfast for reviewing Chapter 5 Epidemiology
and Biostatistics.
• Linda McAlister for secretarial assistance.
• Gavin Smith of Greenwich Medical Media for seeing the book through
completion.
• Finally, I thank my wife Laila and my children Numair and Namiz for their
understanding and willingness to accommodate their life to my chaotic
schedules.
xvii
Contents
Foreword to the Second Edition ...................................................... vii

Foreword to the First Edition ............................................................ ix
Preface to the Second Edition.............................................................. xiii
Preface to the First Edition ................................................................ xv
Acknowledgements ............................................................................ xvii
Abbreviations........................................................................................ xxv
Glossary of Infection Control Terms ................................................ xxvii
1. Principles of Infection Control ............................................................ 1

Chain of Infection ........................................................................ 1
Body’s Defense Mechanisms .......................................................... 6
Strategies to Control Health Care Associated Infection .............. 7
2. Administrative Arrangements .............................................................. 9

Infection Control Doctor................................................................ 9
Infection Control Nurse ................................................................ 10
Infection Control Team .................................................................. 11
Infection Control Committee ........................................................ 11
Infection Control Link Nurse ...................................................... 12
Policies and Procedures Manual .................................................... 13
Occupational Health and Safety .................................................... 13
Education and Training .................................................................. 13
Risk Management in Infection Control ........................................ 14
3. Design and Maintenance of Health Care Facilities .............................. 17

Infection Control Risk Assessment ................................................ 18
The General Hospital Environment .............................................. 18
Patient’s Accommodations .......................................................... 19
Hand Washing Facilities .............................................................. 20
Isolation Rooms .............................................................................. 20
Operating Theatres ...................................................................... 22
Ventilation and Air-Conditioning.................................................. 23
xix
Cooling Towers and Water System .............................................. 23

Construction, Renovation and Demolition ................................ 24
4. Surveillance and Outbreak Control .................................................... 27
Incidence of Various Nosocomial Infections .............................. 27
Surveillance of Nosocomial Infection .......................................... 28
Methods of Surveillance .............................................................. 29
Management of an Outbreak ...................................................... 30
Look Back Investigations .............................................................. 35
5. Epidemiology and Biostatistics ............................................................ 39
Cohort Studies .............................................................................. 39
Case-Control Studies .................................................................... 40
Cross Sectional (Prevalence) Surveys .......................................... 41
Measures of Disease Frequency .................................................... 42
Measures of Association ................................................................ 43
Bias and Confounders .................................................................. 44
Confounders .................................................................................. 45
Biostatistics ........................................................................................ 46
Measures of Central Tendency...................................................... 46
Measures of Dispersion ................................................................ 48
Hypothesis Testing ........................................................................ 49
Error of Hypothesis Testing .......................................................... 49
Test of Statistical Significance ...................................................... 49
The P Value .................................................................................... 50
Confidence Intervals .................................................................... 50
Sensitivity and Specificity ............................................................ 51
6. Disinfection and Sterilization .............................................................. 55
Methods of Decontamination ...................................................... 55
Risks of Infection from Equipment ............................................ 57
Chemical Disinfectants ................................................................ 58
Chemical Disinfectants and Antiseptics ...................................... 59
Disinfection of Flexible Fibreoptic Endoscopes .......................... 69
Environmental Cleaning .............................................................. 73
Management of Infectious Spills .................................................. 78
Cleaning and Disinfection of Medical Equipment .................... 78
7. Isolation Precautions ............................................................................ 95
Source Isolation ............................................................................ 96
Protective Isolation ........................................................................ 98
Practical Issues and Considerations ............................................ 98
Appendix I.......................................................................................... 114
8. Prevention of Infections Caused by Multi-resistant Organisms ...... 119
Methicillin Resistant Staph. aureus (MRSA) .................................... 121
xx
Contents
Vancomycin Resistant Enterococci (VRE) .................................... 130

Multi-resistant Gram-negative Bacilli ............................................ 134
9. Prevention of Infection Caused by Specific Pathogens .................. 137
Tuberculosis (TB) ............................................................................ 137
Clostridium difficile Infection .......................................................... 147
Legionnaires’ Disease ...................................................................... 151
Gastrointestinal Infections and Food Poisoning .......................... 155
Meningococcal Infections .............................................................. 160
Varicella zoster Virus (VZV) ............................................................ 165
Creutzfeldt-Jakob Disease (CJD) .................................................... 169
Viral Haemorrhagic Fevers (VHFs) ................................................ 175
Rabies .............................................................................................. 179
Infestations with Ectoparasites........................................................ 180
10. Blood-borne Hepatitis and Human Immunodeficiency
Virus (HIV) Infections ........................................................................ 185
Viral Hepatitis .............................................................................. 185
HIV Infection .............................................................................. 188
Routes of Transmission .............................................................. 190
Occupational Risks to HCWs .................................................... 192
Risks to Patients from HCWs .................................................... 192
Responsibility of HCWs .............................................................. 193
Exposure-Prone Procedures ........................................................ 194
Surgical Procedure ...................................................................... 194
Protection of the Newborn ........................................................ 198
Procedure after Death.................................................................. 199
11. Protection for Health Care Workers .................................................. 203
Occupation Health Department ................................................ 203
Measures to Protect HCWs ........................................................ 204
Management of Sharps Injury .................................................... 205
Protection Against Tuberculosis ................................................ 213
Pregnant HCWs .......................................................................... 215
12. Hand Hygiene and Personal Protective Equipment ........................ 227
Personal Protective Equipment ...................................................... 235
13. Prevention of Surgical Site Infections................................................ 245
Surveillance .................................................................................. 245
Microbiology ................................................................................ 248
Pre-operative Patient Care .......................................................... 248
Operative Factors ........................................................................ 252
Post-operative Factors ................................................................ 256
Other Factors .............................................................................. 256
Environmental Cleaning of Operating Theatre ........................ 257
xxi
14. Prevention of Infection Associated with Intravenous Therapy ...... 261

Sources of Infection .................................................................... 261
Pathogenesis of Infection ............................................................ 262
Education and Training .............................................................. 263
Monitoring and Surveillance of Catheter-Related Infection .... 263
Intravascular Catheters and Parenteral Solutions .................... 264
Selection of Catheter Type .......................................................... 264
Selection of Insertion Site .......................................................... 265
Aseptic Techniques ...................................................................... 265
Catheter Site Dressing Regimens ................................................ 268
In-line Filters................................................................................ 268
Antimicrobial Prophylaxis .......................................................... 269
Anticoagulant Flush Solutions .................................................... 269
Replacement of Intravascular Set, Tubings and
Parenteral Fluids .......................................................................... 269
Replacement of Catheters............................................................ 269
Guidewire Exchange .................................................................... 270
Catheter-Related Infections ........................................................ 270
Device Reprocessing .................................................................... 270
15. Prevention of Infections Associated with Urinary
Catheterization .................................................................................... 273
Consideration Prior to Catheterization...................................... 273
Maintenance of Catheter ............................................................ 274
Removal of Catheter .................................................................... 278
Use of Antimicrobial Agents ...................................................... 278
Policy and Staff Training ............................................................ 279
Re-use of Catheters...................................................................... 279
16. Prevention of Nosocomial Pneumonia .............................................. 283
Pathogenesis ................................................................................ 283
Strategy for Prevention................................................................ 285
17. Hospital Support Services .................................................................. 291
Food and Catering Service .............................................................. 291
Staff Health/Hygiene.................................................................... 292
Cook-chill Food Production Systems ........................................ 292
Texture Modified Products ........................................................ 293
Food Trolleys .............................................................................. 293
Refrigerators ................................................................................ 294
Inspection .................................................................................... 294
Food Handlers.............................................................................. 294
Hospital Kitchen .......................................................................... 294
Ward Kitchens .............................................................................. 295
Ice Machines ................................................................................ 295
xxii
Contents
Linen and Laundry Service ............................................................ 298

General Principles to Prevent Infection .................................... 298
Laundry Process .......................................................................... 299
Microbiological Sampling .......................................................... 300
Staff Uniforms ............................................................................ 300
Mattresses and Pillows ................................................................ 301
Air-fluidized Beds ........................................................................ 301
Management of Clinical Waste ...................................................... 303
Definition and Categorization of Clinical Waste ...................... 303
Methods for Safe Handling of Clinical Waste ............................ 304
Methods for Safe Use, Handling and Disposal of Sharps ........ 305
Management and Disposal of Clinical Waste ............................ 308
Pest Control...................................................................................... 312
18. Infection Control Information Resources ........................................ 315
Internet Resources .......................................................................... 315
Books ................................................................................................ 317
Computer Software.......................................................................... 321
Index .................................................................................................... 323
xxiii
Abbreviations
AAFB Acid and Alcohol Fast GRE Glycopeptide resistant

Bacilli Enterococci
ACDP Advisory Committee on GISA Glycopeptide resistant
Dangerous Pathogens Staphylococcus aureus
A&E Accident and Emergency HAV Hepatitis A Virus
Department HBIG Hepatitis B
AIDS Acquired Immune Immunoglobulin
Deficiency Syndrome HBeAg Hepatitis B e antigen
AZT Azidothymidine HBsAg Hepatitis B surface antigen
(Zidovudine)
HBV Hepatitis B Virus
BS British Standard
HC Health Circular
BBV Blood-borne Viruses
HCV Hepatitis C Virus
BSE Bovine Spongiform
Encephalopathies HCW Health Care Worker
CDC Centers for Disease Control HEPA High efficiency particulate
and Prevention air
CDSC Communicable Disease HEV Hepatitis E Virus
Surveillance Centre HIV Human Immunodeficiency
CFU Colony forming units Virus
CI Confidence Interval HMSO Her Majesty’s Stationery
Office
CJD Creutzfeldt-Jakob Disease
HN Health Notice
DHSS Department of Health and
Social Services HSE Health and Safety Executive
DoH Department of Health IV Intravenous
EIA Enzyme Immuno Assay ICC Infection Control
Committee
ELISA Enzyme Linked
Immunosorbent Assay ICD Infection Control Doctor
ERCP Endoscopic retrograde ICN Infection Control Nurse
cholangiopancreatography ICT Infection Control Team
xxv
ICU Intensive Care Unit RIBA Recombinant immunoblot

MDA Medical Device Agency assay
MDR-TB Multi-drug resistant SCBU Special Care Baby Unit
Tuberculosis SSD Sterile Supply Department
MRSA Methicillin-resistant SSI Surgical Site Infection
Staphylococcus aureus
TB Tuberculosis
NaDCC Sodium
UTI Urinary Tract Infection
Dichloroisocyanurate
NNIS National Nosocomial vCJD New variant Creutzfeldt-
Surveillance System Jakob Disease
OPA Orthophthaladehyde VHFs Viral Haemorrhagic Fevers
PCR Polymerase Chain Reaction VISA Vancomycin resistant
Staphylococcus aureus
PHLS Public Health Laboratory
Service VRE Vancomycin resistant
ppm av Cl2 Parts per million of Enterococci
available chlorine VZIG Varicella Zoster
QAC Quaternary Ammonium Immunoglobulin
Compound WHO World Health Organization
xxvi
Glossary of Infection
C o n t r o l Te r m s
ANTISEPSIS The destruction or inhibition of microorganisms

on living tissues having the effect of limiting or
preventing the harmful results of infection.
ANTISEPTIC A chemical agent used in antisepsis.
CARRIER A person (host) who harbours a microorganism

(agent) in the absence of discernible clinical disease.
Carriers may shed organisms into environment
intermittently or continuously and therefore act as a
potential source of infection.
CASE A person with symptoms.
CHEMOPROPHYLAXIS The administration of antimicrobial agents to

prevent the development of an infection or the
progression of an infection to active manifest disease.
COHORT A group of patients infected or colonized with same

microorganism, grouped together in a designated
area of a unit or ward.
COLONIZATION The presence of microorganisms at a body site(s)

without presence of symptoms or clinical manifest-
ations of illness or infection. Colonization may be
a form of carriage and is a potential method of
transmission.
COMMENSAL A microorganism resident in or on a body site with-

out causing clinical infection.
COMMUNICABLE PERIOD The time in the natural history of an infection during

which transmission may take place.
xxvii
CONTACT An exposed individual who might have been

infected through transmission from another host or
the environment.
CONTAMINATION The presence of microorganisms on a surface or in a

fluid or material.
DISINFECTANT A chemical agent which under defined conditions is

capable of disinfection.
ENDEMIC The usual level or presence of an agent or disease in

a defined population during a given period.
ENDOGENOUS Microorganisms originating from the patient’s own

INFECTION body which cause harm in another body site.
EPIDEMIC An unusual, higher than expected level of infection

or disease by a common agent in a defined popula-
tion in a given period.
EPIDEMIOLOGY The study of the occurrence and cause of disease in

populations.
EXOGENOUS Microorganisms originating from a source or

INFECTION reservoir which are transmitted by any mechanism
to a person, i.e. contact, airborne routes etc.
FLORA Microorganisms resident in an environmental or

body site.
HOSPITAL-ACQUIRED Infection acquired during hospitalization; not

INFECTION present or incubating at the time of admission to
(Nosocomial infection) hospital.
IMMUNITY The resistance of a host to a specific infectious

agent.
IMMUNOCOMPROMISED A state of reduced resistance to infection that results

from malignant disease, drugs, radiation illness or
congenital defect.
INCIDENCE The number of new cases of a disease (or event)

occurring in a specified time.
INCIDENCE RATE The ratio of the number of new infections or disease

in a defined population in a given period to the
number of individuals at risk in the population.
xxviii
G l o s s a r y o f I n f e c t i o n C o n t r o l Te r m s
INCUBATION PERIOD The time interval between initial exposure to the

infectious agent and the appearance of the first sign
or symptoms of the disease in a susceptible host.
INDEX CASE The first case to be recognized in a series of trans-

missions of an agent in a host population.
INFECTION The damaging of body tissue by microorganisms or

by poisonous substances released by the micro-
organisms.
ISOLATION The physical separation of an infected or colonized

host from the remainder of the at risk population in
an attempt to prevent transmission of the specific
agent to other individuals and patients.
MICROBIOLOGICAL The reduction of the number of pathogenic

CLEARANCE microorganisms in a specimen below that detectable
by conventional means.
MICROORGANISM A microscopic entity capable of replication. It

includes bacteria, viruses and the microscopic forms
of algae, fungi and protozoa.
OUTBREAK An outbreak may be defined as the occurrence of

disease at a rate greater than that expected within a
specific geographical area and over a defined period
of time.
PATHOGEN A microorganism capable of producing disease.
PATHOGENICITY The ability of an infectious agent to cause disease in

a susceptible host.
PREVALENCE RATE The ratio of the total number of individuals who

have a disease at a particular time to the population
at risk of having the disease.
RESERVOIR Any animate or inanimate focus in the environment

in which an infectious agent may survive and
multiply which may act as a potential source of
infection.
SEROCONVERSION The development of antibodies not previously

present resulting from a primary infection.
SOURCE Place where microorganisms are growing or have

grown.
xxix
SPORADIC CASE A single case which has not apparently been associ-
ated with other cases, excreters or carriers in the
same period of time.
STERILE Free from all living microorganisms.
STERILIZATION A process which renders an item sterile.
STERILIZING AGENT An agent or combination of agents which under

(Sterilant) defined conditions leads to sterilization.
SURVEILLANCE A systematic collection, analysis, and interpretation

of data on specific events (infections) and disease,
followed by dissemination of that information to
those who can improve the outcomes.
SUSCEPTIBLE A person presumably not possessing sufficient

resistance (or immunity) against a pathogenic agent
who contracts infection when exposed to the agent.
TRANSMISSION The method by which any potentially infecting agent

is spread to another host.
VIRULENCE The intrinsic capabilities of a microorganism to

infect host and produce disease.
ZOONOSIS An infectious disease transmissible from vertebrate

animals to humans.
xxx
1
Principles of
Infection Control
H ospitalized patients are more prone to develop infection as a result of surgery,

invasive procedures and devices, immunosuppressive drugs, organ transplants
etc. In addition, microorganisms flourish in health care setting and with breaks in
infection control procedures and practices, along with patient’s weakened defense
mechanisms, help set the stage for nosocomial infections. Nosocomial infections
lengthen patients’ hospital stays and increase both morbidity and mortality. In
addition, diagnosing and treating these infections puts intense pressure on the health
services and health care budget.
Chain of infection
In order to control or prevent infection it is essential to understand that transmission
of a pathogen resulting in colonization or infection requires the following six vital
links (Fig. 1.1):
1. Causative agent
2. Infectious reservoir
3. Portal of exit from the reservoir
4. Mode of transmission
5. Portal of entry into the host
6. Susceptible host
Each link must be present for infection or colonization to proceed, and breaking any
of the links can prevent the infection. The aim of isolation precautions is to interrupt
these links.
1. Causative agent
The causative agent for infection is any microorganism capable of producing disease.
Microorganisms responsible for infectious diseases include bacteria, viruses,
1
Causative
agent
le Re
tib se
p r vo
e t
usc os ir
S h
t
Po e xi ir
rt f o
in al o l o rv
to f e tr a ese
r
ho nt Po m
st ry rf o
Mode of
transmission
Figure 1.1 Figure showing chain of infection. An infection can occur only if the six
components shown here are present. Removing any one link breaks the chain and
prevents infection.
Figure 1.2 Endogenous or auto-infection where infec-

tion occurs from the patients’ own colonizing micro-
organisms.
rickettsiae, fungi, and protozoa. Sometimes, microorganisms are part of patient’s

own body flora and can cause infection in the immunocompromised host. These
infections are called endogenous infections (Fig. 1.2). Infections which are acquired
from external sources are called exogenous infections (Fig. 1.3).
2
Principles of Infection Control
Figure 1.3 Exogenous or cross-infection where an infection occurs from an

infected or colonized patient to other patients, health care workers and visitors or
vice versa.
2. Reservoir of infection
The second link in the chain of infection is the reservoir, i.e. the environment or
object in or on which a microorganism can survive and, in some cases, multiply.
Inanimate objects, human beings, and animals can all serve as reservoirs, providing
the essential requirements for a microorganism to survive at specific stages in its
life cycle. Pseudomonas spp. survive and multiply in nebulizers and the hepatitis B
virus (HBV) survives but does not multiply on the surface of haemodialysis
machines.
Infectious reservoirs abound in health care settings, and may include everything
from patients, visitors, and staff members to furniture, medical equipment, medica-
tions, food, water, and blood.
A human reservoir may be either a case or a carrier. A case is a patient with an acute
clinical infection while a carrier is a person who is colonized with a specific patho-
genic microorganism but shows no signs or symptoms of infection. A carrier may
have a subclinical or asymptomatic infection, e.g. Hepatitis B virus.
Carriers fall into four categories: An incubatory carrier is one who has acquired the
infection and has been incubating the illness but does not yet show symptoms.
Incubation periods vary from one infectious disease to other (see page 114). A con-
valescent carrier is in the recovery stage of an illness but continues to shed the patho-
genic microorganism for an indefinite period, e.g. a patient who has had a Salmonella
infection commonly sheds the organism in his faeces even after symptoms disappear.
An intermittent carrier occasionally sheds the pathogenic microorganism from time
to time, e.g. some people are intermittent carriers of Staphylococcus aureus. A chronic
3
SOURCES OF INFECTION
ENVIRONMENT DEVICES
Air: Aspergillus Endotracheal tube, IV lines,
Water: Legionella suction catheters,
Fomites: MRSA, VRE, RSV bronchoscope, respiratory
Food: Enteric pathogens therapy equipment
PERSONNEL
Staff, visitors and other patients,

e.g. influenza, tuberculosis,
Staph. aureus
Figure 1.4 Summary of the modes by which various nosocomial infections are
transmitted.
carrier always has the infectious organism in his system, e.g. chronic carriers of
hepatitis B virus.
Carriers (especially when asymptomatic) may present a risk of transmission to sus-

ceptible patients in health care facilities because their illnesses go unrecognized and
they and those around them are unlikely to take appropriate precautions against
infection.
3. Portal of exit
The portal of exit is the path by which an infectious agent leaves its reservoir. Usually,
this portal is the site where the microorganism grows. Common portals of exit asso-
ciated with human reservoirs include the respiratory, genitourinary, and gastro-
intestinal tracts, the skin and mucous membranes and the placenta (transmission
from mother to fetus).
4
4. Mode of transmission
The microorganism can be acquired by inhalation (through respiratory tract),
ingestion (through gastrointestinal tract), inoculation (through accidental sharp
injury or bites), contact (during sexual intercourse) and transplacental transmission
(microbes may cross placenta from the mother to fetus). It is important to remem-
ber that some microorganisms use more than one transmission route to get from the
reservoir to a new host.
Of the six links in the chain of infection, the mode of transmission is the easiest link
to break and is key to control of cross-infection in hospitals.
Contact transmission: Contact is the most common mode of transmission of infection

in the health care settings. Contact transmission may be subdivided into direct
contact, indirect contact, and contact with droplets that enter the environment.
Direct contact: Direct contact refers to person-to-person spread of microorganisms

through actual physical contact. Microorganisms with a direct mode of transmission
can be transferred during such patient care activities as bathing, dressing changes,
and insertion of invasive devices if the hands or gloves of health care worker (HCW)
are contaminated. Diseases that spread by direct contact include scabies and herpes
simplex (if direct contact with infected oral lesions or secretions occurs).
Handwashing is the most effective way to prevent transmission by the contact route.
Indirect contact: Indirect contact occurs when a susceptible person comes in contact
with a contaminated object. In health care settings, virtually any item could be
contaminated with certain microorganisms, e.g. endoscopes, respiratory equipment,
etc. Thorough cleaning, disinfection, and sterilization are essential in the health care
setting to prevent nosocomial infection acquired from contaminated items and
equipment.
Droplet transmission: Droplet transmission results from contact with contam-

inated respiratory secretions. A person with a droplet-spread infection coughs,
sneezes, or talks, releasing infected secretions that spread through the air to the oral
or nasal mucous membranes of a person nearby. Microbes in droplet nuclei (mucus
droplets) can travel up to about 3 ft (1 m). Droplet transmission differs from
airborne transmission in that the droplets don’t remain suspended in the air but
settle on surfaces. Examples of diseases spread by droplets include influenza,
whooping cough, etc.
Airborne transmission: Airborne transmission occurs when fine microbial particles

or dust particles containing pathogens remain suspended in the air for a prolonged
period, and then are spread widely by air currents and inhaled. The tiny particles
remain suspended in the air for several hours and may cause infection when a
susceptible person inhales them. Examples of diseases spread by the airborne include
pulmonary tuberculosis, varicella, and measles.
5
5. Portal of entry
The portal of entry is the path by which an infectious agent invades a susceptible
host. Usually, this path is the same as the portal of exit. For example, the portal of
entry for tuberculosis and diphtheria is through the respiratory tract, hepatitis B and
Human Immunodeficiency Virus enter through the bloodstream or body
fluids and Salmonella enters through the gastrointestinal tract. In addition, each
invasive device, e.g. intravenous line, creates an additional portal of entry into a
patient’s body thus increasing the chance of developing an infection.
6. Susceptible host
The final link in the chain of infection is the susceptible host. The human body has
many defense mechanisms for resisting the entry and multiplication of pathogens.
When these mechanisms function normally, infection does not occur. However, in
immunocompromised patients, where the body defenses are weakened, infectious
agents are more likely to invade the body and cause an infectious disease. In addition,
the very young and the very old are at higher risk for infection because in the very
young the immune system does not fully develop until about age 6 months, while old
age is associated with declining immune system function as well as with chronic
diseases that weaken host defenses.
Body’s defense mechanisms

The body’s defense mechanisms fall into two general categories:
First line of defense: External and mechanical barriers such as the skin, other body
organs, and secretions serve as the body’s first line of defense. Intact skin, mucous
membranes, certain chemical substances, specialized structures such as cilia, and nor-
mal flora can stop pathogens from establishing themselves in the body. The gag and
cough reflexes and gastrointestinal tract peristalsis work to remove pathogens before
they can establish a foothold. Chemical substances that help prevent infection or
inhibit microbial growth include secretions such as saliva, perspiration, and gastro-
intestinal and vaginal secretions as well as interferon (a naturally occurring glycoprotein
with antiviral properties). Normal microbial flora controls the growth of potential
pathogens through a mechanism called microbial antagonism. In this mechanism,
they use nutrients that pathogens need for growth, compete with pathogens for sites
on tissue receptors and secrete naturally occurring antibiotics to kill the pathogens.
When microbial antagonism is disturbed, such as by prolonged antibiotic therapy, an
infection may develop; for example, antibiotic therapy may destroy the normal flora
of the mouth, leading to overgrowth of Candida albicans and consequent thrush.
Second line of defense: If a microorganism gets past the first line of defense by enter-
ing the body through a break in the skin, white blood cells and the inflammatory
response come into play. Because these components respond to any type of injury,
6
their response is termed non-specific. The main function of the inflammatory

response is to bring phagocytic cells (neutrophils and monocytes) to the inflamed
area to destroy microorganisms.
If a pathogen gets past non-specific defenses, it confronts specific immune responses,

cell-mediated immunity or humoral immunity. Cell-mediated immunity involves
T cells. Some T cells synthesize and secrete lymphokines. Others become killer (cyto-
toxic) cells, setting out to track down infected body cells. Once the infection is under
control, suppresser T cells bring the immune response to a close. Humoral immunity,
mediated by antibodies, involves the action of B lymphocytes in conjunction with
helper T cells. Antibodies produced in response to the infectious agent help fight the
infection. In response to the effects of suppressor T cell activity antibody production
then wanes. Impaired host defenses make patients more susceptible to infection.
Conditions that may weaken a person’s defenses include malnutrition, extremes of
age, inherited and acquired immune deficiencies, chronic disease, immunosuppres-
sive therapy, surgery and inadequate immunization.
Prudent use of antibiotics
Isolation of patients and
items and equipment

Decontamination of
Decontamination of
barrier precautions
Handwashing
environment
Figure 1.5 Five pillars of infection control. Surveillance and audit are essential
tools to monitor the effectiveness of the programme.
Strategies to control health care associated infection

Strategies to control and prevent nosocomial infection fall into three main categories:
• Control or elimination of infectious agents
7
• Control of transmission
• Reservoir control
Control or elimination of the infectious agent: This is achieved by placing patients with
suspected or proven infectious diseases under source isolation and applying barrier
precautions. Infectious agents can be controlled or eliminated by effective disinfection
and sterilization of items and equipments and thorough cleaning of the environment.
This helps reduce the bioburden of microorganisms in health care facilities.
Control of transmission: This can be effectively achieved by handwashing, aseptic

techniques and control of the health care environment. Proper handwashing has
been shown to be effective in preventing the spread of infection. Basic aseptic
technique must be practiced for sterile procedures e.g. insertion of intravenous lines
and urinary catheters. Effective decontamination and control of the environment
(e.g. mechanical ventilation) is essential to control transmission of microorganisms.
Reservoir control: Almost any piece of equipment used in health care facilities may
harbour microorganisms and therefore act as a reservoir (e.g. respiratory therapy
equipment and ventilator circuits, bedpans, urinals, bed linen etc). Interventions
directed at controlling or destroying infectious reservoirs in health care facilities
include using either disposable equipment or decontaminating equipment as soon as
possible after use. In addition, both patients and health care workers may also act as
reservoirs of infection. Identifying and treating these individuals will reduce the
reservoirs and help prevent cross-infection.
References and further reading

Chin J. Control of communicable disease manual, 17th edn. Washington: American Public
Health Association, 2000.
Garner J. The Hospital Infection Control Practice Advisory Committee. Guidelines for
Isolation Precautions in Hospitals. American Journal of Infection Control 1996; 24: 24–52.
Mims C, Nash A, Stephen J. Mims’ Pathogenesis of Infectious Disease, 5th edn. London:
Academic Press, 2000.
8
2
Administrative
Arrangements
T he provision of an effective infection control programme is a key to the quality

and a reflection of the overall standard of care provided by that health care
institution. Although the organization of an infection control programme varies
from countries to countries depending on the available resources, in the majority of
the countries the infection control programme is delivered through an Infection
Control Team (ICT). The ICT is not only responsible for the day-to-day running of
the infection control programme but is also responsible for setting priorities, applying
evidence-based practice and advising hospital administrators on issues relating to
infection control.
It is the responsibility of hospital administrator to ensure that adequate resources

are given to infection control department. He/she should also managerially ensure
that full support is afforded to the ICT so that agreed infection control programmes
are implemented effectively.
Infection Control Doctor (ICD)

The ICD must be a registered medical practitioner. In the majority of countries, the
role is performed either by a medical microbiologist or hospital epidemiologist.
Hospital consultants in other disciplines (e.g. infectious diseases) may be appointed.
Irrespective of their professional background, the ICD should have knowledge and
experience in asepsis, hospital epidemiology, infectious disease, microbiology, steril-
ization and disinfection, and surveillance. It is recommended that one ICD is
required for every 1,000 beds. The role and responsibilities of the ICD are summar-
ized as follows:
• Serves as a specialist advisor and takes a leading role in the effective

functioning of the ICT.
• Should be an active member of the hospital Infection Control Committee
(ICC) and may act as its Chairman.
9
• Assists the hospital ICC in drawing up annual plans, policies and long-term
programmes for the prevention of hospital infection.
• Advises the chief executive/hospital administrator directly on all aspects of
infection control in the hospital and on the implementation of agreed policies.
• Participates in the preparation of tender documents for the support
services and advises on infection control aspects.
• Is involved in setting quality standards, surveillance and audit with regard
to hospital infection.
Infection Control Nurse (ICN)

An Infection Control Nurse or Practitioner is a registered nurse with an additional
academic education and practical training which enables him or her to act as a
specialist advisor in all matters relating to infection control. A recognized qualifica-
tion in infection control should be held which will allow recognition of the ICN as a
specialist practitioner.
The ICN is usually the only full-time practitioner in the ICT and therefore takes the
key role in day-to-day infection control activities, with the ICD providing the lead
role. It is recommended that one Infection Control Nurse is required for every 250
occupied beds. The role and responsibility of the ICN is summarized as follows:
• Serves as a specialist advisor and takes a leading role in the effective

functioning of the ICT.
• Should be an active member of the hospital ICC.
• Assists the hospital ICC in drawing up annual plans and policies for
infection control.
• Provides specialist nursing input in the identification, prevention,
monitoring, and control of infection within the hospital.
• Participate in surveillance, investigation, and control of infection in the
hospital.
• Identify, investigate and monitor infections, hazardous practice and
procedures.
• Advice to the contracting departments, participating in the preparation of
documents relating to service specifications and quality standards.
• Ongoing contribution to the development and implementation of infec-
tion control policy and procedure, participating in audit, and monitoring
tools related to infection control and infectious diseases.
• Presentation of educational programmes and membership of relevant
committees where infection control input is required.
10
Administrative Arrangements
It is essential that the ICN should have an expert knowledge of both general and
specialist nursing practice and must also have an understanding not only of the
functioning of clinical areas but also operational areas and services. He or she must
also be able to communicate effectively with all grades of staff, negotiate and effect
change, and influence practice.
Infection Control Team (ICT)

The ICT comprises the ICD and ICN. The ICT is responsible for the day-to-day
running of infection control programmes. It is important that all acute hospitals
should have an ICT, although smaller health care providers may not find this a viable
option. In cases where the provision of an ICT is not practical, arrangements for the
provision of and access to the infection control service should be arranged with
nearby acute hospital.
The role of the ICT is to ensure that an effective infection control programme has
been planned, co-ordinate its implementation, and evaluate the impact of such
measures. Whilst they will actively participate in most of these areas, some aspects of
the infection control programme may fall under the remit of others. In such cases
the ICT will provide advice and direction, ultimately ensuring that all tasks reach
completion. It is important to ensure that there is provision made for 24-hour access
to the ICT for advice on infection prevention and control of infection, which would
include both medical and nursing advice. The role of the ICT can be summarized as
follows:
• Production of an annual infection control programme with clearly defined

objectives.
• Production of written policies and procedures on infection control, includ-
ing regular evaluation and update.
• Education of all grades of staff in infection control policy, practice and
procedures relevant to their own area of practice.
• Surveillance of infection to detect outbreaks at the earliest opportunity and
provide data that should be evaluated to allow for any change in practice or
allocation of resource to prevent hospital-acquired infections.
• Provide advice to all grades of staff on all matters in relation to infection
prevention and control on a day-to-day basis.
• Participate in the audit activity.
Infection Control Committee (ICC)

The hospital ICC is charged with the responsibility for the planning, evaluation of
evidence-based practice and implementation, prioritization, and resource allocation
of all matters relating to infection control.
11
The membership of the hospital ICCs should reflect the spectrum of clinical services
and administrative arrangements of the health care establishment so that policy deci-
sions take account of implementation issues. As a minimum, the committee should
include:
• ICD or Hospital Epidemiologist who may act as a chairperson.

• Infection Control Nurse/Practitioner.
• Infectious Diseases Physician (if available).
• Chief executive or hospital administrator or his or her nominated
representative.
• Director of Nursing or his/her representative.
• Occupational Health Physician or a representative.
• Representative from the major clinical specialties.
In addition in the UK, a Consultant in Communicable Disease Control should be
included. Large institutions or those operating on multiple sites may need to enlarge
this membership to ensure that all aspects of clinical service are adequately repre-
sented. Additionally, representatives of any other department may be invited as
necessary. The ICC should meet regularly according to local need. A minimum of
two planned meetings a year is recommended.
The function of local ICC is that of supporting the development of an effective infec-
tion control programme. The committee should discuss routine surveillance reports
from the ICT, outbreaks of nosocomial infection, needle stick injury incidents, health
care worker immunization and education, purchasing of equipment, etc. In addition,
it is important that the members of the committee voice areas of concern including
any problems relating to either infection control practice or policy, in particular
highlighting areas which have not been addressed within their own sphere of
responsibility.
Infection control link nurse

One effective way of developing infection control education and operational support
can be through the development of a link system. It has been shown that competent
infection control link nurses can motivate ward staff by enabling more effective
practice. Sustained, consistent and senior management backing and interest are
effective in supporting such link programmes and is essential in ensuring their
success.
However, high staff turnover rates, adequate training time and recognition, the
requirement for the ICT to monitor the link programmes are all resource pressures
inherent in such schemes.
12
Policies and procedures manual

It is essential that each health care establishment should develop a manual of policies
and procedures in infection control. The procedure manual should establish stand-
ards for performance in all aspects of infection control. The recommendations in the
manual must be based on the relevant national guidelines. They should be practical,
workable, necessary and sufficiently flexible to ensure their implementation. Policies
and procedures should identify infection control indicators and desired outcomes.
They should also include some basis for the risk assessment of each procedure.
A comprehensive procedures manual should include policy and procedures on:
• Cleaning and decontamination of surfaces and equipment.

• Procedures for isolation of patients.
• Management of spills or accidents with infectious substances.
• Hygiene and hand washing procedures.
• Use of protective clothing and equipment.
• Safe handling and transport of pathology specimens.
• Handling and cleaning of contaminated linen.
• Handling and disposal of clinical and related waste.
• Handling and disposal of sharps.
• Management of sharps injuries.
The infection control manual must be updated on regular basis. Staff should be
informed of changes to current policy and procedures, as well as the introduction of
new ones. New policies should be carefully monitored and should include HCWs
feedback, with appropriate responses. The manual should be easily accessible and
readily available to all HCWs.
Occupational health and safety

Employers have a responsibility to provide a safe work environment without risk to the
health of their employees. In the health care setting, it is essential that all HCWs must
be given adequate education and training on all issues relating to the control of infec-
tion. In addition, employees also have a responsibility to comply with safety standards
and procedures set by health care establishments, and should ensure that their work
practices do not jeopardize the health and safety of themselves or any other person.
Education and training

Managers of all health care establishments must ensure that all HCWs should be
made aware of the importance and principles of infection control. They should also
emphasize the importance of continuing education and training for all HCWs. New
13
employees should be offered an orientation and induction programme to increase

their awareness and to assist in their understanding of the institutional policies and
programmes for infection control. Education and training programmes should be
flexible enough to encourage participation.
Identify risk
Analyse
Control
Avoid Accept Prevent
Figure 2.1 Principles of risk management.
Risk management in infection control

The purpose of risk management is to minimize exposure of health care workers,
patient and visitors to sources of infection. The primary aim of risk management is to
be pro-active in the reduction of risks to the lowest level that is reasonably practicable.
A practical approach to infection control risk management can be achieved by devis-

ing a structured care plan for each individual patient who is at risk from acquiring
an infection and/or is a source of risk to others. This should be done using a formal
cyclical process considering of the following:
Identification: Identification of activities and tasks that put patients and employees
at risk of infection, the type of infectious agent involved, route of infection and the
evidence that the disease can be spread this way.
Analysis: Analysis of the risk or problem e.g. evaluation of the infective dose of
the infectious agent and the relationship between the dose received and the severity
of the infection. In addition, analyse why they are happening – the possible causes
could be inadequate knowledge, inadequate equipment, lack of motivation or lack
of management reinforcement. Determine how often they are happening and do a
cost benefit analysis.
Control: Think of the best possible solution and how the risk can be eliminated or
minimized. If this is not possible can you accept the risk?
14
When the most suitable control method is implemented, it is essential that the
corrective action should be evaluated and monitored by audit procedures. This
approach can also be used for hazards or risks that arise from the environment or
equipment, as well as patient-related risks.

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Barrett SP. Infection control in Britain. Journal of Hospital Infection 2002; 50: 1106–1109.
Bassetti M, Topal J, Di Biagion A, Salvalaggio P, Basadonna GP, Bassetti D. The organiza-
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Hryniewicz W, Grzesiowski P, Ozoroowski T. Hospital infection control in Poland.
Huskins WC, Soule B. Infection control in countries with limited resources. Current
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177–179.
15
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Millward S, Barnett J, Thomlinson D. A clinical infection control audit programme:
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16
3
Design and Maintenance of
Health Care Facilities
T he provision of a safe environment within health care premises is a statutory

obligation and must be part of the risk management strategy of hospital. The
environment in which patients are nursed must be designed to reduce the risks of
transmission of infection to a minimum.
Advances in medical treatment have changed the types of patients being admitted to
hospital. Currently patients with impaired host defenses represent an increasing pro-
portion of admissions to hospital and to reflect that, the design of health care facil-
ities has undergone substantial changes. From an infection control perspective, the
primary objective of hospital design should be to ensure that patients, especially
immunocompromised ones, are at no greater risk of infection within the hospital
than outside. Microbial flora of a health care facility can be influenced by its design
and the Infection Control Team (ICT) plays a major role in this.
It is essential that the ICT must be involved in the design, construction and commis-
sioning of any new or upgraded building at an early stage. Equally important is the
engagement of the ICT when major decommissioning or demolition work is being
planned as such situations can represent a threat to patient safety through the heavy
release of microorganisms, particularly fungi, into the air. Therefore input from the
ICT at the planning stage and through the entire life of the project is essential to
ensure that the new health care premises meet with infection control requirements.
Early involvement of the ICT in the process is essential to identify potential infection
control issues early and provides an opportunity to design solutions prospectively.
The ICT also play an important role in educating architects, engineers and construc-
tion workers about potential infection control risks and appropriate methods for
reducing them, as they are the only personnel from a clinical background working on
construction project. It is also important that the ICT should visit the construction
site on a regular basis to ensure that agreed plans are been adequately implemented.
It is the responsibility of the hospital administrator to ensure that the policies and
procedures set forth by the ICT are incorporated into the contract.
17
Infection control risk assessment

The association between construction and the development of aspergillosis in
immunocompromised patients and the association between hospitalization and
legionellosis have been known for decades. Therefore it is essential that as part of the
planning process for renovation and constructing of a health care facility, an infec-
tion control risk assessment should be conducted to determine the potential risk of
transmission of microorganisms within the hospital. In general, the risks can be cat-
egorized as infections transmitted by air, water, or the environment.
The general hospital environment

Functional design of health care facilities should allow routine cleaning to be carried
out efficiently. Surfaces, including walls, must be smooth, easy to clean and protected
from damage. Unnecessary horizontal, textured and moisture-retaining surfaces, or
inaccessible areas where moisture or soil will accumulate, should be avoided if pos-
sible. Where possible, all surfaces should be smooth and impervious.
To prevent dust accumulation, cupboards rather than shelves are recommended and
cupboard doors should be easily washable. Consideration must be given to the design
of radiators and other fixed or relatively immovable items, e.g. computer stations and
their wiring, to ensure that all surfaces are accessible for cleaning. When furnishings
and fittings are being selected, they must be assessed against their potential exposure
to disinfectants, and finishes durable enough to withstand the appropriate cleaning
of the hospital environment should be chosen. Items intended for domestic use are
frequently inappropriate for the hospital setting. In equipment-processing areas,
work surfaces should be nonporous, smooth and easily cleaned.
Walls and ceilings: Ideally, walls and ceilings should have a smooth, impervious sur-
face that is easy to clean with minimal likelihood of dust accumulation. In general,
pathogenic microorganisms do not readily adhere to walls or ceilings unless the sur-
face becomes moist, sticky, or damaged. Little evidence exists that walls and ceilings
are a major source for hospital-acquired infection. Wall coverings should be fluid
resistant and easily cleaned, especially in areas where contact with blood or body flu-
ids may occur, e.g. delivery suite, operating rooms, and laboratories. Finishing
around plumbing fixtures should be smooth and water resistant. In addition, pipe
penetrations and joints should be tightly sealed. Acoustical tiles should be avoided in
high-risk areas because they may support microbial growth when wet. False ceilings
may harbour dust and pests that may contaminate the environment if disturbed and
should be avoided in high-risk areas unless adequately sealed.
Floor: Bacteria on hospital floors predominantly consist of skin organisms, e.g. coagu-
lase negative staphylococci, Bacillus spp. and diptheroids; S. aureus and Clostridium
spp. can also be cultured. However, the infection risk from contaminated floors is
small. Gram-negative bacteria are rarely found on dry floors, but may be present after
18
Design and Maintenance of Health Care Facilities
cleaning or a spill. Nevertheless, these microorganisms tend to disappear as the sur-

face dries. All floors should have non-slip coverings. Where there is likely to be direct
contact with patients, or with blood and body fluids, the surface of floors and walls
should be made of smooth, impermeable, seamless materials, such as welded vinyl.
Flooring should be able to be easily cleaned, in good repair and water resistant.
Carpet: Carpet harbours large numbers of microorganisms, e.g. coagulase negative

staphylococci, Bacillus spp., fungi and vancomycin-resistant enterococci (VRE).
These microorganisms can survive on carpets and may pose a greater risk of infec-
tion especially in high-risk areas after vacuuming. Therefore, their use in clinical
areas should be avoided. In addition, carpets are expensive to clean and maintain,
difficult to disinfect and become smelly with time.
If carpets are used in the health care facility, then they must be fitted with a moisture
impermeable barrier. They should be well maintained to ensure that they are vac-
uumed daily and periodically steam cleaned. An appropriate choice of vacuum is
important to minimize airborne dispersal of microorganisms.
Fixtures and fittings: All fixtures and fittings should be designed to allow easy clean-
ing and to discourage the accumulation of dust. When choosing material it is import-
ant to avoid porous or textured material. It must be durable, easy to clean, washable
and able to withstand cleaning with abrasive disinfectant solutions.
Furniture: Various microorganisms have been recovered from furniture. Therefore,

it is important that the furniture used by patients (beds, mattresses, chairs, tables
etc.) must be durable and easily cleaned. Fabrics should be avoided, especially if
soiling with blood and body fluids is possible. Upholstery and protective covers must
be in good repair at all times and breaches in the material must be repaired or
replaced immediately.
Curtains and blinds: Curtains must be easily washable and of a design that does not
attract accumulated dust. Sufficient curtains must be purchased to enable single cur-
tains to be replaced when soiled. There must also be a laundering programme in place,
and the laundering process must not compromise the fire retardant finish. As there is
no evidence to show that frequent changing produces any benefit; curtains need not be
changed after discharge of every patient. Horizontal blinds carry a risk due to their
high surface area with the potential for dust accumulation; vertical blinds are preferred.
Patient’s accommodations
Outpatient accommodation: Patient waiting areas should have provision for separat-
ing patients who may be highly infectious. A triage system should be in place to iden-
tify such patients. Outpatients should have a separate room for patients with known
or suspected infection. Every effort should be made to see these patients as quickly as
possible.
19
Inpatient accommodation: To minimize the risk of cross-infection, hospitals should,

wherever possible, restrict the number of beds per room/bay (ideally not more than
four beds per room/bay); there should be at least 3.6 m between the centres of
adjacent beds. Shared patient accommodation should include facilities such as toilets,
baths and showers that are easy to clean and conveniently located to minimize unneces-
sary patient movement. Staff hand washbasins should also be located in patient areas.
Hand washing facilities

Hand washing is the single most important method of prevention of cross-infection in
hospital. Health care facilities should have an adequate number of hand
washbasins. Each patient room, examination room, and procedure room needs at
least one sink. There must be a minimum of one sink per single room or one sink per
4–6 bedded cubicles. They should be located conveniently (i.e. preferably near the
entrance) for easy access by the health care worker.
The hand washbasin should be large enough to prevent splashing. Too shallow a sink
may cause contamination of hands by bacteria residing in the drain. They should be
sealed to the wall or placed sufficiently far away from the wall to allow effective clean-
ing of all surfaces. Splash backs should be included to prevent wall damage. The sur-
rounding area should be made of non-porous material to resist fungal growth. The
tap outflow should not point directly into the sink outlets as gram-negative bacteria
colonize ‘U bends’ causing splashing and dispersal of contaminated aerosols.
Taps should be fitted with an anti-splash device. Hand washbasins should be fitted
with soap dispensers (i.e. operated by elbow, knee or foot) in order to further reduce
possible cross-contamination. They should be supplied with both hot and cold
water; preferably with a mixer tap to achieve correct temperature. The tap should be
fitted with a hands-off control (e.g. elbow operated) to avoid contamination.
Electronically operated systems may be an acceptable option in specialized areas such
as theatres.
Isolation rooms
In an acute hospital, it is essential that adequate numbers of single rooms are avail-
able for the isolation of patients with suspected or confirmed infection. It is recom-
mended that there is at least one single room for every 4–6 beds or there are four
single rooms for each 24-bedded ward. Each side room should have a clinical hand
basin at the port of exit, a patient’s hand washbasin and an en-suite toilet and bath-
room/shower. It should preferably have an ante-room.
Source isolation room

There should be at least one respiratory isolation room per 100 beds. Negative pres-
sure ventilation is required only for conditions transmitted via the airborne route,
20
Direction of Direction of
airflow airflow
An infected patient in A susceptible patient in

source isolation protective isolation
(NEGATIVE PRESSURE (POSITIVE PRESSURE
VENTILATION ROOM) VENTILATION ROOM)
Figure 3.1 Isolation of patients.
e.g. tuberculosis, measles and chickenpox. Mechanically ventilated rooms should

achieve 6–12 exchanges of air per hour and there 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. No recirculation of air should be permitted for
respiratory isolation rooms. The exhaust air from isolation rooms should be vented
to the exterior. Where dual ventilation is present, there must be local safeguards to
prevent accidental switching between positive and negative pressure.
Regular maintenance and monitoring programmes must be established for ventilated

rooms to ensure that the design criteria are met. Pressure and airflow must be moni-
tored and filters must be replaced on a periodic planned basis according to written
protocols. These rooms should be self-closing, and the walls, windows, ceiling, floor, and
penetrations well sealed. Ideally, they should be located in areas where patients at high-
risk will be cared for, e.g. emergency department, bronchoscopy suite, medical units etc.
Isolation of patients with proven or suspected multiply drug-resistant Mycobacterium
tuberculosis in a single room with negative pressure ventilation is essential.
Protective isolation room

Prevention of aspergillosis is particularly important in patients undergoing solid
organ and bone marrow transplantation. In bone marrow transplant units, the air
should be HEPA filtered with the air pressure in the room positive in relation to the
corridor. In addition, rooms should be tightly sealed, especially around windows, and
the air exchange rate should be high, i.e. !12 air exchanges per hour. It is important
that air should be exhausted to the outside without recirculation.
21
Sidewall (lateral) supply Ceiling (central) supply
Figure 3.2 Airflow in conventionally ventilated operating theatre.
Operating theatres
To prevent contaminated air from reaching the operating theatre, mechanical venti-
lation is recommended. The air within the operating room should be at a positive
pressure compared with other theatre suite rooms and with the external corridors.
Theatre ventilation must be checked regularly and maintained by an appropriate
engineer. The works and maintenance department must keep written records of all
work on the ventilation system. Coarse and fine air filters must be replaced regularly
according to the manufacturer’s instructions or when the pressure differential across
the filter indicates that a change is required.
Conventionally ventilated theatre

For a conventionally ventilated theatre, a minimum of 20 air changes per hour of
filtered air should be delivered. The temperature of the room should be maintained
at 18–25°C. The humidity should be maintained at 40–60% for staff comfort and to
inhibit microbial growth. Additional ventilation units, such as mobile air cooling
devices, must not be introduced into the theatre without consultation with the ICT.
The minimum standard for microbiological air counts for the operating room is
30 cfu m"3 (colony forming units per cubic metre of air) when the theatre is empty, and
less than 180 cfu m"3 when in use. A conventionally ventilated theatre requires micro-
biological checks at commissioning, immediately after commissioning and at any
major refurbishment, by the ICT. Routine bacteriological testing of operating room
air is not necessary but may be useful when investigating an outbreak.
Ultra clean air theatre

It is now accepted that ultra clean air (#10 cfu m"3) reduces the risk of infection in
implant surgery. To achieve this, laminar flow systems (airflow 0.5 m s"1) which
deliver about 300 air changes per hour or special ventilation combined with bacteria
impermeable clothing has to be used. The operating parameters for an ultra clean air
theatre are different from those for a conventionally ventilated theatre, and depend
upon the design of the system. In a fully walled enclosure, the airflow 1 m from the
filter face should not fall below 0.3 m s"1, but in a partially walled enclosure, because
22
Vertical flow Horizontal flow
Figure 3.3 Airflow in conventionally ultra clean operating theatre.
there is a greater diffusion of air, the airflow at 1 m from the floor (above the level of
the operating table surface), should not be less than 0.2 m s"1. Bacterial counts at 1 m
from the floor should be less than 1.0 bcp m"3 (bacteria carrying particles per cubic
metre of air) of air in an empty enclosure and when tested during an operation there
should be less than 10 bcp m"3 at the level of the operating table at the centre of the
enclosure. Additionally, if the system is partially walled, then on each of the four sides
at the periphery of the enclosure, the bacteriological count should not exceed
10 bcp m"3.
Ultra clean air theatres require assessment not only at commissioning, but at regular
intervals as a part of the routine service to theatres, because factors other than sim-
ple ventilation parameters are important in determining the quality of the air. It is
recommended that microbiological checks should be performed every 3 months
because of the long incubation period for joint sepsis. Any system defect needs to be
detected early and rectified quickly.
Ventilation and air-conditioning

A clear distinction must be made between ventilation provided as part of environ-
mental patient comfort and that as part of the control of infection. Air-conditioning or
ventilation systems in critical areas such as operating theatres, respiratory isolation
rooms, bone marrow transplant units as well as in special treatment or procedural areas
should maintain the inflow of fresh air and allows the temperature, humidity and
purity (from dust, infectious agents, and gases) of the air to be maintained within
prescribed limits. Hospital air-conditioning systems must be monitored regularly and
serviced by the hospital estates department and/or other accredited service techni-
cians. Maintenance schedules must be documented and carried out according to
manufacturers’ recommendations.
Cooling towers and water system

Respiratory tract infections from Legionella spp. are exclusively acquired from the
environment, and hospital acquisition is well recognized. The highest concentrations
of Legionella spp. are found in hot water storage tanks, cooling towers, and
23
condensers. Therefore, cooling towers and water systems should be avoided where
possible. If the construction of new cooling towers in the health care facilities is
planned, it is important that they be sited and directed as far as practicable from
patient and public areas. Drift must be directed away from the air-intake system and
drift eliminators should be installed.
Adequate maintenance of wet cooling towers is essential and must be carried out in
accordance with written policy, which must be based on national and international
guidelines. A written record must be kept of detailed maintenance, including envir-
onmental test results. It is important that cooling towers should be drained when not
in use. They should be mechanically cleaned to remove scale and sediment at regu-
lar intervals. Appropriate biocides should be used on a regular basis to prevent the
growth of slime-forming organisms. Despite the potential presence of Legionella in
the water supply, routine culturing of water in the absence of proven or suspected
hospital transmission is not recommended.
Spa pools, heated swimming pools and other water systems are also potential sources
of infection including Pseudomonas spp., Legionella spp. and Cryptosporidium spp.
Each health care facility should develop guidelines based on relevant standards.
Construction, renovation and demolition

Environmental disturbances caused by construction, renovation and demolition
activities in and around hospital markedly increase the airborne Aspergillus spp.
spore counts in the indoor air, thereby increasing the risk of acquiring aspergillosis
among immunocompromised patients. Although one case of healthcare-associated
aspergillosis is often difficult to link to a specific environmental exposure, the occur-
rence of temporarily clustered cases increase the likelihood that an environmental
source within the facility may be identified and corrected. Therefore it is essential
that all the activities related to construction, renovation and demolition should
be planned and coordinated by a multi-disciplinary team to minimize the risk of
airborne infection both during projects and after their completion.
The ICT should carry out a risk assessment before initiating the project to identify
potential exposures of susceptible patients to dust and moisture and determine the
need for dust and moisture containment measures.
Microbiological sampling of air in health care facilities remains a controversial issue

because of currently unresolved technical limitations and the need for substantial
laboratory support.

American Institute of Architects: Guidelines for Design and Construction of Hospital and
Health Care Facilities. Washington DC: The American Institute of Architects, 2001.
24
Anderson K, Morris G, Kennedy H, Croall J, Michie J, Richardson MD, Gibson B.

Aspergillosis in immunocompromised paediatric patients: associations with building
hygiene, design, and indoor air. Thorax 1996; 51: 256–261.
Ayliffe GAJ, Collins BJ, Lowbury EJL, Babb JR, Lilly HA. Ward floors and other surfaces
as reservoirs of hospital infection. Journal of Hygiene 1967; 65: 515–536.
Ayliffe GAJ, Babb JR, Taylor LJ. The hospital environment. In: Hospital-acquired infection:
principles and prevention. Oxford: Butterworth-Heinemann; 1999: 109–121.
Bartley J. (ed). Construction and Renovation: APIC Infection control tool kit series.
Washington DC: Association for Professionals in Infection Control and Epidemiology, 2000.
Bartley JM. The role of infection control during construction in health care facilities.
Carter CD, Barr BA. Infection control issues in construction and renovation. In:
Herwaldt LA, Decker MD (eds). A practical handbook for hospital epidemiologists.
Thorofare (NJ): Slack, Inc; 1997: 317–330.
Carter CD, Barr BA. Infection control issues in construction and renovation. Infection
Control Hospital Epidemiology 1997; 18: 587–596.
Centers for Disease Control and Prevention. Guidelines for preventing opportunistic
infections among hematopoietic stem cell transplant recipients. Morbidity and Mortality
Weekly Report 2000; 49(RR-10): 1–125.
Centers for Disease Control and Prevention. Guidelines for preventing the transmission
of Mycobacterium tuberculosis in health-care settings. Morbidity and Mortality Weekly
Report 1994; 43(RR-13): 1–132.
Cheng SM, Streifel AJ. Infection control considerations during construction activities:
land excavation and demolition. American Journal of Infection Control 2001; 29: 321–328.
Holton J, Ridgway GL. Commissioning operating theatres. Journal of Hospital Infection

1993; 23: 153–160.
Kaatz GW, Gitlin SD, Schaberg DR, Wilson KH, Kauffman CA, Seo SM, et al. Acquisition
of Clostridium difficile from the hospital environment. American Journal of Epidemiology
1988; 127: 1289–1294.
Lai KK. A cluster of invasive aspergillosis in a bone marrow transplant unit related to
construction and the utility of air sampling. American Journal of Infection Control 2001;
29: 333–337.
Marshall JW, Vincent JH, Kuehn TH, Brosseau LM. Studies of ventilation efficiency in a
protective isolation room by the use of a scale model. Infection Control and Hospital
Epidemiology 1996; 17: 5–10.
Noskin GA, Bednarz P, Reiner S, Suriano T, Peterson LR. Persistent contamination of

fabric covered furniture by vancomycin resistant enterococci: implications for upholstery
selection in hospitals. American Journal of Infection Control 2000; 160: 2819–2822.
25
Neely AC, Maley MP. Survival of enterococci and staphylococci on hospital fabrics and
plastic. Journal of Clinical Microbiology 2000; 38: 724–726.
O’Connell NH, Humphreys H. Intensive care unit design and environmental factors in
the acquisition of infection. Journal of Hospital Infection 2000; 45: 255–262.
Pannuti CS. Hospital environment for high-risk patients. In: Wenzel RP (ed). Prevention
and control of nosocomial infections 3rd edn. Baltimore: Williams and Wilkins; 1997:
463–489.
UK Department of Health. Technical memorandum 2025. Ventilation in health care

premises. Part 1 Management Policy, Part 2 Design Considerations, Part 3 Validation and
verification, Part 4 Operational management. London: HMSO, 1994.
UK Department of Health. Technical Memorandum 2040. The control of legionella in

healthcare premises – a code of practice. Part 1 Management Policy, Part 2 Design
Considerations, Part 3 Validation and verification, Part 4 Operational management.
London: HMSO, 1994.
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Office, 2002.
26
4
Sur veillance and
Outbreak Control
A pproximately 10% of hospitalized patients develop infections every year. The

rate of developing nosocomial or hospital-acquired infection in developing
countries is as high as 25%. It has been estimated that up to one third of these infec-
tions are preventable.
An infection is classified as nosocomial if it was not present or incubating at the time

the patient was admitted to the hospital. Infections should be considered nosocomial
if they are related to procedures, treatments, or other events. Most nosocomial infec-
tions appear before the patient is discharged, although some are incubating at dis-
charge and do not become apparent until later.
Thus, an infection is not considered nosocomial if it represents a complication or

extension of an infectious process present on admission. In general, infections that
occur more than 48–72 h after admission and within 10 days after hospital discharge
are defined as nosocomial or hospital-acquired. The time frame is modified for infec-
tions that have incubation periods less than 48–72 h (e.g. gastroenteritis caused by
Norwalk virus) or longer than 10 days (e.g. hepatitis A). Surgical site infections are
considered nosocomial if the infection occurs within 30 days after the operative
procedure or within 1 year if a device or foreign material is implanted.
Incidence of various nosocomial infections

Urinary tract infection (UTI): Most nosocomial UTIs develop after urinary tract
manipulation. UTI arises in 20–25% of the hospitalized patients who have an
indwelling urinary catheter. The risk of UTI increases if the patient has an indwelling
urinary catheter for a longer duration.
Respiratory tract infections: Nosocomial pneumonia is the second most common

hospital-acquired infection and has a mortality rate between 20–50%. Most respira-
tory nosocomial infections are linked to respiratory devices used to aid breathing or
27
Other 24.8%
Blood (septicaemia) 6.2%
Urinary tract 23.2%
Surgical wound 10.7%
Lower respiratory tract 22.9%
Skin 9.6%
Figure 4.1 Sites of the most common nosocomial infections: distribution accord-
ing to the UK Prevalence Study (Emmerson AM, et al. 1996).
administer medications. Nosocomial pneumonia typically lengthens a patient’s

hospital stay by 4–9 days and is associated with very high morbidity and mortality.
Surgical site infections: Surgical site wound infections occur in up to 12% of surgi-
cal patients. Such infections lengthen hospital stays by about 6 days. Surgical site
infections can occur in the incision as well as in the deep tissues of a wound.
Bloodstream infections: Nosocomial infections of the bloodstream account for

approximately 6% of nosocomial infections. Although local infections outside the
bloodstream are sometimes the source of infection, most bacteraemias are related to
intravascular devices.
Surveillance of nosocomial infection

Surveillance of nosocomial infection is the foundation for organizing and maintaining
an infection control programme. In addition, information obtained from surveillance
data is a useful tool for the infection control team (ICT) and the infection control com-
mittee (ICC) in identifying areas of priority and allocating resources accordingly.
Therefore it is essential that each health care establishment tailors its surveillance
systems to maximize the use of all health care resources, given outcome priorities,
population characteristics and institutional objectives.
The main objectives of surveillance are as follows:
• Reducing infection rates within health care facilities.

• Establishing endemic infection rates.
28
Sur veillance and Outbreak Control
• Identifying outbreaks.
• Convincing medical personnel to adopt recommended preventive practices.
• Comparing infection rates between health care establishments.
• Evaluating control measures.
The process of surveillance must incorporate four key stages: data must be collected,
recorded, analyzed and interpreted. The most vital component of surveillance is ensur-
ing that the information obtained is conveyed to those who may influence practice,
implement change or provide financial resources necessary to improve outcomes. It is
a futile exercise to collect and record data without taking any further action.
Ideally surveillance should be carried out in all health care establishments to obtain
baseline information on the frequency and type of nosocomial infections. Any
increase in the rate of infection can then be quickly recognized and appropriate
infection control action taken to minimize its transmission. A change in infection
rates against a baseline rate can also be used to evaluate the effectiveness of new
infection control policies and procedures.
Methods of surveillance
Different methods of surveillance exist and the findings are summarized in table 4.1
and table 4.2. The type of surveillance method depends on the local factors, i.e. the type
and size of hospital, case mix and availability of resources. Continuous surveillance
of an entire health care facility requires staff, IT resource and a well organized report-
ing system. Targeted surveillance aimed at high risk areas is more effective and man-
ageable and is preferred in larger establishments. Irrespective of the methods used,
it is essential that data generated from the surveillance is appropriately risk-adjusted
for the generation of meaningful infection rates, especially when the information is
released beyond the institution.
Surveillance methods should be flexible enough to accommodate technological

changes within health care facilities, shortening lengths of stay and the necessity to
provide post-discharge surveillance, including surveillance of procedures carried out
in the community. Numerator and denominator data should be collected in all situ-
ations for the calculation of rates of infection. For surveillance purposes, the analy-
sis of numerator data alone is meaningless.
A minimum data set for surveillance should include details of the infected individ-
ual, i.e. name or other unique identifier, date of birth, sex, hospital record number,
ward or unit in the hospital, name of the consultant, unit involved, date of admis-
sion, date of onset of infection and date of discharge or death, site of infection or
colonization, organism isolated with antibiotic sensitivities. This minimum data set
should also include information on medical treatment/procedures at the time of
infection and any other information relevant to why the infection may have occurred
29
Table 4.1 Various methods of surveillance used in infection control.

Methods Sources of data Comments
Continuing surveillance Medical, nursing, laboratory Time-consuming and

of all patients (CS) records including temperature not cost effective:
charts, X-ray and antibiotic infection rates are
treatment reports. low in some specialties.
Ward liaison (WL) Twice-weekly visits to wards. Less comprehensive
Discuss all patients with staff than CS, with similar
and review records. disadvantages.
Laboratory-based (LB) Laboratory records only. Depends on samples
taken and information
on request forms.
Laboratory-based ward Follow up of LB in wards. Disadvantages of LB,
surveillance (LBWS) but more accurate.
Laboratory-based ward As LBWS and reporting of As LBWS, but early
surveillance and outbreaks by ward staff and detection of outbreaks
selected continuing CS in special units. and incidence in
surveillance (LBWS (e.g. ITU) or infections studies in selected
and CS) (e.g. wounds). areas of infection.
Laboratory-based ward Combination of LB and LBWS. Time-consuming but
liaison (LBWL) most sensitive after CS.
Adapted from Glenister HM, et al. An evaluation of surveillance methods for detecting infections in hospital
inpatients. Journal of Hospital Infection 1993; 23: 229–242.
including the patient’s underlying medical risk factors, clinical outcome and an
assessment of whether the incident was preventable.
Comparison of infection rates between establishments and the publication of such

comparisons is a contentious issue and needs careful consideration and sensitive
handling. This is mainly because the surveillance data may not be comparable, and
the range of institutions involved will introduce confounding factors inherent in all
surveillance systems. Problems of data interpretation can be overcome when surveil-
lance systems are set up with clearly defined surveillance objectives included in the
expected outputs of surveillance. Unfortunately, at this time, surveillance objectives
rarely underpin surveillance methods.
Management of an outbreak
An outbreak may be defined as the occurrence of disease at a rate greater than that
expected within a specific geographical area and over a defined period of time
(Beck-Sague C, et al. 1997). Day-to-day surveillance is important to identify cases of
nosocomial infections and other infectious diseases so that appropriate action is
taken. Major outbreaks of transmissible infection in both the hospital and commu-
nity require appropriate planning to ensure effective management of such episodes.
30
Table 4.2 Advantages and disadvantages of various surveillance strategies.

Strategy Advantages Disadvantages
Hospital-wide
surveillance
Incidence Provides data on all Expensive.
infection sites, and units. Labour-intensive and time-
Identifies clusters. consuming.
Establishes baseline rates. No defined management
Recognizes outbreaks early. objectives.
Identifies risk factors. Large amounts of data collected
and little time to analyse.
Prevalence Inexpensive. Overestimates rates, important
Time efficient, can be done differences compared with
periodically. incidence surveys.
Objective/ Adapts to hospitals with No baseline infection rates.
priority based special interests and resources. May miss clusters or
Focuses on specific problems outbreaks.
at the individual institution.
Identifies risk factors.
Can include post-discharge
component.
Targeted
surveillance
Site specific Flexible, can be mixed with No defined management
other strategies. objectives.
Can include a post-discharge No baseline rates in other units.
component. May miss clusters.
Unit specific Focuses on patients at Can miss clusters.
greater risk.
Requires fewer personnel.
Simplifies surveillance effort.
Rotating Less expensive.
Less time-consuming and
labour-intensive.
Includes all hospital areas.
Outbreak Valuable when used with all Thresholds are institution
types of surveillance. specific. No baseline
rates provided.
Limited Decreases possibility of missing May miss cluster.
periodic an outbreak.
surveillance Liberates infection control nurse
to perform other activities.
Increase efficiency of
surveillance.
Reproduced with permission from Perl TM. Surveillance, reporting and the use of computers. In: Wenzel RP (ed).
Prevention and Control of Nosocomial Infections 3rd edn. Baltimore: Williams & Wilkins, 1997: 127–161.
31
Therefore it is important that the health care facilities must draw up detailed out-
break control plans appropriate to local situations. These plans should be discussed
and endorsed by the hospital ICC and should include the criteria and method for
convening the Outbreak Control Committee. The plan should also clearly address
the areas of individual responsibilities, and action plans for all involved. Those who
are or may be involved in the management of a major outbreak must be aware of
such a policy and their individual role.
In an outbreak situation, communication to relevant staff is important. Effective

outbreak investigation requires adequate laboratory support. It is particularly import-
ant to ensure that outbreak isolates are stored for further investigation. This is
because many of the infectious agents that cause outbreaks in health care facilities are
endemic organisms, and it may be necessary to use a typing system to evaluate which
isolates are part of any putative outbreak. Although simple antimicrobial susceptibil-
ity testing may be enough to distinguish isolates, against a background of increasing
resistance, other more sophisticated methods of typing may be necessary. These are
usually available from a reference laboratory.
Recognition: The rapid recognition of outbreaks is one of the most important object-
ives of the routine surveillance of infection. Ideally, hospital surveillance systems
should facilitate the early detection of outbreaks. In some instances, the occurrence
of an outbreak may be obvious, such as in an episode of food poisoning that affects
both health care workers (HCWs) and patients, while in other instances the onset
may not be immediately apparent. Sometimes the outbreak may manifest itself
clearly to the medical and nursing staff. However, some outbreaks may arise more
insidiously and reach considerable proportions before they become apparent. These
outbreaks are detected by the laboratory, but under some circumstances may be
identified only through the vigilance of general nursing and medical staff.
Investigation: The principles for investigating outbreaks in hospitals are the same as
for community-based outbreaks. There are three basic steps: i.e. (a) describing the
outbreak, (b) developing a hypothesis and (c) testing the hypothesis with analytical
epidemiology.
Once a possible outbreak has been recognized, the Infection Control Team should
take immediate steps to collect information from the ward and the laboratory, deter-
mine whether an outbreak is occurring and establish a case definition. If the initial
investigation confirms that an outbreak is occurring, it is important to establish its
severity and initiate some immediate control measures. If, after the initial observation,
it is established that no outbreak exists, then it is important that the person who has
made the initial observation should be informed and the reason given. Ward staff
may need reassurance and care should be taken not to discourage further reporting.
Outbreak control: Preliminary control measures should be introduced as soon as

possible and be based on sound infection control practices such as patient isolation
and/or hand washing. Heightened surveillance should be introduced to assess the
32
Summary for investigation of an outbreak

• Begin preliminary evaluation and determine a background rate of
infection.
• Confirm the existence of an outbreak.
• Confirm the diagnosis using the microbiological methods.
• Create a case definition that may include laboratory and clinical data.
Start with a broad case definition that can be redefined at a later
date.
• Develop line listings by identifying and counting cases or exposures.
Describe the data in terms of time, place and person. Remember that
cases may have been discharged from the health care facilities.
• Construct an epidemic curve. This may indicate the source of the
outbreak (see Figs 4.2 and 4.3).
• Develop and test the hypothesis. In larger outbreaks, a case-control
method may be the most efficient way of testing a hypothesis: however,
if a single hospital ward is affected, a retrospective cohort study is
relatively easy.
• Take immediate control measures. Determine who is at risk of
becoming ill. Look at changes that may have affected the rate of
infection, e.g. new staff, new procedures, new laboratory tests, and
health care worker:patient ratio, etc.
• Communicate information to relevant personnel.
• Screen personnel and environment as indicated.
• Write a coherent report (preliminary and final).
• Summarize investigation and recommendations to the appropriate
authorities.
• Implement long term infection control measures for prevention of
similar outbreaks.
impact of all control measures. As soon as possible, information about the outbreak,
the investigation and the results should be conveyed to those at risk.
Outbreak control plan: Depending upon the nature of the infectious disease and
number of cases involved, the Outbreak Control Committee should be convened. The
membership of the committee varies depending upon the type of health care facilities.
33
Removal of source
No. of cases
Figure 4.2 Epidemic curve of a point
source outbreak. Number of cases peaks 1 2 3 4 5 6 7 8 9 10
and then disappears when a single source is Time (days)
identified and removed.
an index case
Admission of
No. of cases
Figure 4.3 Epidemic curve of a common

source outbreak. Figure illustrates an index
case and seven additional cases developing
infection after exposure to the index case.
The epidemic curve is relatively flat, spread 1 2 3 4 5 6 7 8 9 10 11 12
over days and has breaks compared to Time (days)
figure 4.1.
The aim of the Outbreak Control Committee is to:
• Facilitate the investigation of the outbreak.

• Implement measures necessary to control the outbreak.
• Monitor the effectiveness of the control measures.
• Oversee communication to all relevant groups.
• Facilitate the medical care of patients.
Communication: The Outbreak Control Committee will inform the senior manage-
ment of the hospital and other appropriate people on a regular basis. In an outbreak
situation, it is good practice to have one designated person within the health care
facility to respond to enquiries from the public, press and the media. That person
should be kept informed of all the developments by the chairperson of the Outbreak
Control Committee.
34
End of outbreak: At the end of an outbreak, the Outbreak Control Committee will
prepare a final report. When the outbreak has been controlled, a final meeting of the
Outbreak Control Committee should be held to:
• Review the experience of all participants involved in management of

outbreak.
• Identify any shortfalls and particular difficulties that were encountered.
• Revise the outbreak control plan in accordance with the results.
• Recommend, if necessary, structural or procedural improvements which
would reduce the chances of recurrence.
All outbreaks provide the opportunity to educate health care workers about infection
control matters. It is essential that all outbreaks, however minor, should be investi-
gated thoroughly and the outcomes of such investigations documented.
Look back investigations

Look back investigations refer to the process of identifying, tracing, recalling, coun-
selling and testing patients or health care workers who may have been exposed to an
infection. An example is the case of a health care worker who has undertaken
exposure-prone procedures on surgical patients and is later found to be positive for
a blood-borne virus, e.g. HIV, hepatitis B or C virus. A similar process may be needed
if a breakdown in the normal processes of cleaning and disinfection or sterilization
of instruments such as endoscopes is detected, allowing the potential for transfer of
infection from one patient to another.
All types of look back investigation have the potential to cause a great deal of
publicity. This can cause unnecessary anxiety in patients treated at the health care
facility who have not been exposed to infection, as well as anger and distress among
patients who were put at risk of infection. Look back investigations can take up a
great deal of time and resources and should not be undertaken lightly.
The hospital and the local health authority should be involved at the outset and a
planning team established with members who have expertise in infection control,
infectious disease, microbiology, the discipline involved, public relations, representa-
tives of the health authority; legal and indemnity issues should also be included. The
procedures to be undertaken and how these are presented to at-risk patients and the
public should be clearly worked out at the outset. These procedures should also
clearly set out protocols for tracing, counselling and referral of at-risk patients in a
timely manner. Test results should be available with minimal delay, and the planning
team should ensure that the project is completed and a final report produced as soon
as possible.
35

Association of Medical Microbiologists, Hospital Infection Society, Infection Control
Nurses Association and Public Health Laboratory Services. The Infection Control Standards
Working Party. Standards in Infection Control in Hospitals. London: HMSO, 1993.
Beck-Sague C, Jarvis W, Martone W. Outbreak investigations. Infection Control Hospital

Epidemiology 1997; 18: 138.
Coello R, Gastmeier P, de Boer AS. Surveillance of Hospital-Acquired Infection in

England, Germany and the Netherlands: Will International Comparison of Rates Be
Possible? Infection Control and Hospital Epidemiology 2001; 22: 393–397.
Crowe MJ, Cooke EM. Review of case definitions for nosocomial infection – towards a
consensus. Journal of Hospital Infection 1998; 39: 3–11.
Emmerson AM, Ayliffe GAJ. Surveillance of Nosocomial Infections. Clinical Infectious

Diseases 1996; 3(2): 159–301.
Emmerson AM, Enstone JE, Griffin M, et al. The Second National Prevalence Survey of
Infection in Hospitals – overview of the results. Journal of Hospital Infection 1996; 32:
175–190.
Garner JS, Jarvis WM, Emori TG, Horan TC, Hughes JM. CDC definitions for nosoco-
mial infections, 1988. American Journal of Infection Control 1988; 16: 128–140.
Gaynes RP, Emoir TG. Surveillance of Nosocomial Infections. In: Abrutyn E (ed).
Saunders Infection Control Reference Service, 2nd edn. Philadelphia: WB Saunders, 2001:
41–44.
Glenister HM, Taylor LJ, Cooke EM, Bartlett CLR. A Study of Surveillance Methods for
Detecting Hospital Infection. London: Public Health Laboratory Services, 1992.
Glenister HM, Taylor LJ, Bartlett CLR, et al. An evaluation of surveillance methods for
detecting infections in hospital inpatients. Journal of Hospital Infection 1993; 23: 229–242.
Glynn A, Ward V, Wilson J, et al. Hospital-Acquired Infection: Surveillance, Policies and

Practice. London: Public Health Laboratory Services, 1997.
Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control
programs in preventing nosocomial infection in US hospitals (SENIC study). American
Journal of Epidemiology 1985; 121(2): 182–205.
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and Infection Control, 2nd edn. Lippincott Williams & Wilkins 1999: 111–120.
Perl TM. Surveillance, reporting and the use of computers. In: Wenzel RP (ed). Prevention
and Control of Nosocomial Infections 3rd edn. Baltimore: Williams & Wilkins, 1997:
127–161.
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Control and Hospital Epidemiology 1997; 18: 513–527.
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Nosocomial Infection Rates for Interhospital Comparison: Limitations and Possible
Solutions. Infection Control and Hospital Epidemiology 1991; 12: 609–621.
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Nosocomial Infections Surveillance (NNIS) System Report, Data Summary from January
1992–June 2001. American Journal of Infection Control 2001; 29: 404–421.
37
5
Epidemiology and
Biostatistics
T his chapter provides basic information about the epidemiological principles and
statistical methods used in the practice of infection control surveillance, preven-
tion and control. It is intended to be a brief introduction, since a thorough discussion
of each of these concepts cannot be accomplished in one chapter. The reader who
wishes to obtain more information on these topics should refer to the References and
further reading list at the end of this chapter.
There are two major categories of epidemiological studies:
Experimental: In experimental studies, the investigator controls the exposures to

specific factors and then follows the subjects to determine the effect of the expos-
ure, e.g. a clinical trial of a new drug.
Observational: In observational studies, the group being compared is already defined

and the investigator merely observes what happens. These observations are used to
analyse outbreaks because the investigator is observing the outcomes to prior expos-
ures over which the investigator has no control.
Case-control, cross-sectional and cohort are types of observational studies that typ-
ically consider features of the past, present and future respectively, to try to identify
differences between the groups.
Cohort studies
Cohort studies are observational studies usually carried out over a number of years,
and designed to investigate the aetiology of diseases or outcomes. The aim of such
studies is to investigate the link between a hypothetical cause and a defined outcome.
Prior to undertaking a cohort study, investigators should seek statistical advice
regarding the number of subjects needed in each group.
Cohort studies originate with a hypothesis that the outcome (an infection or disease)
is caused by exposure to an event (risk factor). Subjects exposed to the suspected risk
39
factor (cases) and a similar group that have not been exposed (control) are identi-
fied. Often, a complete population sample (cohort) is followed prospectively over a
period of time (usually a number of years) to identify the incidence of the outcome
in both groups. These results are then analysed to determine if the group exposed
to the risk factor has a higher incidence of disease than those not exposed. Cohort
studies are usually prospective but they can be performed retrospectively if there is a
clearly documented point of first exposure.
A cohort study with a case-control design is often called a nested case-control study.
Disadvantages of cohort studies

• Time-consuming and costly (unless the outcome has a high incidence and
short latent period).
• Long studies inevitably increase the drop-out rates.
• Cohort studies are not useful investigations for rare diseases as large
numbers of subjects are required.
Advantages of cohort studies

• The prospective design of the ‘standard’ cohort study provides an oppor-
tunity for accurate data collection that is not normally available from
retrospective studies.
• The incidence, relative risk and attributable risk can be calculated from the
results.
• An estimate of the time from exposure to disease development is possible.
• Occasionally, cohort studies can be performed retrospectively and can thus
be cheaper and less time-consuming.
Case-control studies
Case-control studies are analytical epidemiological studies whose aim is to investi-
gate the association between disease and suspected causes and are usually cross-
sectional or retrospective in nature.
In case-control studies, people with an outcome (an infection or disease) are identified
and their medical and social history examined retrospectively in an attempt to identify
exposure to potential risk factors. A matched control group free from the disease or
infection are also identified and data collected from them in an identical fashion. The
two sets of data are compared to determine whether the disease group was exposed in
significantly higher numbers to the suspected risk factors than the control group.
A case-control study must contain a sufficiently large number of study subjects in order
to be able to detect an association, if one exists, between an exposure and a disease.
40
Epidemiology and Biostatistics
As the number of study subjects increases, the power to detect a statistically significant
association increases.
When designing a case-control study it is important to tightly define what constitutes

a ‘case’. However, in the initial stages of an outbreak, a case definition may be broad
in order to identify all potential cases. The case definition may be refined as the
investigation progresses and potential risk factors are identified. If the number of
cases is small, it is possible to include all of them in a case-control study. In a large
outbreak, however, it may not be practical, or possible, to identify and include all of
the cases. In this instance, cases are selected from those who are ill. Care must be
taken to ensure that the cases selected are representative of the entire population with
disease so that the study findings can be extrapolated to the whole population.
Controls must come from the same environment where the cases’ exposures occurred,
i.e. they must be from the same population at risk for exposure and must be at the
same risk of acquiring the disease. Controls should be similar to the cases in many
respects except for the presence of the disease being studied. Ideally, controls should
be randomly selected from the population at risk to avoid selection bias.
Disadvantages of case-control study

• It is not possible to calculate the true incidence and relative risk. The results
should be expressed as odds ratios.
• The study design inevitably means that data are collected retrospectively
and hence the information may not be available or may be of poor quality.
Advantages of case-control study

• These studies are relatively quick and cheap to perform.
• Case-control studies are useful for investigating rare diseases.
• Case-control studies can be used to evaluate interventions.
Case-control or cohort studies can be used in outbreak investigations to compare rates
of infection in various populations in order to determine which exposures or risk
factors are most likely responsible for the infection. A case-control study differs from
a cohort study in that the subjects are enrolled into a case-control study based on
whether or not they have a disease. In a cohort study, subjects are included in the study
based on their exposure and are then followed for the development of disease. Case-
control study is the method most commonly used to investigate outbreaks because it
is relatively inexpensive to conduct, is usually of short duration and requires relatively
few study subjects.
Cross-sectional (prevalence) surveys

Cross-sectional studies are descriptive studies in which a sample population’s status
is determined for the presence or absence of exposure and disease at the same time.
41
These surveys take a ‘snapshot’ of the population and thus detect the presence of
disease at a point in time (prevalence) as opposed to the frequency of onset of the
disease (incidence).
Measures of disease frequency

Rates
Rates describe the frequency with which events occur. In other words, a rate measures
the occurrence of an event in a defined population over time. Rates are used to track
trends, such as the occurrence of nosocomial infections over time. The rates most
frequently used are incidence, prevalence, and attack rates. When an increase in a
disease or other health-related event is suspected, rates can be calculated and used to
determine if there is a change in the occurrence of disease from one period of time
to the next.
Basic formula for all types of rates
Numerator
Rate ! " Constant (k)
Denominator
where k ! 100 for discharges and 1,000 for device-days (e.g. IV lines).
Incidence rates
Incidence rates are used to measure and compare the frequency of new cases or
events in a population.
Number of new cases that occur in

a defined period
Incidence rate ! "k
Population at risk during the same period
Prevalence rate
Prevalence is a measure of the number of active (new and old) cases in a specified
population either during a given period of time (period prevalence) or at a given
point in time (point prevalence). A prevalence rate is used to describe the current
status of active disease at a particular time in a particular population. It is sometimes
helpful to review the incidence and prevalence simultaneously.
Number of all (new and existing) cases

of a disease at specified period or point in time
Prevalence rate ! "k
Population at risk during the same time period
42
Attack rate
Attack rate is another type of incidence rate that is expressed as cases per 100 popu-
lation (or as a percentage). It is used to describe the new and recurrent cases of
disease that have been observed in a particular group during a limited time period in
special circumstances, such as during an epidemic.
Number of new and recurrent cases that occur

in a population in a specified time period
Attack rate ! " 100
Population at risk for same time period
Measures of association
Measures of association are used during outbreak investigations to evaluate the
relationship between exposed and unexposed populations. These statistical measures
can express the strength of association between a risk factor (exposure) and an out-
come (disease).
Risks
Risk represents chance; usually the chance of an unwanted event. There are several
ways to express risk, such as the relative risk, the odds ratio, the relative risk reduction
or the absolute risk reduction. The measures of association used for outbreak investi-
gations are the risk ratio (or relative risk) and the odds ratio.
Risk ratio
The risk ratio is the ratio of the attack rate (or risk of disease) in the exposed
population to the attack rate (or risk of disease) in the unexposed population. If the
value of the risk ratio (relative risk) is equal to 1, the risk is the same in the two
groups and there is no evidence of association between the exposure and outcome. If
the risk ratio is greater than 1, the risk is higher for the exposed group and exposure
may be associated with the outcome. If the risk ratio is less than 1, the risk is lower
for the exposed group and the exposure may possibly protect against the outcome.
Relative risk, absolute risk and individual risk

Relative risk provides an estimate of the chances of an exposed individual to develop
an illness, complication or response to therapy in comparison with a non-exposed
individual.
The absolute risk is the risk in the exposed and the non-exposed group as a whole and
the individual risk computes the risk according to the levels of exposure. However,
one should remember that these chances have been calculated from observations on
large groups of patients and the result of the group as a whole may not automatically
apply to the patient that is presently sitting in front of you.
43
Table 5.1 The two-by-two contingency table.

Disease No disease
a b
Exposed number of individuals number of individuals a#b
with exposure and disease with exposure and no
disease
c d
Unexposed number of individuals number of individuals c#d
with no exposure and with no exposure and
disease no disease
Total a#c b#d N
a # b: total number with exposure

a # c: total number with disease
b # d: total number with no disease
c # d: total number with no exposure
N ! a # b # c # d ! total population in the study.
⎛ a /(a + b ) ⎞ (risk of disease in exposed compared

Risk ratio (relative risk) ! ⎜ ⎟
⎝ a /(c + d ) ⎠ to that in unexposed)
Incidence rate among exposed

Relative risk =
Incidence rate among unexposed
Odds ratio
The odds ratio is similar to the risk ratio except that the odds, instead of the risk
(attack rates), are used in the calculation. It is the ratio of the probability of having a
risk factor if the disease is present to the probability of having the risk factor if the
disease is absent. If the odds ratio is equal to 1, the odds of disease are the same if the
exposure is present (i.e. there is no evidence of association between the exposure and
disease). If the odds ratio is greater than 1, the odds of disease are higher for the
exposed group and the exposure is probably associated with the disease.
Number of diseased persons exposed (a) " number

without disease and not exposed (d)
Odds ratio !
Number of well persons exposed (b) " number
with disease but not exposed (c)
Bias and confounders

Bias
Bias refers to errors in study design and execution, and to interpretation and imple-
mentation of its results, which systematically influence the eventual outcome for the
44
patient. Bias occurs in both quantitative and qualitative research and it can occur at
any stage from conception of a study through to marketing and implementation of
its results. Bias can be deliberate or unintentional.
The perfect study is one that is both accurate and precise without bias. An accurate study
may be imprecise but not biased. A biased study can be precise but still be inaccurate.
The following are the most common and important biases occur in the study design:
Selection bias can occur when the cases selected for study do not represent the
entire population at risk. This can occur if a non-random method is used to select
study subjects (e.g. the selection is unconsciously or consciously influenced in some
way) or if some of the study subjects are unavailable (e.g. they refuse to participate,
their records are missing, their disease is mild and they do not seek medical care and
are therefore not detected, and their disease is undiagnosed or misdiagnosed).
Information bias can occur if the information collected is incorrect because of

inaccurate recall or because it is inconsistently collected (observer bias). Observer bias
occurs when collection or interpretation of data about exposures is systematically
different for persons who have the disease than those who do not or when data about
outcomes are systematically different for persons who are exposed than for persons
who are not exposed.
Bias can result from misuse of statistical tests. The most common types of bias are:
1. Using the wrong test for the data.

2. Inferring that there is no difference between treatments when the study is
underpowered.
3. Multiple testing.
Confounders
Confounders are factors extraneous to the research question that are determinants
of the outcome of the study. If they are unevenly distributed between the groups they
can influence the outcome. A confounder need not be causal; it might be just a correl-
ate of a causal factor. For example, age is associated with a host of disease processes
but it is only a marker for underlying biological processes that are causally responsible
for these diseases. Similarly, the water pump disconnected by John Snow in Limehouse
was not the cause of the cholera, just the conduit that delivered the causal agent.
Procedures for dealing with confounders prior to a study include exclusion, stratified
sampling, pairwise matching and randomization. After a study, corrections can be
made by using standardization techniques, stratified analysis or multivariate analysis.
Prior randomization, whenever possible, is the preferred method of eliminating the
effect of confounders.
45
BIOSTATISTICS
It is important that those responsible for implementing infection control and
quality management programmes are familiar with the statistical measures. Basic stat-
istical methods can be used to organize, summarize and analyze data to determine if
there are trends or associations in observations.
Numerous computer database and statistical programmes are available and these
have virtually eliminated the need to calculate complicated mathematical formulas
by hand or by using a hand held calculator. However, the investigator still needs to
understand which statistical methods to use and when to use them. There are several
computer software programmes that can be used to store, manage, and analyse
epidemiological data. Epi Info is a software programme that was developed by the
Centers for Disease Control and Prevention (CDC) to manage and analyse data col-
lected during an epidemiological investigation and can be downloaded from the
CDC web site www.cdc.gov free of cost.
Measures of central tendency

A set of data, which comprises a number of individual results for a particular
single variable is said to make up a distribution in the group as a whole. Measures of
central tendency describe the values around the middle of a set of data. The mean,
median, and mode are the principal measures of central tendency.
Mean: Mean is an arithmetic average of a group of numbers. The value of the mean
is affected by extreme values in the data set. When extreme values appear in a data
set, the distribution of the data becomes skewed and the mean does not give a
representative picture of the data.
Median: The median is the middle number or point in an ordered group of numbers –
the value at which half of the measurements lie below the value and half above the
value. The median is useful when there are extreme values in a data set, i.e. the data are
skewed.
Mode: The mode is the most frequently occurring value in a set of observations.
Mode is not often used as a measure of central tendency, particularly in small data
sets.
In a normal (symmetric) distribution, the mean, median, and mode have the same
values (Fig. 5.1). A curve of a histogram that is not symmetrical is referred to as
skewed or asymmetrical. A curve that is said to be negatively skewed (Fig. 5.2) has a
tail off to the left and most of the values are above the mean. The mean is less than
the median, which is less than the mode. In contrast, a positively skewed (Fig. 5.3)
curve value would depict a mirror image of this and the mean will be greater than
the median, which will be greater than the mode.
46
Mode
Median
Mean
Figure 5.1 Symmetric distribution.
Mode
Median
Mean
Figure 5.2 Negatively skewed distribution.
Mode
Median
Mean
Figure 5.3 Positively skewed distribution.
47
Measures of dispersion
Measures of dispersion describe the distribution of values in a data set around the
mean. The most commonly used measures of dispersion are range, deviation, vari-
ance and standard deviation.
The difference between the highest and lowest values in a data set is termed the
range. The deviation is the difference between an individual measurement in a data
set and the mean value for the set. A measurement may have no deviation (equal to
the mean), or a positive deviation (greater than the mean). The variance measures
the deviation around the mean of a distribution. The standard deviation, which
may be represented as s or SD, is a measure of dispersion that reflects the distribu-
tion of values around the mean. A normal distribution represents the natural dis-
tribution of values around the mean with progressively fewer observations toward
the extremes of the range of values. A normal distribution plotted on a graph shows
a bell-shaped curve, in which 68.3% of the values fall within one standard deviation
of the mean, 95.5% of the values fall within two standard deviation of the mean,
and 99.7% of the values fall within three standard deviations of the mean (Fig. 5.4).
68.3% of data
95.5% of data
99.7% of data
$3 SD $2 SD $1 SD Mean #1SD #2SD #3SD
Figure 5.4 A normal distribution showing the area under the curve that lies
between 1, 2 and 3 standard deviations on either side of mean.
48
Hypothesis testing
The traditional method of determining whether one set of data are different from
another is hypothesis testing. By convention, the investigator will usually assume the
null hypothesis, which predicts that the two sets of data are from the same popula-
tion and therefore not different. The probability that the null hypothesis is correct is
then determined. This probability is referred to as the P value. A P value of 0.10 tells
us that there is a 0.10 probability or 10% chance that the null hypothesis (that there
is no difference) is correct. An arbitrary cut-off of 0.05 or 5% has been chosen to
indicate that the null hypothesis can be reasonably rejected. If the P value falls below
this level, the observed difference is regarded as a true difference or a statistically
significant difference. Of course there is a 5% chance that this inference is incorrect.
Error of hypothesis testing

An investigator’s inference about an association can be wrong if the findings are due
to bias or confounding in the study or to chance alone.
Type I (alpha) error: A type I (alpha) error occurs when an investigator states that
there is an association when in fact there is no association, i.e. the investigator rejects
a true null hypothesis.
Type II (beta) error: A type II (beta) error occurs when the investigator states that
there is no association when in fact there is an association, i.e. the investigator fails to
reject a null hypothesis that is actually false.
Although these errors are not always avoidable, the likelihood of making a type II
error can be minimized by using a larger sample size. By choosing the statistical
cut-off level, the investigator decides before beginning the study what probability of
committing a type I error can be accepted (usually 5%).
Test of statistical significance

Z score
Z score is the simplest example of the statistical test which gives the deviation from
the mean value expressed in standard deviation units. The Z score (or critical ratio)
is the number of standard deviations that a value in a normally distributed popula-
tion lies away from the mean. Thus, in a normally distributed population, 95% of the
population lie within 1.96 Z scores of the mean.
Chi-square test
The chi-square test is commonly used in outbreak investigations to evaluate the
probability that observed differences between two populations, such as cases and
controls, could have occurred by chance alone if an exposure is not truly associated
49
with disease. It is calculated by using two-by-two contingency tables (table 5.1).

Because it takes a lot of patience to calculate chi-squares by hand, most investigators
opt to use a computer with a statistical software package. The chi-square test can be
used if the number of subjects in a study is approximately 30 or more. For smaller
populations, or if the value of any of the cells in a two-by-two table is less than 5, the
Fisher exact test should be used.
Fisher exact test

The Fisher exact test is used, for evaluating two-by-two contingency tables, is a vari-
ant of the chi-square test. The Fisher exact test is the preferred test for studies with
few subjects. The formula for the Fisher exact test calculates the P value directly, so a
table of chi-squares is not needed. However, in order to calculate the P value for the
study, one must calculate the P value for the observations in the study and then add
this P value to the P values of all possible combinations that have lower P values. This
calculation should be done with the aid of a computer.
The P value
In the results of most research reports and scientific articles the P value seems to play
a pivotal role. A P value less or greater than 0.05 conventionally indicates whether the
findings are statistically, ‘significant’ or ‘not significant’ respectively.
This level of P value certainly means that there is statistical significance but does not
necessarily mean that the results are clinically significant. Sometimes, a statistically
significant difference may be clinically irrelevant.
Pitfalls of the P value

As has been mentioned earlier, the absence of a P value of 0.05 does not mean that
there is no difference between the groups. The P value does not convey any informa-
tion about the magnitude of differences between groups. Furthermore, the P value is
equally influenced by the precision of the study results. Hence, a small (but consistent)
difference may be highly statistically significant and a very large difference may lack
statistical significance due to a variability of the test result. The P value can only be
considered as an instrument to express the statistical certainty of a detected difference.
Alternatives to the use of the P value

Many researchers and biomedical journals prefer the use of 95% confidence intervals
(CI) to the use of the P value. Briefly, a 95% CI reflects the range of differentiation that
may be encountered in 95% of the cases if the experiment were repeated endlessly.
Confidence Intervals (CI)

Confidence intervals are estimates of where ‘true’ answers are most likely found.
Whereas P values denote statistical significance, CI indicate clinical significance.
50
The CI (sometimes referred to as the margin of error) of a study with a stated prob-
ability (usually 95%) indicates that the true value of a variable, such as the mean,
proportion, or rate, falls within the interval. In other words, a person using a 95% CI
can be confident that if a study were repeated many times, the observed value would
fall within the CI in 95 out of a 100 studies. Unlike the P value, which provides infor-
mation on statistical significance only, the CI expresses the statistical precision of a
point estimate and the strength of an association. The statistical precision is measured
by the size (range) of the CI: the narrower the computed interval, the more precise the
estimate. The strength of the association is measured by the magnitude of the differ-
ence in the measured outcomes between the two groups, e.g. the higher the numerical
value of the risk ratio, the more likely the exposure is related to the outcome.
Confidence intervals provide an alternative to hypothesis testing when ratios of risk

or rates are being compared. A 95% CI provides information on whether or not an
observation is statistically significant with a P value less than or equal to 0.05. As noted
previously, an odds (or risk) ratio of 1.0 means that the odds (or risk) of disease are
the same between the comparison groups whether or not the exposure occurs. If the
value of a risk ratio is greater than one, the risk of disease in the exposed population
is greater than the risk of disease in the unexposed population. If a ratio of 95% CI
does not include 1.0, then statistical significance is implied (P % 0.05). If the CI for an
odds or risk ratio includes 1.0, then the findings are not statistically significant.
For example, if the odds ratio (the point estimate) for an exposure is said to be 8.1
with a 95% CI of 6.3–10.7, this means:
• persons with the disease were 8.1 times more likely to have been exposed to
the risk factor than those without the disease, and
• one can be 95% confident (probability of 0.95) that the odds ratio in the
population is between the confidence limits of 6.3 and 10.7 (i.e. it may be
as low as 6.3 or as high as 10.7).
Although P values alone have traditionally been used to show the statistically signifi-
cance between disease and risk factors in outbreaks, odds ratios/risk ratios and 95%
CI are now frequently reported.
The calculation of CI depends on a representative sample from a normally distributed

population. The width of the interval is determined by the degree of confidence desired
(i.e. 90%, 95% or 99%), the variability of the data (standard error) and the number of
observations (n). Larger numbers of observations result in narrower intervals.
Sensitivity and specificity

Sensitivity and specificity are terms that provide information about the accuracy of
a diagnostic test. A diagnostic test is usually performed to establish the presence or
51
absence of a disease. However, diagnostic tests are rarely 100% accurate and may give
false-positive (i.e. the test indicates there is a disease, while this is in fact not true) or
false-negative (i.e. the test falsely overlooks the presence of the disease) results.
The sensitivity of a test reflects the proportion of patients with the disease that have
a positive test result, from the total number of patients with the disease. The speci-
ficity of a test reflects the proportion of healthy patients that have a negative test
result, from the total number of patients that do not have the disease.
Test result Disease present Disease absent
Positive True-positive (TP) False-positive (FP)

Negative False-negative (FN) True-negative (TN)
Sensitivity ! Percentage of cases with the disease who are detected by the test.
TP
× 100%
TP + FN
Specificity ! Percentage of people without the disease who were correctly labelled by
the test as not diseased.
TN
× 100%
TN + FP
Positive predictive value ! Percentage of all test-positives who are truly positive
(e.g. diseased).
TP
× 100%
TP + FP
Negative predictive value ! Percentage of all test-negatives who are truly negative
(e.g. not diseased).
TN
× 100%
TN + FN

Abramson JH. Making sense of data: A self-instruction manual on the interpretation of
epidemiology data, 2nd edn. New York: Oxford University Press, 1994.
Birnbaum D, Sheps S. The merits of confidence intervals relative to hypothesis testing.

Infection Control and Hospital Epidemiology 1992; 13: 553–555.
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Centers for Disease Control and Prevention. Principles of Epidemiology: An Introduction

to Applied Epidemiology and Biostatistics, 2nd edn. Atlanta, GA: US Dept of Health and
Human Services, 1992.
Campbell MJ, Machin D. Medical Statistics: A Common Sense Approach. Chichester: John
Wiley & Sons, 1990.
Edmiston CE, Josephson A, Pottinger J, et al. The numbers game: sample-size determin-
ation. American Journal of Infection Control 1993; 21: 151–154.
Freeman J, Hitchison GB. Prevalence, incidence and duration. American Journal of

Epidemiology 1980; 112: 707–723.
Freeman J. Modern quantitative epidemiology in the hospital. In: Mayhall CG (ed.),

Hospital Epidemiology and Infection Control, 2nd edn. Philadelphia: Lippincott Williams
& Wilkins, 1999: 15–48.
Gaddis ML, Gaddis CM. Introduction to biostatistics: part 1, basic concepts. Annals of
Emergency Medicine 1990; 19: 86–89.
Gaddis ML, Gaddis GM. Introduction to biostatistics: part 2, Annals of Emergency

Medicine 1990; 19: 309–315.
Gaddis ML, Gaddis GM. Introduction to biostatistics: part 3, Sensitivity, specificity,

predictive value, and hypothesis testing. Annals of Emergency Medicine 1990; 19: 591–596.
Gaddis ML, Gaddis GM. Introduction to biostatistics: part 4, statistical inference

techniques in hypothesis testing. Annals of Emergency Medicine 1990; 19: 820–825.
Gaddis ML, Gaddis GM. Introduction to biostatistics: part 5, statistical inference techniques
for hypothesis testing with nonparametric data. Annals of Emergency Medicine 1990; 19:
1054–1059.
Gaddis ML, Gaddis GM. Introduction to biostatistics: part 6, correlation and regression.
Annals of Emergency Medicine 1990; 19: 1462–1468.
Gardner MJ, Aftman DG. Confidence intervals rather than P values: estimation rather
than hypothesis testing. British Medical Journal 1986; 292: 746–750.
Giesecke J. Modern Infectious Disease Epidemiology, 2nd edn. London: Arnold, 2002.
Jackson MM, Tweeten SM. General principle of epidemiology. In: APIC Infection
Control and Applied Epidemiology: Principles and Practice. St Louis: Mosby, 2000:
17.1–17.17.
Morris JA, Gardner MJ. Calculating confidence intervals for relative risks (odds ratios)
and standardized ratios and rates. British Medical Journal 1988; 296: 1313–1316.
Mufloz A, Townsend T. Design and analytical issues in studies of infectious diseases. In:
Wenzel RP, Prevention and Control of Nosocomial Infections. Baltimore: Williams &
Wilkins, 1997: 215–230.
53
Ning L. Statistics in infection control studies. In: Wenzel RP. Prevention and Control of
Nosocomial Infections. Baltimore: Williams & Wilkins, 1997: 231–240.
Phillips DY, Arias KM. Statistical methods used in outbreak investigation. In: Arias KM.
Quick reference to outbreak investigation and control in Health care facilities. Gaithersbrug,
Maryland: Aspen Publication; 2000: 191–209.
Riegelman RK, Hirsch RP. Studying a Study and Testing a Test: How to Read the Health
Science Literature, 3rd edn. Philadelphia: Lippincott Raven, 1996.
Rowntree D. Statistics without tears: A primer for non-mathematicians. London: Penguin

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(ed.), Hospital Epidemiology and Infection Control, 2nd edn. Philadelphia: Lippincott
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control studies. I. Principles. American Journal of Epidemiology 1992; 135: 1019–1028.
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1042–1050.
54
6
Disinfection and
Sterilization
M edical and surgical devices may serve as vehicles for the transmission of
infectious diseases to susceptible hosts. Therefore it is important that all health
care facilities should have a comprehensive disinfection policy. The aim of a disin-
fection policy is to make items and equipment safe for patients’ use by effectively
removing microorganisms by cleaning, disinfection and sterilization.
Methods of decontamination
The choice of method of disinfection or sterilization depends mainly on the type of
material to be disinfected, the level of decontamination required for the procedure
and the microorganisms involved. It is important to have a clear understanding of
the terms and classification used in this context.
Cleaning: Cleaning of instruments before decontamination is an essential procedure.

This allows the physical removal of microorganisms which prevents inactivation of
the disinfectant by organic matter and allows complete surface contact during further
decontamination procedures. Therefore thorough cleaning of items is a prerequisite
before disinfection and sterilization is commenced.
Cleaning should be carried out by trained staff in the sterile supply department
(SSD). Machine washing is the preferred option, however some instruments may
require washing by hand. Staff performing these procedures must be trained in safe
systems of work and wear appropriate protective equipments. During cleaning, care
should be taken not to produce splashes, high pressure sprays or aerosols.
Disinfection by either heat or chemicals will destroy microorganisms but not

bacterial spores. Chemical disinfection does not necessarily kill all microorganisms
present but reduces them to a level not harmful to health. Chemical disinfection
should only be used if heat treatment is impractical or may cause damage to the
equipment. Chemical disinfectants are classified as chemical ‘sterilant’ which are
55
used to disinfect heat-sensitive items if they can kill bacterial spores (which normally
require prolonged exposure time); this process may be more accurately described as
high-level disinfection.
The outcome of a disinfection procedure is affected by the presence of organic load

(bioburden) on the item, type and level of microbial contaminant, prior cleaning of
the object, disinfection concentration and exposure time, physical structure of the
object and temperature and pH of the disinfection process.
Besides effective cleaning of items or equipments, the concentration and contact time
are critical factors that determine the effectiveness of disinfection process.
Antiseptics: Chemicals used to kill microorganisms on skin or living tissue are

known as antiseptics; disinfectants are used on inanimate objects only. Two factors
must be evaluated in determining the effectiveness of antiseptics, i.e. the agents must
have effective antimicrobial activity and must not be toxic to living tissues.
Sterilization is a process which achieves the complete destruction or removal of all

microorganisms, including bacterial spores. Equipment and materials used in proced-
ures involving a break in the skin or mucous membranes should be sterilized, e.g.
surgical instruments and products intended for parenteral use or for instillation into
sterile body cavities. In many procedures, high temperatures are used to achieve
sterilization.
Dry heat sterilization: Dry heat sterilization requires higher temperatures for much
longer exposure periods to kill all microorganisms. Exposure in an oven for 2 h at 170°C
(328°F) is generally used for the dry heat sterilization of glassware and other items.
Moist heat sterilization: Moist heat is far more penetrating than dry heat and, hence,
more effective for killing microorganisms. Steam under pressure is frequently used in
sterilization procedures which can be achieved in an autoclave or sterilizer. A ster-
ilizer is basically a chamber (see Fig. 6.1) that can withstand pressures of greater than
two atmospheres. The materials to be sterilized are placed in a chamber, and the
chamber is sealed. Steam is then transferred from a jacket into the chamber, forcing
out all of the air to create a vacuum. The steam is held in the chamber for the neces-
sary time and then vented from the chamber. Sterilizers have pressure gauges and
thermometers that monitor the sterilization process. In addition to these, sterilizers
are also monitored using chemical and biological indicators. The cycles most
frequently used for sterilization are 134–138°C for 3 min, 121–124°C for 15 min or
115°C for 30 min.
If sterilization is not carried out in the hospital SSD then it is vital that sterilization
procedures outside a central processing department promote the same level
of safety and efficiency. Requirements include routine biological, mechanical and
chemical monitoring to ensure that all parameters of sterilization are met before
using the instrument on patients.
56
Disinfection and Sterilization
Safety valves
Pressure gauge
Manual operating
valves
Door handles
Steam
Chamber
Baffle
Jacket
Thermometer
Pressure regulator
Steam
supply
Thermostatic traps
Figure 6.1 Diagram of a Sterilizer or an Autoclave showing basic features.

Reproduced from Atlas RM: Microorganisms in our world, St Louis Mosby, 1995.
Risks of infection from equipment

Spaulding outlined three categories of risks (‘critical’, ‘semi-critical’, and ‘non-
critical’) from medical and surgical instruments based on the potential for the
instrument to transmit infection if it is microbiologically contaminated before use.
In 1991, Centers for Disease Control and Prevention (CDC) proposed an additional
category designated ‘environmental surfaces’ to Spaulding’s original classification.
These are non-critical surfaces that generally do not come into direct contact with
patients during care.
Critical or high risk items: Critical items are those that come into close contact with
a break in the skin or mucous membrane or are introduced into a sterile body area.
Items in this category should be sterilized by heat if possible. Heat-labile items may
be treated with low-temperature steam and formaldehyde, ethylene oxide, or by
irradiation. Liquid chemical sterilant should be used only if other methods are
unsuitable.
Semi-critical or intermediate risk items: Semi-critical items are those that come into
close contact with intact mucous membranes, or body fluids or are contaminated
with particularly virulent or readily transmissible microorganisms or are to be used
57
on highly susceptible patients or sites. In certain circumstances it may be preferable

to transfer the items to the ‘High Risk’ category. Disinfection by heat is preferred
where this is possible.
Non-critical or low risk items: Non-critical items are those that come into contact
with normal and intact skin. Cleaning and drying of these items is usually adequate.
Minimal risk: Minimal risk items do not come into close contact with the patient
or their immediate surroundings. Items in this category are either unlikely to be
contaminated with significant numbers of potential pathogens, or transfer to a
susceptible site on the patient is unlikely, e.g. bed-frames, lockers, flower vases, walls,
floors, ceilings, sinks and drains. Cleaning and drying of these items is adequate.
Chemical disinfectants
Various chemical agents are used to disinfect items or equipment in a health care
setting. Ideally, a disinfectant should have high germicidal activity. They should
rapidly kill a wide range of microorganisms, including spores. The agent should be
chemically stable and effective in the presence of organic compounds and metals.
The ability to penetrate into crevices is desirable. It is essential that a disinfectant
should not destroy the materials to which it is applied. Furthermore, it should be
inexpensive and aesthetically acceptable.
Microorganisms vary in their sensitivity to particular antimicrobial agents. Generally,

growing microorganisms are more sensitive than microorganisms in dormant stages,
such as spores. Similarly, viruses are more resistant than other microorganisms to
antimicrobial agents because they are metabolically dormant outside host cells.
Chemical disinfectants are hazardous substances and may cause damage on contact
with skin, eyes or mucous membranes, by inhalation of vapours or by absorption
through the skin. Some individuals may be allergic to disinfectants, or more sensitive to
them than other people. This may take the form of skin rashes, contact dermatitis or,
in rare cases, difficulty in breathing. Therefore it is important that relevant safety
precautions are observed when using chemical disinfectants. Concentrated disinfectants
should always be stored and handled with care and appropriate protective equipment
must be worn. For certain chemical disinfectants (e.g. glutaraldehyde) proper ventila-
tion is required.
The following points should be kept in mind when using chemical disinfectants:
• The efficacy of chemical disinfection is often uncertain and, wherever

possible, disinfection by heat is preferable to chemical methods.
• All chemical disinfectants must be clearly labelled and used within
the expiry date. They should be freshly prepared. They must be used at the
correct concentration and stored in an appropriate container. Chemical
58
disinfectant solutions must not be mixed or detergents added unless they

are compatible.
• Disinfectant or detergent solutions must not be prepared and stored in
multi-use containers for occasional use. Solutions prepared and stored in
this manner may easily become contaminated with microorganisms; using
such solutions will therefore readily contaminate a surface rather than
clean it.
• Disinfectants can be corrosive and may damage fabrics, metals and plastics.
Manufacturer’s instructions must be consulted on compatibility of materials
with the method of sterilization or disinfection.
Chemical disinfectants and antiseptics

Alcohol
Alcohol does not penetrate well into organic (especially protein-based) matter, and
should therefore be used only on physically clean surfaces.
Uses: Alcohol impregnated wipes are used for disinfection of skin prior to injection.
It can be used as a base for other antiseptics, e.g. chlorhexidine and iodine for pre-
operative skin disinfection. Alcohol may be used for disinfecting physically clean
equipment or hard surfaces as specified in the local disinfection policy.
Precautions: Alcohol should be stored in a cool place. Alcohol-alcohol mixtures are

flammable. Do not allow contact with hot surfaces, flames, electrical equipment or
other sources of ignition. If an alcohol preparation is used to disinfect pre-operative
skin, caution must be exercised whilst using diathermy as it may ignite, causing skin
burns if incorrectly used. Therefore all spirit-based skin cleaning and preparation
fluids must have a cautionary statement, e.g. ‘This preparation contains spirit. When
use is to be followed by surgical diathermy, do not allow pooling of the fluid to occur
and ensure that the skin and surrounding areas are dry’.
Do not leave bottles uncapped as alcohol vapours irritate mucous membranes, espe-
cially in an enclosed space. It may cause eye and skin irritation if used in a large
quantity in an enclosed space, therefore its use should be avoided in a poorly venti-
lated area. If inhaled in large quantities, it may cause headache and drowsiness.
Chlorine-based disinfectants
Hypochlorites are the most widely used of the chlorine disinfectants. They are
available as a liquid (sodium hypochlorite), or as a solid (calcium hypochlorite or
sodium dichloroisocyanurate [NaDCC]). NaDCC tablets are stable and the antimi-
crobial activity of a solution prepared from NaDCC tablets may be greater than that
of sodium hypochlorite solutions containing the same total available chlorine.
Aqueous solutions of sodium hypochlorite are widely used as household bleach.
59
Table 6.1 Uses of hypochlorite and strengths of solution.

Uses Dilutions Available chlorine
(%) (ppm)
Blood spills 1:10 1.0 10,000

Laboratory discard jars 1:40 0.25 2,500
General environmental 1:100 0.1 1,000
disinfection
Disinfection of clean 1:200 0.05 500
instruments
Infant feeding utensils, catering 1:800 0.0125 125
surfaces and equipment
Reproduced with permission from Ayliffe GAJ, Coates D, Hoffman PN. Chemical Disinfection in Hospitals,
2nd edn. London: Public Health Laboratory Service, 1993.
Hypochlorites are fast acting, have a broad spectrum of antimicrobial activity, do not
leave toxic residues and are not affected by water hardness. They are inactivated by
organic matter, particularly if used in low concentrations. They are incompatible
with cationic detergents. Diluted solutions are unstable and should be freshly
prepared daily. In addition, decomposition is accelerated by light, heat and heavy
metal. Chlorinated disinfectants are corrosive to metal, damaged plastic, rubber and
similar components on prolonged contact, or if used at an incorrect concentration.
They also bleach fabrics, carpets or soft furnishings.
Uses: Hypochlorite is very active against viruses and is the disinfectant of choice for
environmental decontamination following blood spillage from a patient with known
or suspected blood-borne viral infection. It is also incorporated into some non-
abrasive cleansing agents which may be used for environmental disinfection on hard
surfaces such as baths or sinks. It is used in water treatment and in food preparation
areas and milk kitchen. Other uses in hospital and the recommended in-use concen-
trations are shown in Table 6.1.
Precautions: Chlorinated disinfectants can cause irritation of the skin, eyes and lungs
if used frequently in a poorly ventilated area. They should not be used in the presence
of formaldehyde as some of the reaction products are carcinogenic. Appropriate pro-
tective equipment must be worn when hypochlorite is handled, whether in liquid or
powdered/granulated form. Skin and eyes should be protected when using undiluted
hypochlorite solutions. Sodium hypochlorite should not be mixed with ammonia or
acid or acidic body fluids (e.g. urine), as toxic chlorine gas will be released.
Phenolics
Phenol (carbolic acid) is probably the oldest recognized disinfectant. Its use as a
germicide in operating rooms was introduced by Joseph Lister in 1867. Phenol and
its chemical derivatives (phenolics) disrupt plasma membranes, inactive enzymes,
and denature proteins, thereby exerting antimicrobial activities. They are usually
60
LEVEL OF
MICROORGANISMS EXAMPLES
DISINFECTION
PRIONS Agents for Creutzfeld-Jakob disease. PRION

REPROCESSING
Bacillus subtilis, Clostridium

BACTERIAL SPORES STERILIZATION
sporogenes, Clostridium difficile, etc.
COCCIDIA Cryptosporidium
MYCOBACTERIA Mycobacterium tuberculosis HIGH LEVEL

DISINFECTION
NONLIPID OR Poliovirus, Coxsackie virus, INTERMEDIATE

SMALL VIRUSES Rhinovirus, etc. LEVEL DISINFECTION
Trichophyton spp., Cryptococcus spp.,

FUNGI
Candida spp., etc.
VEGETATIVE Pseudomonas aeruginosa, E. coli, Staph. LOW LEVEL

BACTERIA aureus, Salmonella spp., Neisseria DISINFECTION
meningitidis, Enterococci, etc.
Herpes simplex, Cytomegalovirus,

LIPID OR
Respiratory syncytial, Hepatitis B,
MEDIUM-SIZED
Human Immunodeficiency Virus (HIV), etc.
VIRUSES
Figure 6.2 Descending order of resistance to germicidal activity of chemical disin-

fectants against various microorganisms.
Reproduced with modification from Block SS: Disinfection, Sterilization and Preservation, 4th edn.
Philadelphia, Lea & Febiger, 1991.
supplied in combination with a detergent to aid the cleaning process. They also retain
their activity in the presence of organic material. They are incompatible with cationic
detergents and absorbed by rubber and plastics. Cresols, which are phenolic deriva-
tives of coal tars, are good disinfectants. The active ingredient in Lysol, a commonly
used household disinfectant, is the cresol o-phenylphenol. The distinctive aroma of
these phenolics gives many hospitals their characteristic smell.
Uses: Phenols are used for environmental disinfection. Routine-use dilution for the
commonly used clear soluble phenolics is 1% v/v for ‘clean’ (low organic soiling)
and 2% v/v for ‘dirty’ (high organic soiling) conditions. They are the agents of choice
for mycobacteria including M. tuberculosis in the environment. Clear soluble (2%)
phenolics can be used in laboratory discard jars in bacteriology.
61
62
Table 6.2 Antimicrobial activity of antiseptic agents.
Group Gram- Gram- Mycobacteria Fungi Viruses Speed of action
positive negative
bacteria bacteria
Alcohols !!! !!! !!! !!! !!! Fast

Chlorhexidine !!! !!! ! ! !!! Intermediate
(2% and 4% aqueous)
Hexachlorophane !!! !! ! ! ! Intermediate
(3% aqueous)
Iodine compounds !!! !!! !!! !! !!! Intermediate

Iodophors !!! !!! ! !! !! Intermediate
Phenol derivatives !!! ! ! ! ! Intermediate
Triclosan !!! !! ! " !!! Intermediate
Quaternary ammonium ! !! " " ! Slow
compounds
Activity: !!!: Good; !!: Moderate; !: Poor; ": no activity or not sufficient.
Table 6.3 Antimicrobial activity and summary of properties of disinfectants.
Disinfectant Antimicrobial activity Other properties
Bacteria Mycobacteria Spores Viruses Stability Inactivation Corrosive/ Irritant/

by organic damaging sensitizing
Enveloped Non matter
enveloped
Alcohol !!! !!! " !! !! Yes Yes Slight No

60–70% (in closed (fixative) (lens
(ethanol or container) cements)
isopropanol)
Chlorine !!! !!! !!! !!! !!! No Yes Yes Yes
releasing (#1 day)
agents
(0.5–1%
available
chlorine)
Clear soluble !!! !! " !! ! Yes No Slight Yes
phenolics
(1–2%)
Glutaraldehyde !!! !!! !!! !!! !!! Moderately No (fixative) No Yes
(2%) (14–28 days)
Peracetic acid !!! !!! !!! !!! !!! No (#1 day) No Slight Slight
(0.2–0.35%)
Peroxygen !!! $ $ !!! $ Moderately Yes Slight No
compounds* (7 days)
(3–6%)
Good % !!!, Moderate % !!, Poor % !, Variable % $, None % ".

*Activity varies with concentration.
63
Precautions: Respiratory irritation may occur if used at concentrations above those

listed in the disinfection policy. Appropriate protective clothing must be worn when
handling phenolic disinfectants. Skin and eyes must be protected while ‘making up’
or discarding a phenolic solution. Phenolic disinfectants can be absorbed through
the skin, therefore skin must be protected during its use. Use latex gloves for inter-
mittent use; medium weight washing up gloves are appropriate for more prolonged
contact.
Phenolic disinfectants should not be used to clean infant bassinets and incubators
because of the occurrence of hyperbilirubinaemia in infants. If phenolics are used to
clean nursery floors, they must be diluted according to the manufacturer’s recom-
mendation. Phenol must not be used on items and equipments that may come into
contact with skin or mucous membranes. Phenolic disinfectants may taint food and
should not be used on food preparation surfaces.
Chlorhexidine
Chlorhexidine is inactivated by soap, organic matter and anionic detergents. It also
stains fabrics brown in the presence of chlorine-based disinfectants.
Uses: Used exclusively as an antiseptic where contact with skin and mucous membranes
is involved. Chlorhexidine solutions are usually combined with detergent which is used
for hand disinfection or with alcohol which is useful if rapid disinfection is required for
physically clean hands. It is combined with alcohol for pre-operative skin disinfection
and with other antiseptics for cleaning dirty wounds.
Precautions: Chlorhexidine is relatively non-toxic. It must not be allowed to come into

contact with the brain, meninges, eye or middle ear.
Iodine and iodophors

This group includes aqueous iodine and tincture of iodine. It is inactivated by organic
matter and may corrode metals. Iodophors do not stain skin and are non-irritant.
Uses: Alcoholic preparations containing iodine and iodophors are suitable for pre-
operative skin preparation. Povidone iodine detergent preparations are used for
surgical hand-disinfection.
Precautions: Use gloves for prolonged handling of iodine/iodophors preparation.

An alcoholic iodophor is less irritant than an alcohol/iodine mixture. Tincture of
iodine and aqueous iodine solutions can cause skin reactions in some individuals;
therefore iodophor solution is usually preferred.
Quaternary ammonium compounds (QAC)

The most widely used cationic detergents are QAC. Several quaternary ammonium
cationic detergents are used as antiseptic agents. These compounds are relatively
64
non-irritating to human tissues at concentrations that are inhibitory to micro-

organisms. However, they act slowly and are inactivated by soaps, anionic detergents
and organic matter. Their antimicrobial activity is lowered if they are absorbed by
porous or fibrous materials such as gauze bandages. Hard water containing calcium
or magnesium ions interferes with their action. They can also cause metal objects
to rust.
Uses: QAC may be used as antiseptics for cleaning dirty wounds. They should not be
used in operating theatres because of the danger that they will permit growth of
Pseudomonas spp. which can cause infection in surgical wounds (see below). Their
use as an environmental disinfectant is usually not recommended.
Precautions: QAC inhibit the growth of bacteria (bacteriostatic) but do not kill them.
Gram-negative bacilli (e.g. Pseudomonas spp.) may cause contamination and grow in
diluted solution. Therefore, any unused solutions should be discarded immediately
after use. Decanting from one container and topping-up should be avoided. This can
result in contamination and promote growth of Gram-negative bacilli which may
then colonize the wound. The correct strength of solution should be obtained from
the pharmacy. Single-use sachets should be used, if possible. Liquid should be stored
in closed bottles until immediately before use. Benzalkonium chloride is one of the
leading allergens amongst health care personnel.
Hexachlorophane
Hexachlorophane is a chlorinated bisphenol and one of the most useful of the phe-
nol derivatives. Unlike most phenolic compounds, hexachlorophane has no irritating
odour and has a high residual action. Hexachlorophane is not fast acting and its
rate of killing is classified as slow to intermediate. The major advantage of hexa-
chlorophane is its persistence. Soaps and other organic materials have little effect.
Hexachlorophane is more effective against Gram-positive than against Gram-
negative bacilli.
Uses: Hexachlorophane (0.33%) powder has good residual effect on the skin and can be
used as an anti-staphylococcal agent. Use of hexachlorophane on broken skin or mucous
membranes or for routine total body bathing is contraindicated. Hexachlorophane
should not be applied on neonates because it can cause neurological damage.
Triclosan
Triclosan phenol or Irgasan is a diphenyl ether. It can be absorbed through intact skin
but appears to be non-allergenic and non-mutagenic with short term use. Its speed
of killing is intermediate but it has excellent persistent activity on skin. Its activity is
only minimally affected by organic matter. It is commonly used in deodorant soaps
and health care hand washes. It has a similar range of antimicrobial activity as
hexachlorophane but exhibits no documented toxicity in neonates.
65
Aldehydes
Glutaraldehyde
Most preparations of glutaraldehyde are non-corrosive to metals and other materials
and inactivation by organic matter is very low. Alkaline solutions require activation;
once activated they remain active for 2–4 weeks depending on the brand or prepar-
ation used and the frequency of use. Acidic solutions are stable and do not require
activation, but slower in activity than alkaline buffered solutions.
Uses: 2% glutaraldehyde is used to disinfect heat-sensitive items such as endoscopes.
Precautions: Glutaraldehyde may be irritant to the eyes and nasal pathway and may
cause respiratory illness (asthma) and allergic dermatitis. Glutaraldehyde should not
be used in an area with little or no ventilation, as exposure is likely to be at or above
the current Occupational Exposure Standards (OES: 0.2 ppm/0.7 mg m"3, 10 min
only). Eye protection, a plastic apron and gloves must be worn when glutaraldehyde
liquid is made up, disposed of, or when immersing instruments. Latex gloves may be
worn and discarded after use if the duration of contact with glutaraldehyde is brief,
i.e. less than 5 min. For longer duration, nitrile gloves must be worn. It should be
stored away from heat sources and in containers with close-fitting lids.
Formaldehyde
Uses: Formaldehyde is used mainly as a gaseous fumigant to disinfect safety cabinets
in the laboratory and to fumigate the rooms of patients with highly dangerous
pathogens. These uses may only be carried out by fully trained persons.
Precautions: Formaldehyde is a potent eye and nasal irritant and may cause respiratory
distress and allergic dermatitis. Gloves, goggles and aprons should be worn when
preparing and disposing of formaldehyde solutions. Monitoring may be required if
formalin is used regularly as a disinfectant.
Peracetic acid
Peracetic acid is characterized by a very rapid action against all microorganisms.
A special advantage of peracetic acid is that it has no harmful decomposition
products and leaves no residue. It remains effective in the presence of organic
matter and is sporicidal even at low temperatures. Peracetic acid can corrode
copper, brass, bronze, plain steel, and galvanized iron but these effects can be
reduced by additives and pH modifications. It is considered unstable, particularly
when diluted. The advantages, disadvantages, and characteristics of peracetic acid
are listed in Table 6.4.
An automated machine using peracetic acid chemically sterilizes medical, surgical
and dental instruments including endoscopes and arthroscopes. It is more effective
than glutaraldehyde at penetrating organic matter such as biofilms. It is used as a
cold ‘sterilant’ to disinfect endoscopes. The solution is activated to provide the appro-
priate in-use strength. Once prepared, the current manufacturer’s recommendation
is that it should be used within 24 h.
66
Table 6.4 Summary of advantages and disadvantages for liquid chemical sterilants
used primarily as high-level disinfectants.
Sterilization method Advantages Disadvantages
Peracetic acid • No activation required. • Materials compatibility

• Odour of irritation not concerns (lead, brass,
significant. copper, zinc) both
cosmetic and functional.
• Limited clinical use.
Glutaraldehyde • Numerous use studies • Respiratory irritation from

published. glutaraldehyde vapour.
• Relatively inexpensive. • Pungent and irritating
• Excellent materials odour.
compatibility. • Relatively slow
mycobactericidal
activity.
• Coagulates blood and
fixes tissue to surfaces.
Hydrogen peroxide • No activation required. • Material compatibility
• May enhance removal concerns for brass, zinc,
of organisms. copper, and nickel/silver
• No disposal issues. plating (cosmetic only).
• No odour or irritation • Serious eye damage if
issues. contacted.
• Compatible with metals,
plastics and elastomers.
• Does not coagulate blood
or fix tissues to surfaces.
• Inactivates Cryptosporidium.
Ortho-phthaladehyde • Fast acting high-level • Stains skin, clothing and
disinfectant. environmental surfaces.
• No activation required. • Limited clinical use.
• Odour not significant.
• Excellent materials
compatibility.
• Does not coagulate blood
or fix tissues to surfaces.
Peracetic acid • Rapid sterilization cycle • Potential material
(Steris System 1) time (30–45 min). incompatibility (e.g.
• Low-temperature (50–55°C) aluminium anodized
liquid immersion coating becomes dull).
sterilization. • Used for immersible
• Environmental friendly instruments only.
by–products (acetic acid, • Biological indicator may
O2, H2O). not be suitable for routine
• Fully automated. monitoring.
• No adverse health effects • One scope or a small
to operators. number of instruments can
• Compatible with wide be processed in a cycle.
variety of materials and • More expensive
instruments. (endoscope repairs,
67
Table 6.4 Continued
Sterilization method Advantages Disadvantages
• Does not coagulate blood operating costs, purchase

or fix tissues to surfaces. costs) than high-level
• Rapidly sporicidal. disinfection.
• Provides procedure • Serious eye and skin
standardization (constant damage (concentrated
dilution, perfusion of solution).
channel, temperatures, • Point-of-use system, no
exposure). long-term sterile storage.
Adapted and modified from Rutala WA, Weber DJ. Disinfection of endoscopes: Review of chemical sterilants
used as high-level disinfectants. Infection Control and Hospital Epidemiology 1999; 20: 69–76.
Hydrogen peroxide
Hydrogen peroxide works by the production of destructive hydroxyl free radicals that
can attack membrane lipids, DNA, and other essential cell components. Hydrogen
peroxide is active against a wide range of microorganisms. Under normal conditions
hydrogen peroxide is extremely stable when properly stored (e.g. in dark containers).
Hydrogen peroxide and peroxygen compounds have low toxicity and irritancy.
Uses: Commercially available 3% hydrogen peroxide is a stable and effective disinfectant
when used on inanimate surfaces. It has been used in concentrations from 3 to 6% for
the disinfection of soft contact lenses, tonometer, biprisms, ventilators and endoscopes.
Precautions: A chemical irritation resembling pseudomembranous colitis has been
reported in a gastrointestinal endoscopy unit with use of 3% hydrogen peroxide. As
with other chemical sterilants, dilution of hydrogen peroxide must be monitored by
regularly testing the minimum effective concentration (i.e. 7.5–6.0%). Hydrogen
peroxide has not been widely used for endoscope disinfection because of concerns
that its oxidizing properties may be harmful to some components of the endoscope.
Manufacturer’s approval should be obtained before using on equipment where
corrosion may present problems, such as endoscopes or centrifuges.
Ortho-phthaladehyde (OPA)
OPA has an excellent antimicrobial activity. The product currently marketed as a
sterilant is a premixed, ready-to-use chemical that contains 7.5% hydrogen peroxide
and 0.85% phosphoric acid (to maintain a low pH).
OPA has several potential advantages compared to glutaraldehyde. It has excellent

stability over a wide pH range (pH 3–9), is not a known irritant to the eyes and nasal
passages, does not require exposure monitoring, has a barely perceptible odour,
and requires no activation. OPA, like glutaraldehyde, has excellent material compati-
bility. A potential disadvantage of OPA is that it stains proteins grey (including
unprotected skin) and thus must be handled with caution. However, skin staining
68
would indicate improper handling that requires additional training and use of
personal protective equipment, e.g. gloves, eye and mouth protection, fluid-resistant
gowns. In addition, equipment must be thoroughly rinsed to prevent discoloration
of a patient’s skin or mucous membrane. Since OPA was only recently cleared for
use as a high-level disinfectant, only limited clinical studies are available. Disposal
must be undertaken in accordance with local regulations; OPA solution may require
neutralization before disposal to the sanitary sewer system.
Ethylene oxide
Ethylene oxide has several applications as a sterilizing agent. The ethylene portion
of the molecule reacts with proteins and nucleic acids. Ethylene oxide kills all
microorganisms and endospores. It is toxic and explosive in its pure form, so it is
usually mixed with a non-flammable gas such as carbon dioxide or nitrogen. A special
autoclave-type sterilizer is used for ethylene oxide sterilization. Because of their
ability to sterilize without heat, gases like ethylene oxide are also widely used on
medical supplies and equipment that cannot withstand steam sterilization.
Examples include disposable sterile plastic-ware such as syringes and Petri plates,
linens, sutures, lensed instruments, artificial heart valves, heart-lung machines and
mattresses.
Disinfection of flexible fibreoptic endoscopes

The number of endoscopic procedures used on patients for diagnostic and thera-
peutic reasons is increasing each year. Although the overall incidence of
infection following endoscopy is very low, it can only be avoided by maintaining the
highest standards of decontamination after each use.
Rigid endoscopes (e.g. arthroscopes) are relatively easy to clean while flexible endo-
scopes (e.g. bronchoscopes and gastrointestinal endoscopes) are complex and
difficult to clean, disinfect and sterilize.
Endoscopes (e.g. arthroscopes, cystoscopes, laparoscopes) that pass through normally

sterile tissues must be subjected to a sterilization procedure before each use; if this is
not feasible due to damage caused by exposure to high sterilizing temperatures, they
should receive high-level disinfection using liquid chemicals.
The endoscope must be disinfected according to the written protocol based on the
manufacturer’s recommendations. Effective decontamination of endoscopes requires
input from:
• The user of the instrument who is familiar with the risks associated with
the procedure.
• Infection control personnel who are responsible for advising on the
selection and use of a suitable decontamination process.
69
• Endoscopy nurse, sterile services personnel or other persons responsible for

processing.
• Instrument manufacturer or supplier who is familiar with the design
and function of the item and its compatibility with heat and chemical
disinfectants.
Cleaning and high-level disinfection or sterilization should be undertaken before the

endoscopy list, between each patient, at the end of the list and prior to inspection,
service or repair. This should be carried out by fully trained staff using appropriate
protective equipment.
A log should be maintained indicating, for each procedure, the patient’s name and
medical record number (if available), the procedure, the endoscopist, and the serial
number or identifier of the endoscope used.
Endoscopic unit
Facilities where endoscopes are used and disinfected should be designed to provide
a safe environment for health care workers (HCWs) and patients. Air-exchange
equipment (e.g. ventilation system, exhaust hoods) should be used to minimize the
exposure of all persons to potentially toxic vapours (e.g. glutaraldehyde). The vapour
concentration of the chemical sterilant used should not exceed allowable limits.
Personnel responsible for the reprocessing of endoscopes must receive training in the
reprocessing of equipment to ensure proper cleaning and high-level disinfection
or sterilization is carried out. Competency testing of personnel should be done on
commencement of employment and then on an annual basis. All personnel working
in an endoscopy unit must be educated about the biological, chemical, and environ-
mental hazards. Personal protective equipment (e.g. gloves, eyewear, and respiratory
protection) should be readily available and should be used as appropriate. Staff
should also be immunized against hepatitis B virus.
Chemical disinfectants
The problems associated with the use of the most commonly used disinfectant,
glutaraldehyde, have prompted the development of non-aldehyde alternatives (see
Table 6.4). It is essential that advice is sought from the endoscope manufacturer on
compatibility with any new disinfectant or process.
Formulations containing glutaraldehyde, OPA, hydrogen peroxide, chlorine, per-

acetic acid, and both hydrogen peroxide and peracetic acid can achieve high-level
disinfection if the objects are properly cleaned and exposed to disinfectant solution
at recommended concentrations and for recommended exposure times. The selec-
tion and use of new disinfectants in the health care facilities should be approved by
the persons or committees responsible for selecting disinfectants and should be guided
by information in the scientific literature.
70
It is essential that exposure time beyond the minimum effective time should not be
used because of risk of damage to delicate instruments. Avoid the use of high-level
disinfectants on an endoscope if the endoscope manufacturer warns against use
because of functional damage (with or without cosmetic damage).
Routine testing of the disinfectant solution should be performed to ensure minimal

effective concentration of the active ingredient. Check the solution each day of use (or
more frequently) and document the results. If the chemical indicator indicates that the
concentration is less than the minimum effective concentration, discard the solution.
Cleaning and disinfection of the endoscope

Thorough manual cleaning of the instrument and its internal channels with deter-
gent is the most important part of the disinfection procedure. Without this, dry
residual organic material such as blood or mucous may prevent penetration of the
disinfectant. It also ensures better contact between the disinfectant or sterilant and
removal of any remaining microorganisms in subsequent stages of decontamination.
Cleaning with warm water and a neutral or enzymatic detergent is recommended,
though advice on suitable cleaning agents should be sought from the endoscope’s
manufacturer. The detergent should be changed frequently to prevent its contam-
ination with organic matter. It is important that the instrument is in full working
order and that a ‘Leak Test’ has been performed to ensure that it is watertight prior
to any cleaning procedure.
There are many automatic endoscope reprocessors available that are capable of
cleaning as well as disinfecting endoscopes. However, it is essential that initial man-
ual cleaning at the point of use is performed to ensure the effectiveness of subsequent
processing and prevent the machine and the disinfectant becoming contaminated
with excess organic matter or body fluids.
Ultrasonic washers may be used for most rigid endoscope components and accessories
with the exception of the telescope. All lumens should be irrigated after ultrasonic
cleansing to remove dislodged organic matter. Irrigation pumps are available for flush-
ing instrument lumens and components.
• All accessories should be disconnected and disassembled as far as possible

and completely immersed in the enzymatic detergent.
• All of the channels should be flushed and brushed, if accessible, to remove
all organic materials (e.g. blood, tissue) and other residue.
• Reusable accessories (e.g. biopsy forceps or other cutting instruments) that
break the mucosal barrier should be cleaned and then sterilized between
each patient.
• External surfaces and accessories of the devices should be cleaned using a
soft cloth, sponge, or appropriate brushes.
71
• The instrument must be completely immersed in the high-level disinfectant,

ensuring that all channels are perfused.
• Detergents should be discarded after each use, as these products are not
microbicidal and may allow microbial growth.
• The instrument and its channels should be thoroughly forced-air dried.
A final drying step that includes flushing all channels with alcohol followed
by purging the channels with air greatly reduces the possibility of recontam-
ination of the endoscope by waterborne microorganisms.
• Endoscopes should be hung in a vertical position to facilitate drying.
Endoscopes should be stored in a manner that will protect them from
contamination.
• After high-level disinfection, endoscopes (including channels) must be
rinsed with sterile water, filtered water, or tap water, followed by a rinse
with 70–90% ethyl or isopropyl alcohol.
• The water bottle, used to provide intra-procedural flush solution, and its
connecting tube should be sterilized or receive high-level disinfection at
least daily. Sterile water should be used to fill the water bottle.
• After decontamination, final rinsing of endoscopes and accessories with
sterile water is important as many of the agents used for this process
deposit toxic residues which must be adequately rinsed off before the
endoscope can be used.
Automatic endoscope reprocessor

If an automatic endoscope reprocessor is used, the endoscope should be placed in the
reprocessor and the air channel connectors attached according to the manufacturer’s
instructions to ensure exposure of all internal surfaces with the high-level disinfect-
ant/chemical sterilant. Since design flaws have compromised the effectiveness of
the automatic endoscope reprocessor, the infection control staff should routinely
review the scientific literature to ensure that all components of the endoscope are
effectively reprocessed.
Problems due to inadequate decontamination

Major problems leading to inadequate decontamination include inadequate cleaning
which may lead to failure to remove deposits of blood, faeces, tissue, mucous,
microorganisms, film or slime. These may result in infection, misdiagnosis or instru-
ment malfunction.
A number of factors have been associated with contamination of machines:
• Inadequate cleaning and maintenance of the machine.

• The use of static water, i.e. within pipework or tank.
72
• The use of water of poor microbiological quality.

• The use of hard water.
• Inadequate cleaning of the endoscope.
• The formation of biofilm within the machine.
All tank and fluid pathways in endoscope washer/disinfectors should be regularly

drained, cleaned and disinfected to prevent colonization of the fluid pathway which
could be responsible for misdiagnosis of a patient’s infection. Disinfection should be
performed at the start of each session prior to using the endoscope reprocessor.
Water used to rinse endoscopes following disinfection must be of a suitable quality
with respect to hardness and freedom from microbiological contamination.
A record must be kept of the number of washing cycles to ensure that the disinfect-
ant is not unreasonably diluted or neutralized by organic matter. Appropriate records
on disinfection of the equipment must be maintained by the department.
Microbiological quality of water or other fluids

Hardness of water results in the build-up of lime scale on the internal pipework of the
washer/disinfector and poor microbiological quality of water may result in microbial
contamination. Use pre-sterilized bottled water for stand alone machines and pre-
treated water for machines connected to the main water supply. Tap water may contain
microbes including Pseudomonas spp. and Mycobacterium spp. and there are many
reports of procedure-acquired infection with these organisms. Misdiagnosis of tuber-
culosis has been reported due to contamination of the instruments with environmental
mycobacteria (e.g. M. chelonae) from the rinse water which subsequently contaminated
bronchial washings sent for culture. Therefore, sterile water is recommended for the
final rinsing of all types of endoscope to be used for all invasive procedures.
Renewal of disinfectant
Serial processing of endoscopes in automated systems may reduce disinfectant
potency due to constant dilution of the disinfectant by wet instruments. Therefore,
disinfectant should be changed frequently; at least weekly, depending on usage and
its contamination with organic matter. The concentration of glutaraldehyde in the
solution should not be allowed to fall below 1.5% and solutions must not be used
beyond the manufacturer’s recommended post-activation life. Test kits are available
which indicate glutaraldehyde concentration. The rinse water should also be changed
regularly to avoid build-up of glutaraldehyde on the instrument and eyepiece
assembly, as residues may cause skin and eye irritation.
Environmental cleaning
Effective environmental cleaning is essential because microbiologically contaminated
surfaces may act as a reservoir of potential pathogens. The transfer of microorganisms
73
from environmental surfaces to patients is largely via hand contact with the contamin-
ated surface. While handwashing is important to minimize the impact of this transfer,
cleaning is a form of decontamination that renders the environmental surface safe by
reducing the number of microorganisms and helps prevent cross-infection.
Housekeeping surfaces requires regular cleaning and removal of soil and dust. Dry
conditions favour the persistence of Gram-positive cocci (e.g. coagulase-negative
staphylococci) in dust and on surfaces, whereas moist, soiled environments favour the
growth and persistence of Gram-negative bacilli. Fungi are also present on dust and
proliferate in moist, fibrous material. Hot water and detergent are sufficient
for most purposes. Thorough cleaning and adequate disinfection is particularly
indicated for pathogens that can survive in the general environment for prolonged
periods, e.g. the spores of Clostridium difficile, vancomycin resistant enterococci
(VRE) and MRSA. Routine environmental swabbing to monitor the effectiveness of
cleaning process should not be done.
Cleaning removes organic matter, salts, and visible soils, all of which interfere with
microbial inactivation. The physical action of scrubbing with detergents and surfac-
tants and rinsing with water during environmental cleaning effectively removes
microorganisms. Adding detergent aids cleaning because one end of the detergent
molecule is hydrophilic and mixes well with water. The other end is hydrophobic and
is attracted to non-polar organic molecules. If the detergents are electrically charged,
they are ionic. Anionic (negatively charged) detergents are only mildly bactericidal.
Anionic detergents are used as laundry detergents to remove soil and debris. They
also reduce the number of microorganisms associated with the item being washed.
Cationic (positively charged) detergents are highly bactericidal.
Cleaning of environmental surfaces

Strategies for cleaning and disinfecting surfaces in patient care areas take into
account:
• Potential for direct patient contact.

• Degree and frequency of hand contact.
• Potential contamination of the surface with body substances or environ-
mental sources of microorganisms (e.g. soil, dust, or water).
The number and types of microorganisms present on environmental surfaces are

influenced by several factors:
• Number of people in the environment.

• Amount of activity.
• Amount of moisture.
• Presence of material capable of supporting microbial growth.
74
Procedure for terminal cleaning of a room

Terminal cleaning of a room should be done when a patient who has
been under source isolation is discharged. Fumigation of the room is not
necessary. The following procedure should be followed:
• Domestic staff should wear appropriate personal protective equip-

ment, e.g. household-type gloves, disposable plastic apron.
• Discard all disposable items or equipment as appropriate. Seal
clinical waste bags before leaving the room and dispose off according
to local policy.
• Remove any items or equipment to the dirty utility area for cleaning
and disinfection. Send appropriate items to SSD for sterilization.
• Gently place all linen into the appropriate laundry bags. Bags must be
sealed before leaving the room or the area.
• Dust the high ledges, window frames and curtain tracks.
• Wet clean all ledges, fixtures and fittings, including taps and door
handles.
• Vacuum clean fixtures, fittings and floor. Only use a suitable vacuum
cleaner with a high filter mechanism.
• The bed mattresses should be wiped with warm water and detergent
and dried thoroughly. If disinfection is required use appropriate disin-
fectant, e.g. freshly prepared hypochlorite (1:100 dilution) solution.
• Wash sink with warm water and detergent. Rinse and dry thoroughly.
Hypochlorite/detergent cleanser may be used, if indicated.
• Wash floor and spot clean walls with detergent solution. Rinse and
dry thoroughly.
• Open windows, if required, to facilitate thorough drying of all surfaces.
• The room may be re-used again by the next patient when all
surfaces are dry.
NOTE: Routine environmental swabbing to monitor the effectiveness of cleaning process
should not be done.
75
• Rate at which organisms suspended in the air are removed.

• Type of surface and orientation, e.g. horizontal or vertical.
Housekeeping surfaces can be divided into two groups: those with minimal hand
contact (e.g. floors, wall, window sills and ceilings) and those with frequent hand
contact. Horizontal surfaces with minimal hand contact in routine patient-care areas
require cleaning on a regular basis, when soiling or spills occur, and when a patient
is discharged. Cleaning of walls, blinds, and window curtains is recommended when
they are visibly soiled. Areas of frequent hand contact should be cleaned more
frequently than surfaces with minimal hand contact. The methods and frequency for
these processes, and the products used, are a matter for local policy.
Cleaning special-care areas

Since immunosuppressed patients are more susceptible to infection, it is essential that
the following points should be taken into consideration when cleaning is undertaken
in such an area:
• Wet dusting of horizontal surfaces should be done daily with cleaning

cloths pre-moistened with a water and detergent. It is important that care
should be taken to avoid patient contact with the detergent/disinfectants.
• Since dispersal of microorganisms in the air from dust or aerosols can be
problematic for these patients, the cleaning equipment that produces mists
or aerosols should be avoided. There is the potential for vacuum cleaners to
serve as dust disseminators if they are not operating properly. Therefore it
is essential that the vacuum cleaner should be equipped with high
efficiency particulate air (HEPA) filters, especially for the exhaust. They
should be used in any patient care area where immunosuppressed patients
are present. Doors to patients’ rooms should be closed when vacuuming
areas where immunosuppressed patients are located. Bacterial and fungal
contamination of filters in cleaning equipment is inevitable, and these filters
should be cleaned regularly or replaced as per equipment manufacturer
recommendation.
Cleaning method and equipment

It is essential that the methods of cleaning produce minimal mists and aerosols or
dispersion of dust in patient care areas. Bucket solutions become contaminated
almost immediately during cleaning, and continued use of the solution transfers
increasing numbers of microorganisms to each subsequent surface to be cleaned.
Therefore, cleaning solutions should be replaced frequently. Another reservoir for
microorganisms in the cleaning process may be diluted solutions of the detergents or
disinfectants (e.g. phenolics). Therefore it is essential that fresh cleaning solution
should be made daily and any remaining solution discarded after use.
76
Management of blood spills

Splashes and drips
Procedure
• Wear non-sterile gloves for this procedure.

• Wipe the area immediately with paper towel soaked in hypochlorite
(household bleach) solution 1:100 dilution; alternatively a disposable
alcohol wipe can be used.
• Rinse treat surface with clean water as hypochlorite solution may be
corrosive.
• Clean the area with water and detergent.
• Dry the surface with disposable paper towels.
• Discard gloves and paper towels as clinical waste according to local
policy.
• Wash and dry hands immediately.
Larger spills
Procedure
• Sprinkle the spill with NaDCC granules until the fluid is absorbed if
the quantity is small (&30 ml). For larger spills, cover the spillage with
paper towels to absorb all liquid and carefully pour a freshly prepared
hypochlorite (household bleach) solution 1:10 dilution.
• Leave the spill for a contact period of about 3 minutes to allow for
disinfection.
• Depending on the method used, either scoop up the absorbed
granules or lift the soiled paper towels and discard into a yellow
plastic waste bag as clinical waste.
• Wipe the surface area with fresh hypochlorite (1:100 dilution)
solution and rinse with clean water as the hypochlorite solution may
be corrosive.
• Dry the surface with disposable paper towels.
• Remove gloves and plastic apron and discard as clinical waste
according to local policy.
• Wash hands and dry immediately.
77
Another source of contamination in the cleaning process is the cleaning cloth or mop
head, especially if left soaking in dirty cleaning solutions. Laundering of cloths and
mop heads after use, and allowing them to dry before reuse, can help to minimize
the degree of contamination. A simplified approach to cleaning involves replacing
soiled cloths and mop heads with clean items each time a bucket of detergent is
emptied and replaced with fresh, clean solution. Buckets should be emptied after use,
washed with detergent and warm water and stored dry. Mops should be cleaned in
detergent and warm water, then stored dry. Disposable cleaning cloths and mop
heads are an alternative option, if costs permit.
Brooms disperse dust and bacteria into the air and should not be used in patient
areas. Dust-retaining materials, which are specially treated or manufactured to
attract and retain dust particles, should be used as they remove more dust from
surfaces.
Management of infectious spills

There is no documented evidence that any blood-borne virus (HIV, Hepatitis
B or C) has been transmitted from an environmental surface. Nonetheless prompt
removal and surface disinfection of an area contaminated by either blood or body
fluids is necessary as a part of good infection control practice. Health care facilities
should have management systems in place for dealing with blood and body substance
spills. Protocols for spills management should be included in procedural manuals
and emphasized in ongoing education and training programmes.
Management of a spill depends on a number of factors, including:
• The nature of the spill (e.g. sputum, vomit, faeces, urine, blood or labora-
tory culture).
• The pathogens most likely to be involved in these different types of spills
(e.g. Mycobacterium tuberculosis in sputum).
• The size of the spill (e.g. spot, small or large spill).
• The type of surface (e.g. carpet or impervious flooring).
It is not necessary to use bleach for managing all spills but it may be used if the
circumstances indicate that it is necessary. Spills of blood and high risk body
fluids should be removed as soon as possible and the area washed with detergent/
disinfectant and dried as outlined on page 77.
Cleaning and disinfection of medical equipment

Manufacturers of medical equipment should provide care and maintenance instruc-
tions specific to their equipment. These instructions should include information
about materials compatibility with chemical disinfectants, whether or not the
78
equipment can be safely immersed for cleaning, and how the equipment should be
decontaminated if servicing is required. In the absence of manufactures’ instructions,
a member of the Infection Control Team should be consulted.
Decontamination of equipment prior to inspection, service or repair

Equipment and items which have been contaminated by contact with blood and
high risk body fluids, pathological specimens, or exposure to patients in isolation
will require decontamination prior to examination by third parties who perform
inspection, service or repair. It is the responsibility of the individual heads of
departments to ensure the policy is implemented. It is important that all decontam-
ination procedures should be undertaken by suitably qualified and trained staff.
The method of decontamination to be used should be one that does not damage the
article or any of its components and could include steam sterilization, dry heat, or
chemical methods. In cases of doubt about the appropriate method, advice should
be sought from:
• The manufacturer or agent.

• Hospital engineering staff.
• The sterile services manager.
• A member of the Infection Control Team.
A record of the procedures used should be kept in the equipment log book. A written
declaration of decontamination status should be provided. If the equipment is to
leave the premises, the certificate/statement should be enclosed in an envelope
affixed to the outside of the package.
In certain situations, equipment may not be decontaminated before inspection,

service or repair, either because the equipment is subject to investigation as the result
of a complaint or it may not be adequately decontaminated without engineering
assistance. In such cases, the advice of the investigating body or engineering depart-
ment should be sought. If such an item is to leave the premises, the following precau-
tions must be taken:
• A prior warning should be given to the intended recipient.

• The condition of the item should be clearly labelled on the outer
packaging.
• The packaging should be suitably robust to ensure that the inner
pack cannot contaminate the outer pack or become damaged in
transport.
• The agreement of any transporters may be required.
79
Decontamination of suction equipment

Suction systems can either be: (i) fixed unit, which can be used with a
reusable (suction jar) or disposable (liner) reservoir or (ii) portable unit
which is usually used with re-usable suction jar. Suction tubing, handles
and catheters are all disposable. Suction containers or reservoir can
either be disposable or non-disposable. When emptying non-disposable
suction jar the following precautions should be taken:
• A plastic apron and household gloves should be worn. In addition,
eye protection should be worn if the patient belongs to a high risk
group. High filtration mask should be worn for a patient with
pulmonary tuberculosis.
• The jar must be disconnected from the vacuum system, carried
carefully to the dirty utility room and poured gently into the sluice
hopper. The contents should be flushed with copious amounts of
running water.
• The jar should be rinsed and then washed with a neutral pH detergent
and hot water solution. It should be rinsed again in fresh water and
dried with disposable wipes.
• A weak solution of sodium bicarbonate (mucolytic agent) may be
used to help remove mucous material. Alternatively the suction jar
may be machine washed in a washer/disinfector unit.
• The bottle should be emptied when full and cleaned at least daily
irrespective of the amount of fluid aspirate. Fresh tubing should be
attached just prior to use.
• The routine use of a disinfectant is not necessary for cleaning suction
jars as the organic matter in the contents readily inactivates disinfect-
ants. The only exception to this is when the patient has pulmonary
tuberculosis or other infectious diseases. In such cases send the
equipment to SSD for decontamination.
• A fresh single-use disposable suction catheter must be used each time
a patient undergoes tracheo-bronchial aspiration. Yankaeur suction
catheters or handles can be re-used on the same patient provided they
are flushed after use by drawing a sodium bicarbonate solution through
the tip followed by aspirating the air for 20 s, drying with a disposable
tissue and storing in a protective cover. Approximately 10 ml of an anti-
foaming agent may be added just prior to use to prevent excessive
foaming of the bottle contents, which may wet the filter and enter the
pump mechanism. The filter should be changed between patients or if
it becomes moist or discoloured or used by an infected patient.
80
Table 6.5 Disinfection procedures for individual items and equipment.
Equipment or site Suggested method(s) Acceptable alternative or

additional recommendations
Airways and Single-use disposable or Use single-use disposable

endotracheal tubes heat sterilize in the SSD. item or heat sterilize for
patients with known
infections, e.g. tuberculosis,
AIDS, etc.
Ampoules Wipe neck with a 70% When a sterile ampoule
isopropyl alcohol exterior is required it will be
impregnated swab and processed by the SSD, by
allow to dry before opening agreement with medical and
or piercing. pharmaceutical staff. Do not
immerse an ampoule in a
disinfectant solution.
Apnoea and Clean and dry regularly as
enuresis monitors part of a routine. If
contaminated disinfect and
then rinse and dry.
Arm splint Wash with detergent, rinse
and dry.
Auroscope tip Use single-use tips and
discard after single-use.
If reusable tip then wash
and disinfect between
patient use.
Babies feeding Use pre-sterilized or Chemical disinfectant should
bottles and teats heat-treated feeds. be used only when other
Non-disposable bottles: methods are unavailable.
Wash thoroughly, rinse Non-disposable bottles
and place in fresh which originate from a milk
hypochlorite (125 ppm av kitchen must be returned for
Cl2) solution for 30 min. disinfection.
Baths Non-infected patients: Clean Infected patients: Disinfect
with detergent or use a by cleaning with a chlorine-
non-abrasive cream cleanser based agent or non-abrasive
to remove stain or scum if chlorine releasing powder.
necessary. Rinse and dry Patients with open wounds:
after cleaning, before and For patients with unhealed
after use. wounds and those who are
immunocompromised,
disinfect before use with a
non-abrasive hypochlorite
powder. Apply powder to a
wet surface, rinse thoroughly
and dry.
Bath water Do not add an antiseptic For staphylococcal
bath additive routinely. dispensers seek advice from
a member of the ICT.
81
Table 6.5 Continued

Beds and cots Wash with detergent and dry. Infected patients: Use
hypochlorite (1,000 ppm
av CI2) solution for
disinfection.
Do not use phenolic
disinfectants on infant cots,
prams or incubators as
residual fumes may cause
respiratory irritation.
Bed-frames For normal cleaning use Infected patients: Wipe with
detergent and hot water. disinfectant, wash with
Perform cleaning after detergent, rinse and dry.
discharge of each patient
and regularly in the case
of long stay patients.
Bedpans and urinals Dispose after single-use. Infected patients: Gloves
If reusable heat disinfect in and plastic aprons must be
a washer/disinfector (80°C worn when handling
for 1 min). contaminated items from
Store dry. infected patients.
Alternatively, single-use
disposable items may be
used. These should always
be disposed of into a
macerator unit.
Birthing pools Use disposable pool liner.
Clean and disinfect paying
particular attention to the
outlet.
Bowls (washing) Individual wash bowls Infected patients: After
should be available for each thorough cleaning, disinfect
patient. After each use, wash by wiping with a
with detergent, rinse, dry and disinfectant solution.
store inverted and tilted
forward to avoid trapping of
water which may harbour
microorganisms.
Bowls (surgical, sterile) Return to SSD for autoclaving.
Bowls (vomit) Empty and rinse.Wash with For infected patients [see
detergent and hot water, above under Bowls
rinse and dry. (washing)].
Breast pumps For single patient use only.
Wash with detergent and
water and then rinse.
82
Table 6.5 Continued

Immerse in hypochlorite
(125ppm av Cl2) solution
for 30min. Before use by
subsequent patients clean,
disinfect and autoclave.
Cardiac monitors, If patient contact, then
defibrillators and surface clean and disinfect
ECG equipment unless disposal is necessary
(if single-use item).
Carpets Suction clean daily with a For known contaminated spills,
vacuum cleaner with an disinfect with an agent that
effective filter. Shampoo does not damage carpet and
periodically by hot water then clean with a detergent.
extraction or when soiled. Seek advice from the Infection
Control Nurse.
Cheatle forceps Do not use. If used in an exceptional
circumstance, autoclave
daily and store in a fresh 1%
clear soluble phenolic
disinfectant which must be
changed daily.
Cleaning equipment Mops: The detachable heads Colour coded cleaning
of used mops must be equipment should be used
machine laundered, for each area, i.e. clinical,
thermally disinfected and non-clinical, kitchen and
dried daily. sanitary area according to
Mop bucket: Wash with the local policy.
detergent. Rinse, dry and
store inverted.
Scrubbing machine: Drain
reservoir after use and
store dry.
Commodes For single patient use only, If faecal contamination has
wash with detergent and occurred, remove soil with
rinse. tissue. Wash with detergent
Between use clean and and hot water. Wipe with
disinfect. disinfectant, wash, rinse
and dry.
Crockery and cutlery Machine wash with rinse Infected patients: For
temperature above 80°C patients with enteric
and dry or hand wash in infections or open
detergent and hot water pulmonary tuberculosis,
(approx. 60°C), rinse and heat disinfect in a
allow to dry thoroughly. dishwasher.
Rubber gloves will be
required at this temperature.
83
Table 6.5 Continued

Drains Clean regularly as outlined When blockage occurs,

in the maintenance contact Works and
programme. Maintenance Department.
Chemical disinfection is
not required.
Drip stands Clean after each use.
Duvets Launder to thermal Launder after each patient use,
disinfection temperatures. weekly or if visibly soiled.
Endoscopes Flexible fibreoptic
endoscopes: (See page 69).
Arthroscopes and
laparoscopes: Clean and
wash thoroughly. Rinse,
dry and send to SSD for
sterilization.
If this is not possible a If used on a patient where
10 min exposure to alkaline tuberculosis is suspected,
glutaraldehyde is used. then the contact time with
The instrument must be 2% alkaline glutaraldehyde
dismantled before must be extended to 60 min.
disinfection and rinsed in
sterile water afterwards.
Procto/sigmoidoscope: Clean
and wash thoroughly. Rinse
and dry and send it to SSD
for sterilization or use
disposable if available.
If this is not possible a If used on a patient where
10 min exposure to 2% tuberculosis is suspected,
alkaline glutaraldehyde must then the contact time with
be dismantled and thoroughly 2% alkaline glutaraldehyde
cleaned before disinfection must be extended to 60 min.
and rinsed in sterile water
afterwards.
Enteral feeding Single-use disposable.
lines
Floors Vacuum clean or use a Never use brooms in patient
(dry cleaning) dust-attracting dry mop. areas.
Floors Wash with a detergent If contaminated, disinfect and
(wet cleaning) solution. Disinfection is not clean.
routinely required.
Fixtures and fittings In clinical areas damp dust In known contaminated and
daily with detergent solution. special areas, damp dust with
a disinfectant solution.
84
Table 6.5 Continued

Furniture and ledges In clinical areas damp dust

daily with warm water and
detergent.
Haemodialysis Clean and disinfect, paying
machines particular attention to the
microbial quality of water
and the fluid pathway.
Regular microbiological
monitoring is essential to
validate effective disinfection.
Hoist (patient) Sling to be washed with
detergent, rinse and dry
between patients. Examine
material and clips for wear
or damage before each use.
Surface clean the hoist.
Humidifiers Clean and sterilize device Seek advice from the ICT.
between patients and fill with
sterile water which must be
changed every 24 h or sooner
if necessary. Single-use
disposables are available.
Hydrotherapy pools Filter, drain and clean
regularly as part of a routine.
Maintain disinfectant levels
within water. Microbiological
monitoring is recommended.
Infant incubators After use, wash all removable Infected patients: After
parts and clean with cleaning, wipe with 70%
detergent. Clean and dry isopropyl alcohol impregnated
regularly as part of a routine. wipe or with hypochlorite
If contaminated disinfect (125 ppm av Cl2) solution
and then rinse and dry. before re-use. Do not use
phenolic disinfectant.
Alcohol may damage the
plastic surfaces. Please refer to
the manufacturer’s
instructions.
Instruments Return to SSD for machine Contaminated instruments
(surgical, sterile) washing and sterilization. should be cleaned by trained
Transport safely in a closed staff in SSD before
rigid container. sterilization.
85
Table 6.5 Continued

Laryngoscope blade Wash with detergent, rinse, Contaminated instruments

dry and wipe with an alcohol should be sterilized in SSD.
impregnated wipe.
Linen Refer to the local policy.
Locker tops Treat as ‘Fixtures and Fittings’.
Mattresses and Clean and disinfect the cover Should be protected by a
pillows regularly as part of a routine. waterproof cover.
Rinse thoroughly and dry. Infected patients: Disinfect
Mattresses should be enclosed with a disinfectant solution.
in a waterproof cover and Allow 2 min contact time then
routinely inspected for rinse and dry.
damage. Do not disinfect unnecessarily
as this damages the mattress
cover.
Mops (dish) Do not use.
Mops (dry, dust Do not use if overloaded or Non-disposable dust mop
attracting) for more than 1–2 days covers must be vacuumed
without reprocessing or after each use. Single-use
washing. Alternatively a covers should be of the type
single-use disposable cover which is impregnated with
may be used and disposed mineral oil to enhance dust
of after each use. attracting properties.
Mops (wet) Mop heads must be changed If chemical disinfection is
daily. Reprocess by machine required, rinse in water,
washing to thermal immerse in hypochlorite
disinfection temperature and (1,000 ppm av Cl2) solution
tumble dry. for at least 30 min.
Nail brushes Use only if essential. Heat Do not soak in a disinfectant
disinfect in SSD after each solution.
use or use sterile pre-packed Never use a nail brush to
single-use disposable. scrub skin.
Nebulizers Empty in hot wash with
detergent between single
patient’s use. Re-fill with
sterile water only. Dispose
of on patient discharge.
Neurological Single-use only.
test pins
Oxygen tents Wash with hot water Store covered with clean
detergent solution, rinse plastic sheeting in a clean
well and dry thoroughly. area.
Pillows Use only with water Damaged pillows must be
impermeable cover. Treat as replaced immediately.
‘mattresses’.
86
Table 6.5 Continued

Razors (electric) Detach head, clean Ideally each patient should

thoroughly, and immerse have their own shaving
in 70% isopropyl alcohol equipment or use single-use
for 10 min, remove and disposable.
allow to dry between each
patient.
Razors (safety and Use disposable or autoclave For clinical shaving use
equipment) with single-use disposable clipper.
head.
Rhino/laryngoscope Clean the blade thoroughly In cases of suspected/
with detergent and hot water. confirmed transmissible
Dry thoroughly and wipe with infection or visible blood, the
a 70% alcohol impregnated blade should be sterilized
wipe. before further use.
Rooms (terminal Wash surfaces with detergent Transmissible infection:
cleaning) solutions (see page 75). Disinfect surface with
disinfectant solution, wash
with detergent, rinse and dry.
Scissors Surface disinfection with a
70% alcohol impregnated
wipe.
Shaving brushes Do not use for clinical Use brushless cream or
shaving. shaving foam.
Patients may use their own
brush for face shaves, it
should be rinsed under
running water and stored dry.
Sheepskins Synthetic: Return to laundry
department for washing in
the usual way.
Natural fibre: For individual Seek advice from the ICN.
use only.
Speculae Single-use or clean and
steam sterilize.
Splints and Wash and clean with
walking frames detergent.
Sputum containers Use disposable only. Seal
and discard as clinical waste
daily or sooner if required.
Stethoscope Surface disinfect after
each use.
87
Table 6.5 Continued

Suction equipment Following use, the reservoir When using a disposable

should be emptied into the system, great care is required
sluice hopper, washed with to ensure the safe disposal of
hot water and detergent, liners according to waste
rinsed and store dried. disposal policy. For infected
Wear a plastic apron and patients seek advice from the
non-sterile disposable for this ICN.
procedure.
The reservoir of the suction
apparatus should be kept
empty and dry when
not in use.
Thermometers Where possible use a single- Do not use without sleeve or
(electronic) use sleeve. If not possible on patients with an infectious
use either single-use disease.
thermometer or clean and
disinfect between use.
Thermometers Individual thermometers: Communal thermometers:
(oral) Wipe with a 70% isopropyl Wipe clean, wash in a cold
alcohol impregnated wipe neutral detergent, rinse, dry
after each use and store dry. and immerse in 70%
On discharge, wash with isopropyl alcohol for 10 min.
detergent, immerse in 70% Wipe and store dry.
alcohol for 10 min. Wipe
and store dry.
Thermometers Wash in detergent solution
(rectal) after each use, wipe dry and
immerse in 70% alcohol for
10 min. Wipe and store dry.
Toilet seats Wash daily with detergent Infected patient or if grossly
and dry. contaminated: Wash with
disinfectant solution, rinse and
dry. This is important in areas
where soiling is more likely,
i.e. gynaecology, maternity,
urology department, etc.
Tooth mugs Use disposable. Heat disinfect in SSD, if
non-disposable.
Toys Soft toys: Machine wash, For children with infectious
rinse and dry thoroughly. diseases do not use
Do not soak toys in a communal toys or those
disinfectant solution. which cannot easily be
Others: Wash with detergent, disinfected. Heavily
rinse and dry or wipe with contaminated soft toys may
an alcohol impregnated swab. have to be destroyed.
88
Table 6.5 Continued

Trolleys (dressing, Clean and surface disinfect. Wipe trolley tops with an
patient theatre alcohol impregnated wipe
table) before and after use. If
contaminated, clean first, then
use an alcohol impregnated
wipe.
Tubing (anaesthetic Reprocess by washing and Infected patients: For patients
or ventilator) sterilization in SSD. with respiratory infection,
tuberculosis or patients with
AIDS use disposable tubing.
Never use glutaraldehyde to
disinfect respiratory
equipment.
Ultrasound Clean and surface disinfect
ultrasound head with 70%
isopropyl alcohol between
each patient.
Urinals Heat disinfect in a bedpan Disposable urinals must be
washer at a temperature of disposed of in a macerator
80°C for 1 min or use unit.
disposables.
Ventilators Cleaning and disinfecting the Contact a member of the ICT
equipment is a procedure for advice if required.
which is normally carried
out in specified areas (i.e.
ICU, special care baby unit,
sterile supply department
(SSD)) according to
written protocol based
on manufacturer’s
recommendations.
Washbasin/sink Clean with detergent, use Disinfection may be required
cream cleaner for stains, if contaminated. Use
scum, etc. Disinfection is non-abrasive hypochlorite
not normally required. powder or hypochlorite/
detergent solution.
Wheel chairs Clean and surface
disinfect. Rinse and dry.
X-ray equipment Damp dust with detergent Clean with detergent and then
solution, do not over-wet wipe with an alcohol
and allow surface to dry impregnated wipe to disinfect.
before use. For specialized equipment,
draw up local protocol for
cleaning and disinfection
based on the manufacturer’s
recommendations.
89

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7
Isolation
Precautions
I n the past, in order to prevent the spread of infectious conditions, patients with
communicable diseases were often segregated. However, as our understanding of
the transmission of infection has improved, isolation practices have accordingly been
refined and moved from an early empirical approach to become more evidence-
based and targeted.
The advent of HIV/AIDS epidemic by the mid 1980s created an urgent need for
new strategies to protect health care workers (HCWs) from blood-borne viral
infections. In 1985, universal blood and body fluid precautions (universal precau-
tions) were proposed by the Centers for Disease Control and Prevention (CDC).
This new approach emphasized, for the first time, the universal use of blood and
body fluid precautions regardless of presumed infectious status. However, the term
‘universal precautions’ was thought to be ambiguous, leading to universal confu-
sion in its interpretation and a false sense of security in its application. There was
also concern that the use of gloves was considered to be a substitute for hand wash-
ing, and that this perception could increase the risk of nosocomial transmission of
infection.
In response to these pressures, the CDC and the Hospital Infection Control
Practices Advisory Committee revised the guidelines for isolation precautions in
hospitals in the US (Garner JS, 1996). However, it is important to emphasize
that there are sufficient differences in the approaches and practices used in the US,
Europe and other part of the world. In addition, any such ‘standardised’ guidelines
cannot address the needs of every hospital and hence it is essential that individual
health care facilities should write policies relevant to local need. In essence, isolation
procedures can be divided into two main categories, i.e. source isolation and
protective isolation.
Source isolation: The aim is to prevent the transfer of microorganisms from infected
patients, who may act as a source of infection to staff or other patients.
95
Protective isolation: The aim is to prevent infection in severely immunocompromized

patients who are highly susceptible to infection both from other persons and the
environment.
Source isolation
The CDC guidelines recommend a two-tier approach. The first tier or standard precau-
tions are aimed at all patients within health care facilities, regardless of their diagnosis
or infectious status. The second tier or additional precautions are transmission-based
precautions that are used for patients who are known or suspected of being colonized
or infected with pathogens transmitted by contact (with skin or contaminated surface),
droplet and airborne routes.
The standard precautions contain a basic level of infection control precautions that
are designed for the care of all patients regardless of their diagnosis or presumed
infectious status. The goal of using standard precautions is to reduce the risk of
transmission of microbes from both recognized and unrecognized sources of infec-
tion. Routine practice of these precautions should become second nature for any
HCW. These precautions are the primary strategy for the successful control of noso-
comial infectious for the following reasons:
• Infectious patients may not show any signs or symptoms of infection that
can be detected in a routine history and medical assessment.
• Infectious status is often determined by laboratory tests that cannot be
completed in time to provide emergency care.
• Patients may be infectious before laboratory tests are positive or symptoms
of disease are recognized.
• Patients may be asymptomatic but infectious.
The additional precautions go beyond standard precautions and are based on the
transmission of infection. They are designed to supplement infection control precau-
tions which cannot be contained by standard precautions alone. These precautions
are transmission-based and grouped into various categories according to the mode of
transmission of microorganisms.
Airborne precautions
Airborne precautions apply to patients with known or suspected infections caused by
airborne pathogens such as tuberculosis, varicella (chickenpox or disseminate vari-
cella infection), and rubella (measles). Such pathogens are transmitted when a sus-
ceptible person inhales the small droplet nuclei of particle size !5 "m. Such particles
are dispersed by air currents and can remain airborne for long periods of time, caus-
ing infection in a susceptible person if exposed at or beyond 3 ft or 1 m of the particle
96
Isolation Precautions
source. When a susceptible person inhales dust particles that contain infectious
microbes, they can reach the alveoli of the recipient to cause infection. Mechanical
ventilation is helpful in diluting and removing this source of infection. The source
isolation room should be under negative pressure ventilation (see page 21). The door
should be kept closed.
A non-susceptible person, if possible, should replace a HCW who is susceptible to

measles or chickenpox instead of caring for a patient with one of these diseases. If
this is not possible, the susceptible worker should wear a mask. Airborne precautions
require that HCWs wear respiratory protection when entering the room of a patient
with known or suspected pulmonary tuberculosis (see page 137).
Droplet precautions
Droplet precautions are intended to reduce the transmission of infections spread by
large particle droplets. Droplet transmission occurs when such particles come into
contact with the eyes or mucous membranes of a susceptible person’s nose or mouth,
such as when an infected person coughs, sneezes, talks, or during procedures involv-
ing the respiratory tract such as suction, physiotherapy, intubation, or bronchoscopy.
In addition, droplets are also produced when water is converted to a fine mist by a
device such as an aerator or showerhead.
Large droplet transmission requires close contact with the infected person. The
droplets travel only short distances (up to 3 ft or 1 m) from the source and do not
remain in the air for long periods. Therefore, special ventilation is not necessary to
prevent droplet transmission. Examples of infection caused by large droplet nuclei
are meningitis caused by Neisseria meningitidis, pertussis, streptococcal pharyngitis,
multi-drug resistant Streptococcus pneumoniae, influenza virus, measles, mumps,
rubella virus etc.
Contact precautions
Contact is the most important and frequent route of spread of nosocomial infections.
It occurs by either the direct or indirect route. Direct contact transmission involves
skin-to-skin contact and physical transfer of microbes from an infected or colonized
patient to a susceptible host. Direct contact may also occur between patients by
means of a HCW’s hand. Indirect contact transmission occurs when a susceptible host
comes in contact with a contaminated object (such as bed scale, or commode) in the
infected person’s environment.
Examples of microorganisms spread by contact with secretions includes

Staphylococcus aureus (including methicillin-resistant Staphylococcus aureus (MRSA)),
faecal contamination from carriers of vancomycin-resistant enterococci, scabies,
Escherichia coli 0157, Clostridium difficile, Herpes simplex, respiratory syncytial
virus etc.
97
Protective isolation
Immunocompromised patients are generally at increased risk from both endogenous
and exogenous sources of infection. They need protection from infection both from
personnel and the environment. Their susceptibility to nosocomial infection may vary
depending on the severity and duration of immunosuppression. Most infections
acquired by immunosuppressed patients are endogenous in origin and isolation in a
single room is not required. However, immunocompromised patients who have the
greatest risk of infection include individuals who are severely neutropenic (i.e. #1,000
polymorphonuclear cells/"L for 2 weeks or #100 polymorphonuclear cells/mL for
1 week), allogeneic hematopoietic stem cell transplant patients, and those who have
received intensive chemotherapy, e.g. childhood acute myeloid leukaemia. Isolation
measures are usually maximal for patients undergoing transplantation. These patients
may be particularly susceptible to environmental contaminants, such as aspergillosis
or legionnaires’ disease. A specialized room with positive pressure ventilation
(see page 21) and high efficiency particulate air filtration is required.
In additions the following precautions should be kept in mind when dealing with
immunocompromised patients:
• Where invasive medical or dental procedures are involved, it would be

reasonable to place immunocompromised patients at the start of the
operating schedule.
• In an outpatient waiting room, additional precautions for the control of
airborne transmission of disease may be required. These patients should be
seen ahead of others in the waiting room, to minimize the time for which
they are exposed to other patients.
• They should be kept separate from other patients who are infected or have
conditions that make the transmission of infection more likely.
Practical issues and considerations

Whenever isolation of a patient is considered, assessment of risk should be carried
out and the disadvantages must be weighed against the benefits. The placement of a
patient into isolation should never be undertaken as a matter of convenience. The
patient’s underlying condition is the driver for determining the provision of care and
where it should be delivered. Isolation of patients may not only have a psychological
impact on the patient, but isolation wards may also have an adverse influence on the
quality of care by distancing the patient from specialist care. Therefore it is essential
that the need to continue isolation should be reviewed on a daily basis and the patient
should be discharged to the community or re-entered into the general hospital
population at the earliest possible opportunity.
If isolation of patients is considered necessary, then it must be done at the time of
admission in an appropriate single room, preferably with en suite toilet facilities.
98
Appropriate infection precautions must commence on clinical suspicion. If a single

room is not available, then patients with the same infection or colonized with the
same microorganisms may be cohorted in a designated area; this is particularly use-
ful in an outbreak situation.
Patients with highly transmissible and dangerous infections, e.g. viral haemorrhagic
fevers must be admitted or transferred to a local Infectious Diseases Unit under strict
isolation.
All HCWs should be appropriately and adequately immunized against infectious dis-
eases, both for their own protection and the protection of others. They must follow
basic infection control procedures at all times. In addition, they must be given
adequate education and training in all activities to prevent exposure of micro-
organisms to themselves and others. The education programme should be regularly
updated in view of changing knowledge and work practice.
It is essential that senior medical staff must act as role models for good infection
control practice. During the ward round they must observe all the necessary infection
control precautions (esp. hand washing) and if possible, should attend the patient in
source isolation last, after dealing with all non-infected patients.
Hand washing is absolutely essential to reduce the risk of infection transmission.

Antiseptic hand wash preparations or alcoholic hand rub should be used. Hands
must be washed or disinfected after removing gloves, between patient contacts, after
touching contaminated patient care equipment, and after coming in contact with
blood or body fluids.
An admissions policy to deal with potentially infectious patients, inter-hospital

transfers and patients from overseas should be drawn up. The initial point of contact
between a hospital and the infectious patient may be the accident and emergency
(A&E) department. There is a greater risk of transfer of microorganisms in A&E as
they are often crowded, may have prolonged patient stays and are usually manned by
staff working under considerable pressures. In order to reduce these risks, hospitals
should consider establishing a fast track or triage system through the accident and
emergency department for potentially infectious patients.
Once admitted, every effort should be made to limit the movement of infectious
patients for essential purpose only. Visits to other departments must be managed to
limit the time out of isolation and contact with other patients. If possible, the patient
should be advised of ways in which he or she can assist.
Door sign
An appropriate sign should be prominently displayed, providing sufficient informa-
tion whilst ensuring that there is no breach of medical confidentiality. Care must be
taken not to stigmatize the patient in isolation.
99
Visitors
All visitors must report to the nurse-in-charge before entering the room for instruc-
tion on protective clothing and other precautions. Effective communication by
the infection control team (ICT) is necessary with visitors and staff who may need
information regarding the risk of acquisition of infection.
Personal protective equipment

Gloves: Wear clean, non-sterile gloves for procedures that may involve contact with
blood or body fluids, secretions, excretions, or non-intact skin or mucous mem-
branes. Remove gloves promptly after use; wash hands after removing gloves.
A separate pair of gloves should be used for the next patient.
Masks and eye protection: Masks and eye protection help to guard the mucous
membranes of the eyes, nose, and mouth from exposure to blood or body fluids that
may be splashed, sprayed, or splattered into the face. Wear such protective gear if
splashing of blood or high risk body fluid is anticipated. Masks are single-use items
and should be disposed of as clinical waste.
Aprons: Single-use disposable plastic aprons are recommended for general use and
should be worn when there is a risk that clothing or uniform may become exposed
to blood, body fluids, secretions and excretions. Plastic aprons should be worn as
single-use items for one procedure or episode of patient care only. They should be
removed immediately after use by tearing the neck strap and the waist tie and dis-
carded into clinical waste bag before leaving the room. Hands must be washed
immediately after removing and bagging the soiled plastic apron.
Gowns: Clean, non-sterile gowns should be worn during procedures which are likely
to exposed HCWs with spraying or splashing of blood, body fluids, secretions, or
excretions. Gowns should be impermeable and water repellent. If the gown is
expected to become wet during the procedure and if a water repellent gown is not
available, a plastic apron should be worn over the gown. Grossly soiled gowns should
be promptly removed and placed in the designated leak-proof laundry bag. Hands
should be washed immediately after removing and bagging of the soiled gown.
Crockery and cutlery

Crockery and cutlery used by infectious patients can be washed in the normal hos-
pital dishwasher and represent a very low risk for the transmission of infection. The
combination of hot water and detergent used by well-maintained dishwashing
machines is sufficient to decontaminate crockery and cutlery. Washing by hand may
not always guarantee decontamination. Disposable utensils are not normally required.
Linen
Wear appropriate protective equipment when handling linen contaminated with
blood, body fluids, secretions, or excretions. Handle soiled linen as little as possible
100
and place it in a appropriate laundry bag. To avoid contaminating a uniform, soiled

linen should be held away from body.
Environmental cleaning
Whilst in use by a patient, the room and its equipment should be cleaned using the
agreed Standard Isolation procedures unless the infecting microorganism or the
degree of environmental contamination indicates a need for special action. Hot
water and detergent are sufficient for most purposes. Thorough cleaning and
adequate disinfection is particularly indicated for pathogens that can survive in the
general environment for prolonged periods, e.g. the spores of C. difficile.
When the patient is discharged from an isolation room, before re-use, the room
should be thoroughly cleaned, including all furniture and equipment (see page 75).
When dry, it may be occupied by the next patient. The methods and frequency
for these processes, and the products used, are a matter for local policy. Staff
employed for these purposes should receive specific training in the relevant aspects
of infection control, which includes issues for specific areas such as isolation
rooms.
Spillage of blood and body fluids should be disinfected and cleaned promptly using
a safe method (see page 77). Appropriate protective clothing should be worn and
waste should be discarded as clinical waste.
Decontamination of items and equipment

Reusable equipment should not be used for the care of another patient until it has
been cleaned and adequately decontaminated. If the equipment is soiled with blood,
body fluids, secretions, or excretions, wear appropriate protective gear when cleaning
or handling it. Discard single-use items after their use.
Bedpans/urinals
Excreta from infected patients should be disposed of as soon as practicable; prior
soaking in disinfectant is not required. Commodes, bed pan carriers, urine measur-
ing jugs, and toilets are a risk particularly for enteric pathogen transfer and must be
regularly and adequately cleaned according to local policies.
Single-use bedpans and urinals can be employed and are disposed of in a macerator.
Reusable bedpans/urinals should be cleaned and heat disinfected in a bedpan washer.
The bedpan washer must be included in a planned preventative maintenance
programme.
Clinical waste
Waste from patients with a known or suspected infection should be treated as clin-
ical waste. It is important that the amount of waste classified as clinical waste should
be reviewed and minimized as far as possible. All clinical waste should be put into an
101
Table 7.1 Summary of infection control precautions for various categories.
Activity Standard Additional precautions

precautions
Airborne Droplet Contact
transmission transmission transmission
Single room Noa Yes – door Yes Yes – if possible.

closed (cohort with
patient with the
same infection)
Negative No Yesb No No
pressure
ventilation
Handwashing Yes Yes Yes Yes
Gloves For body For body For body Yes
substances substances substances
Gown If soiling If soiling If soiling If HCW’s clothing
likely likely likely will have
substantial
contact with
the patient,
environmental
surfaces or
items in the
patient’s room
Mask Protect face Particulate Noc Protect face if
if splash mask for splash likely
likely tuberculosis
only. All others,
regular mask.
Goggles/ Protect face Protect face Protect face Protect face
face-shields if splash if splash if splash if splash
likely likely likely likely
Miscellaneous Avoid Teach patient Provide Remove gloves
contaminating to cover nose 1 m of and gown, wash
environmental and mouth separation hands before
surfaces with when between leaving patient’s
gloves coughing or patients in room
sneezing cohort
a
Except certain circumstances determined by those responsible for infection control.
b
Keep room vacant 1 h postdischarge of patient. 2–3 h for measles.
c
Only for situations that may provoke contamination of mucous membrane. Procedures
that are likely to create significant aerosols, e.g. suctioning, dentistry, intubation, chest
physiotherapy etc.
appropriate plastic bag. All used sharps must be discarded, without re-sheathing, into
an approved container. Sharps boxes should be readily accessible and must be
securely fastened. Clinical waste should be segregated, stored and transported
according to local policy.
102
Transport of pathology specimens

Collection, labelling and transportation of laboratory specimens from patients in
isolation rooms should follow written policies that reflect national guidelines. The
specimens should be taken before starting antimicrobial therapy. Laboratory speci-
mens must be correctly labelled and packaged, i.e. the request form must be kept sep-
arate from the specimen in a self-sealing plastic bag. Specimens must be handled
carefully, ensuring that the outside of the container is not contaminated. Specimens
from a patient with known or suspected infectious disease should have a ‘Danger of
Infection – Take special care’ label both on the request form and on the specimen.
All specimens must be transported in an appropriate con-

tainer to the laboratory. The specimens from a patient
with known or suspected to be infected with highly trans-
missible and dangerous pathogens must not be sent to the
laboratory without prior arrangement with the laboratory
staff.
When a specimen pneumatic tube system exists this should only be used after appro-
priate consideration of the risks. Porters and others who transport specimens must
be aware of the procedures for transportation and follow appropriate procedures in
the event of spillage or breakage of specimen containers. Up-to-date standard oper-
ating procedures should be available for all these processes.
Commercial containers are available for safe transportation of specimens.

Transportation of infectious material from one laboratory to another should follow
local guidelines. International and national transport of infectious material by post,
road, rail and air is subject to strict controls.
Deceased patients
As a general rule, the infection control precautions prescribed during life are con-
tinued after death. If a person known or suspected to be infected dies either in hospital
or elsewhere, it is the duty of those with knowledge of the case to ensure that those
who handle the body should be aware of the potential risk of infection, so that the
appropriate control measures are taken. In cases where there is an infection risk from
the body, a ‘Danger of Infection’ label should be attached to the patient’s armband.
103
Table 7.2 Type and duration of isolation precautions.
Disease Category of Duration of Comments

isolation and infection control
precautions precautions
AIDS Standard See page 188
Actinomycosis Standard
Amoebiasis Standard As long as cysts

appear in faeces
Anthrax Standard Duration of Laboratory must be

hospitalization; informed if the
until off antibiotics specimens are sent
and cultures are for examination
negative
Ascariasis Standard
Aspergillosis Standard No person-to-person

transmission
Botulism Standard
Brucellosis Contact Precautions only if Person-to-person

draining lesions(s) transmission rare
Campylobacter Standard Duration of Person-to-person

gastroenteritis diarrhoea transmission rare
Candidiasis Standard Spread rare, except

in high dependency
units, i.e. SCBU, ICU
etc
Chickenpox Airborne and Exclusion should See page 165.

(Varicella) contact continue until Discharge patient
lesions are home if clinical
encrusted. condition permits.
Patient is infectious HCWs should have
until 5 days after a clear history of
rash appears. chicken pox or
should know that they
are immune.
Visitors who have
not had the disease
to be warned of the
risk.
Chlamydia Standard Duration of

trachomatis symptoms
infection
Cholera Standard Duration of illness Until three

cultures of
stools are negative
104
Table 7.2 Continued

Clostridium
perfringens
Food poisoning Standard
Gas gangrene Standard Duration of illness Usually autogenous
infection.
Not transmitted from
person-to-person.
Isolation of patient
not necessary.
Clostridium difficile Contact Duration of diarrhoea See page 147
Conjunctivitis
Acute bacterial and Standard
chlamydial
Gonococcal Standard Until 24 h after
starting antibiotic
therapy
Acute viral Contact
haemorrhagic
Cryptococcus Standard Duration of illness
Cryptosporidiosis Standard Duration of diarrhoea
Creutzfeldt-Jacob Standard No person-to-person
disease transmission
Cytomegalovirus Standard Pregnant staff should
infection (neonates & avoid contact,
immunocompromised) particularly with
patient’s urine (see
pages 216–217)
Diarrhoea Standard See page 155
Diphtheria
Cutaneous Contact Until off antibiotics Throat and nasal
and three swabs are swabs should be
culture negative from taken from all
skin lesions taken at close contacts.
least 24 h apart after Notify laboratory
antibiotic therapy before swabbing
contacts.
Pharyngeal Droplet Until off antibiotics Culture positive
and three consecutive carriers of toxigenic
swabs from nose and C. diphtheria should
throat are culture receive
negative chemoprophylaxis
with erythromycin
105
Table 7.2 Continued

and swabs repeated

after treatment.
No admission of
patients until contacts
are bacteriologically
clear.
Dysentery Standard
Amoebic Standard As long as cysts
appear in faeces
Bacillary Contact Duration of diarrhoea Discharge patient
home if clinical
condition permits
Echinococcosis Standard
(Hydatidosis)
Ebola virus Contact During hospitalization See page 175
Encephalitis or Contact Until off antibiotic

encephalomyelitis and cultures are
negative
Enteric fever
Typhoid Standard Duration of diarrhoea
Paratyphoid Standard Duration of diarrhoea
Epiglottis Droplet Close contacts should

(H. Influenzae be given rifampicin as
type b) chemoprophylaxis
Gas gangrene Contact Usually autogenous

infection.
person-to-person.
Isolation of patient
not necessary.
Gastroenteritis Standard See page 155
Glandular fever Standard Until acute phase is Isolation of patient

over not necessary
German measles Droplet From 7 days before up Discharge patients

(Rubella) to 10 days from onset home if clinical
of rash condition permits.
Exclude non-immune
women (staff or
visitor) of child
bearing age.
106
Table 7.2 Continued

Gonococcal
Ophthalmia Contact For 24 h after the
neonatorum start of effective
antibiotic therapy
Gonorrhoea Contact For 24 h after the
start of effective
antibiotic therapy
Hepatitis viral
Type A Standard and 7 days before to Hepatitis A is most
Contact 7 days after onset contagious before
of jaundice jaundice and is
infectious in the early
febrile phase of
illness. Close contacts
may be given gamma
globulin within 14 days
to abort or attenuate
clinical illness.
Type B & C Standard
Type E Standard
Herpes simplex Contact Until vesicles healed Protect
immunologically
compromised
patients. Wear gloves
when hands are in
contact with oral or
genital secretions.
Staff with cold sores
should not work with
compromised
patients, neonates
or burns patients.
Herpes zoster Contact Length of acute illness, As Herpes zoster may
(Shingles) i.e. until vesicles dry lead to cases of
chicken pox,
susceptible
individuals and staff
who have not had
chickenpox should be
excluded from contact
with the patient.
Visitors who have not
had chickenpox
should be warned
of the risks.
HIV infection Standard Isolation required
only in special
107
Table 7.2 Continued

circumstances.
See page 186
Hookworm disease Standard
Impetigo Contact For 24 h after start
of effective antibiotic
therapy
Infectious Standard Until acute phase is Oral secretions
mononucleosis over precautions
(Glandular fever)
Influenza Droplet In prodromal phase and Immunization can
for 5 days after onset be offered to a
selected group
Lassa fever Contact Duration of See page 175 for
hospitalization details
Legionnaire’s Standard Not transmitted from
disease person-to-person;
isolation of patient
not necessary
See page 151
Leprosy Standard
Leptospirosis Standard Duration of Contact precautions
(Weil’s disease) hospitalization for urine only.
person-to-person;
isolation of patient
not necessary.
Listeriosis Contact Duration of Person-to-person
hospitalization spread rare
Lyme disease Standard
Malaria Standard
Marburg virus Contact Duration of See page 175
disease hospitalization for details
Measles Droplet For 5 days start Discharge patient
of rash, except in home if clinical
immunocompromized condition permits.
patients with whom Immunoglobin for
precautions should exposed
be maintained for immunocompromised
duration of illness patient.
If outbreak
in a paediatric ward,
do not admit
108
Table 7.2 Continued

children who are not

immunosuppressed
until 14 days after
the last contact has
gone home.
Meningitis
‘Coliforms’ None
Listeria None See under
monocytogenes Listeriosis.
Neisseria meningitidis Droplet For 48 h after start Visiting by all children
(Meningococcal) of effective antibiotic should be
therapy and patient has discontinued.
received See page 160.
chemoprophylaxis
Haemophilus Droplet Duration of illness Close contacts should
influenzae (type b) be given rifampicin as
prophylaxis.
Pneumococcal Standard
meningitis
Tuberculosis Standard or Isolate if patient has
airborne if respiratory open
pulmonary TB pulmonary TB.
Meningitis Droplet
Viral Standard Until virus no longer Seek advice from a
present in stool member of infection
control team (ICT)
Meningococcal Droplet For 48 h after start See page 160.

septicaemia of effective antibiotic
therapy and patient has
received
chemoprophylaxis
MRSA Contact Until three swabs are See page 121.

negative
Multi-resistant Contact See page 134.

Gram-negative
organisms
Mumps Droplet 7 days before to 9 days Exclude non-immune

after onset of parotid staff.
swelling Inform visitors who
are not immune.
Persons with
subclinical infections
may be infectious.
109
Table 7.2 Continued

Mycoplasma Standard
Norcadia Standard
Orf Standard Contact precautions
for exudates.
Isolation of patients
not necessary.
Pertussis (see Droplet
Whooping cough)
Pinworm infection Standard
Plague
Bubonic Standard Duration of
hospitalization until
culture negative
Pneumonic Droplet Duration of
hospitalization until
culture negative
Pneumonia Usually none Isolation required
(see comments) with respiratory
precautions for
Strep. pneumonia
resistant to penicillin
MRSA, plague and
psittacosis.
Poliomyelitis Contact Until stools negative Droplet spread is
for polio virus or possible during
7 days from onset its earliest phase
first week; masks
should be worn.
Subsequently, faecal
excretion is more
important.
Visitors and staff
should be immunized.
Gamma globulin for
non-immuno contacts
booster for
immunized contacts.
No elective surgery
on non-immunized
contacts.
Virus shedding may
follow vaccination with
a live oral polio vaccine
for several weeks.
110
Table 7.2 Continued

Psittacosis (Q fever) Standard For 7 days after onset

Rabies Standard Duration of Immunize staff in
hospitalization close contact. See
page 179 for details.
Ringworm Standard Isolation in a cubicle
is advisable especially
in paediatric ward.
Rubella Droplet From 7 days before up Discharge patient
to 10 days from onset home if clinical
of rash condition permits.
Exclude non-immune
women (staff or
visitor) of child
bearing age.
Salmonellosis Standard Duration of diarrhoea Staff (except in
catering or food
handler) may return
to work when free of
symptoms (i.e. formed
stool).
Scabies Contact Until completion of See page 181–182 for
appropriate treatment details.
Schistosomiasis Standard
(Biliharziasis)
Shigellosis Standard Until three cultures of
stools are negative
Streptococcal Standard
infection
Group A (Strep. Contact Until off antibiotics
pyogenes) and cultures are
negative
Group B Standard Cross-infection can
occur in SCBU.
Group C Standard
Group G Standard
Staphylococcal None
(food poisoning)
Syphilis
Congenital, primary Contact For 48 h after start Skin lesions of
and secondary of effective therapy primary and
secondary syphilis
may be highly
infectious.
111
Table 7.2 Continued

Latent (tertiary) and Standard

seopositive without
lesions
Tetanus Standard
Thread worm Standard
Toxocara Standard
Toxoplasmosis Standard
Trichomoniasis Standard
Trichuriasis Standard
(Whipworm)
Tuberculosis
Pulmonary (open) Airborne Two weeks after start Staff and visitors who
of effective anti-TB are not immune
treatment and sputum should be warned
is negative for AAFB. of the risk. Face mask
Four weeks in neonatal should be given.
and paediatric wards or Refer to page 142
if immunosuppressed for details.
patients are present.
Closed Standard Isolation of patient
not necessary
Typhoid/Paratyphoid Standard and
fever contact
Vincent’s angina Standard
(Trench mouth)
Viral Haemorrhagic Contact Duration of See page 175.
Fevers hospitalization
VRE (Vancomycin Contact See page 130.
resistant enterococci)
Whooping cough Droplet Until 3 weeks after Discharge patient
(Pertussis) onset of paroxysmal home if clinical
cough or 7 days after condition permits.
start of effective Visiting by children
antibiotic therapy should be restricted
to those who are
immune.
Prophylactic erythromycin
to close contacts.
Yellow fever Standard
112

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113
APPENDIX I
Incubation periods
Diseases Average period (range)
AIDS/HIV Variable – may be years

Amoebic dysentry 2–4 weeks (few days to several months)
Anthrax A few hours to 7 days (most cases occur
within 48 h after exposure)
Ascariasis 4–8 weeks
Aspergillosis Unknown
Botulism 12–36 h (up to several days)
(Infant botulism 3 days to 2 weeks)
Brucellosis 5–60 days (highly variable may be up to
several months)
Campylobacter enteritis 3–5 days (1–10 days)
Candidiasis 2–5 days
Cat-scrath disease 3–10 days to appearance of primary lesion,
further 2–6 weeks to appearance
of lymphadenopathy
Chancroid (H. ducreyi) 3–5 days (up to 14 days)
Chickenpox (Varicella) 13–17 days (10–21 days; may be prolonged
after passive immunization against varicella
and in the immunodeficient)
Chlamydial conjunctivitis 5–12 days (3 days to 6 weeks in newborns;
(Chlamydia trachomatis) 6–19 days in adult)
Cytomegalovirus (CMV) Within 3–8 weeks after transplant or transfusion
with infected blood; infection acquired during
first birth is demonstrable 3–12 weeks in
newborn after delivery
Dengue Fever 7–10 days (3–14 days)
Dermatophytoses See under Tinea
Diphtheria 2–5 days (2–7 days)
Erytherma infectiosum 4–10 days (variable)
(Fifth disease or parvovirus)
Gastroenteritis (viral)
Adenovirus 8–10 days
Astrovirus 1–2 days
Calcivirus 1–3 days
Norwalk 12–48 h
Rotavirus 1–3 days
Continued over the page
114
Gastroenteritis &
food poisoning (bacterial)
Salmonellosis 12–36 h (6–72 h)
Shigellosis (Bacillary dysentry) 1–3 days (12–96 h)
Campylobacter jejuni/coli 3–5 days (1–10 days)
Staphylococcus aureus 2–4 h (30 min to 7 h)
Clostridium difficile 5–10 days (few days to 8 weeks)
after stopping antibiotics
Clostridium perfringens 10–12 h (6–24 h)
Clostridium botulinum 12–36 h (12–96 h)
Cryptosporidiosis 7 days (2–14 days)
Giardiasis 7–10 days (5–25 days)
(Giardia lamblia)
Bacillus cereus 1–6 h where vomiting is
predominant symptom
6–24 h where diarrhoea is
predominant
Cholera 1–3 days (few hours to 5 days)
Escherichia coli 10–18 h
(Entero-invasive
[EIEC])
Escherichia coli 9–12 h (probably)
(Enteropathogenic
[EPEC])
Escherichia coli 1–5 days
(Enterotoxigenic
[ETEC])
Escherichia coli 0157:H7 1–3 days (12–60 h)
(Verocyotoxin [VTEC])
Vibrio parahaemolyticus 12–24 h (2–96 h)
Yersinia enterocolitica 24–36 h (3–7 days)
Aeromonas hydrophila 12–48 h
Listeria monocytogenes 48 h to 7 weeks
Gonorrhoea 2–7 days genito-urinary; 1–5 days
ophthalmia neonatorum
Haemophilus influnenzae 2–4 days (probably)
type b infection
Hand, foot and mouth disease 3–5 days
Hepatitis
Hepatitis A 25–30 days (15–50 days)
Hepatitis B 75 days (45–180 days)
Hepatitis C 20 days to 13 weeks
(2 weeks to 6 months)
Hepatitis D 35 days (2–8 weeks)
Hepatitis E 15–64 days (26–42 days)
115
Herpes simplex 2–14 days (2–28 days perinatal

infection)
Impetigo
Streptococcal 7–10 days
Staphylococcal 1–10 days
Infectious mononucleosis 4–6 weeks
(Glandular fever)
Influenza 1–5 days
Legionnaires’ disease 5–6 days (2–10 days
for pneumonia);1–2 days for
pontaic fever
Leishmaniasis
Visceral Few weeks to 6 months
Cutaneous Few weeks
Leptospirosis 10 days (4–19 days)
Listeriosis 3 days to 10 weeks
Lyme disease 7–10 days (3–32 days)
after tick exposure
Lymphocytic
choriomeningitis 8–13 days (15–21 days)
Lymphogranuloma
venereum 3–30 days
Malaria
P. falciparum 7–14 days
P. vivax 8–14 days
P. ovale 8–14 days
P. malariae 7–30 days
Measles 8–12 days (7–18 days)
Meningococcal disease 3–4 days (2–10 days)
Molluscum contagiosum 2–7 weeks (7 days to
6 months)
Mumps 16–18 days (12–25 days)
Mycoplasma pneumoniae 6–23 days
Pertussis (Whooping cough) 7–10 days (6–20 days)
Plague
Bubonic 2–6 days
Pneumonic 2–4 days
Pneumocystis carinii Unknown
Poliomyelitis 7–14 days (3–35 days)
116
Psittacosis 1–4 weeks

(Chlamydia psittaci)
Q fever 2–3 weeks (depends on size
(Coxiella burnetii) of infecting dose)
Rabies 2–8 weeks (5 days to a year or more,
depends on the site and severity of
the wound; injury closer to brain
has shorter incubation period)
Relapsing fever 8 days (5–15 days)
(B. recurrentis)
Respiratory syncytial virus 4–6 days (2–8 days)
Ringworm
Tinea capitis 10–14 days
(scalp ringworm)
Tinea corporis 4–10 days
(body ringworm)
Tinea pedis Unknown
(athlete’s foot)
Tinea unguim Unknown
Roseola infantum 8–10 days
Rubella (German measles) 16–18 days (14–32 days)
Salmonellosis 12–36 h (6 h to 3 days)
Scabies 2–6 weeks without previous
exposure; 1–4 days re-infection
Shigellosis 1–3 days (12–96 h)
Syphilis 3 weeks (10 days to 3 months)
Tetanus 3–21 days (1 day to several
months depending
upon the character, extent
and the location of wound)
Threadworms Unknown
Toxic shock syndrome 2 days
Toxocariasis Weeks to several months
depending on the intensity of
infection. Up to 10 years for
ocular symptoms
Toxoplasmosis 7 days (4–21 days)
Tuberculosis 4–12 weeks (variable)
Typhoid and paratyphoid 1–3 weeks (3–60 days)
fevers
117
Typhus fever 12 days (1–2 weeks)

Viral haemorrhagic fevers
Marburg 3–9 days
Ebola 2–21 days
Lassa 6–21 days
Yellow fever 3–6 days
118
8
Prevention of Infections
Caused by Multi-resistant
Organisms
R esistance to antimicrobial agents among clinically important bacteria has

increased in recent decades and occurs worldwide. The impacts of resistance
range from the failure of an individual patient to respond to therapy and the changes
needed in empirical therapy to the economic impact of prescribing costs, hospital
stay, and the social costs of morbidity and mortality from infection.
Acute health care facilities serve both as a point of origin and as a reservoir for highly
resistant pathogens. This is because patients admitted to hospitals are highly susceptible
and are usually subjected to intensive and prolonged antimicrobial use. In addition,
failure in infection control practice can result in cross-infection and outbreak
of nosocomial infections with highly resistant bacterial pathogens such as methicillin-
resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and
multi-resistant Gram-negative bacilli as well as resistant fungal infections. Some of
these resistant strains have now spread outside hospitals causing infections in the com-
munity. In addition, patients admitted to hospital can bring with them resistant
microorganisms acquired in the community, including penicillin-resistant Streptococcus
pneumoniae, multi-resistant salmonellae and multi-resistant M. tuberculosis.
The key element in minimizing the emergence of multi-resistant microorganisms

and control include:
• Active surveillance of infections and antimicrobial resistance pattern

recognition, investigation and control of outbreaks or clusters of
infections.
• Good microbiology laboratory practice using international accepted
method of antibiotic susceptibility testing is the key to the prompt identi-
fication of resistant pathogens and collection of accurate surveillance data.
119
• Effective control of antimicrobial use in health care setting by developing

antibiotic policies based on local antibiotic resistance pattern and surveil-
lance data. This should be supplemented by regular audit and feedback of
date to the prescribers.
• Development and implementation of appropriate infection control measures
including hand decontamination and isolation/cohorting of affected
patients.
• Adequate disinfection and sterilization of items and equipment, which
come into contact with patients.
• Effective cleaning and decontamination of the hospital environment.
• Education and training of health care personnel in appropriate aseptic
techniques for medical and nursing procedures, infection control proced-
ures, and antibiotic prescribing.

Bonten MJM, Austin DJ, Lipsitch M. Understanding the spread of antibiotic resistant
pathogens in hospitals: mathematical models as tools for control. Clinical Infectious
Diseases 2001; 33: 1739–1746.
Goldmann DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent and control the
emergence and spread of antimicrobial-resistant microorganisms in hospitals. Journal of
American Medical Association 1996; 275(3): 234–240.
Nicolle L. Infections control programmes to control antimicrobial resistance. Geneva: World

Health Organization, 2001. WHO/CDS/CSR/DRS/2001.7.
SHEA Position paper. Society for Healthcare Epidemiology of America and Infectious
Disease Society of America Joint Committee on the Prevention of Antimicrobial
Resistance: Guidelines for the Prevention of Antimicrobial Resistance in Hospitals.
Society for Healthcare Epidemiology of America and Infectious Disease Society of

America. Global Consensus Conference: Final Recommendations. American Journal of
Infection Control 1999; 27: 503–513.
UK Department of Health. The Path of Least Resistance. Standing Medical Advisory

Committee-Sub-Group on Antimicrobial Resistance. London: DoH, 1998.
120
Prevention of Infections Caused by Multi-resistant Organisms
METHICILLIN-RESISTANT Staph. aureus

Staph. aureus is one of the most common pathogens well known for causing skin and
soft tissue infection, e.g. impetigo, folliculitis, cellulitis etc. In addition, Staph. aureus
may cause systemic infections such as abscesses, pneumonia, osteomyelitis, septi-
caemia, endocarditis and meningitis. Up to 30% of healthy people carry Staph.
aureus in their nose and other moist and hairy areas of the body.
Methicillin (flucloxacillin or cloxacillin) resistant Staph. aureus (MRSA) are import-

ant in that they are resistant not only to flucloxacillin and erythromycin, the most
commonly used antibiotics to treat Staph. aureus infection, but also to other oral
antibacterial agents, leaving only intravenous (IV) antibiotics for treatment. MRSAs
do not generally appear to be more virulent than sensitive strains but, because of
their resistance patterns, they are more difficult to treat if infection occurs. In add-
ition, intermediate vancomycin or glycopeptide resistant Staph. aureus (VISA or
GISA) have been detected in some countries. In June 2002, the first clinical occurence
of Staph. aureus fully resistant to vancomycin (VRSA) was isolated from the USA.
Despite vigorous attempts at eradication over the last 20 years, MRSA continues to
be the major nosocomial pathogen worldwide. The level of hospital MRSA infection
is indicative of the overall infection rate of the institution and usually reflects:
• Higher concentrations of sicker patients

• Overcrowding of wards
• Higher throughput of patients
• Heavy nursing load and under staffing, and
• Increased use of agency nursing staff unfamiliar with local infection
control procedures.
There is a high patient morbidity and mortality associated with hospital-acquired

MRSA especially in intensive care wards, infected vascular/orthopaedic prostheses,
surgical wound infection and cases where septicaemia and pneumonia develop.
Source of infection
MRSA is common in many hospitals, and has a high propensity to become endemic.
MRSA colonization precedes infection. Infected and colonized hospital patients are
the major primary reservoirs in the health care setting. Colonization of hospital
patients is dependent on:
• Length of hospital stay

• Severity of underlying disease
• Presence of wounds and/or invasive devices
121
• Recurrent or recent antibiotic treatment, and

• Nutritional status of the patient.
Community reservoirs include:
• Patients recently discharged from hospital

• Patients with chronic leg ulcer
• Nursing and residential home residents
• Patients with dermatological disease, e.g. eczema, and
• IV drug users.
Mode of transmission
The major route of transmission of MRSA within institutions is from patient-
to-patient via the hands of hospital health care workers (HCWs) who acquire the
organism after direct patient contact or after handling contaminated materials. This
is usually associated with inadequate handwashing. Unfortunately it has been shown
that HCWs, particularly doctors, frequently fail to wash their hands between seeing
patients. Other forms of transmission, such as from colonized HCWs or from the air
or environmental surfaces, are usually less important.
Control measures
It is important to ensure that a proper surveillance and monitoring system is in
place. If it becomes apparent that the rate of MRSA is disproportionately high, then
specific and locally appropriate preventative measures need to be developed and
implemented. Although various guidelines have been published, there are no uni-
versally agreed standards for control. The approach of management depends on two
factors:
• Endemicity of the resistant organism in the institution, and

• Vulnerability of the patients in the wards/unit where they occur.
In non-endemic institutions, the object should be elimination (‘search and destroy’
policy) of MRSA. Elimination involves confining the organisms to the individual(s)
first identified as colonized or infected, and detecting other patients to whom the
infection may have been transmitted (as for outbreak screening). Elimination
is usually achieved by discharging colonized/infected patients. An alert system for
readmission of these patients is required to make this fully effective, because carriage,
(particularly of MRSA and VRE) can be very prolonged. The role of broader screen-
ing of risk groups on a routine basis is less clear, and costs can be considerable.
In an institution where MRSA is endemic the object is of minimization which involves

ensuring that further transmission to new patients is minimized. Segregation of
122
known colonized and infected patients still plays a useful role. In high-risk patients
and clinical areas (e.g. intensive care units), some form of ongoing screening
programme may be of benefit in identifying new admissions who are colonized.
In an acute health care facility, where the organisms are not endemic, rigorous applica-
tion of infection control measures have been shown to be effective in containing or elim-
inating the problem, although this can be expensive and its cost-effectiveness is unclear.
Infection control precautions
All patients admitted from other hospitals and patients from other countries requir-
ing medical treatment, especially with a history of previous hospital admission,
should be admitted to a side ward and screened for carriage of MRSA. The patient’s
case notes must be identified with a warning MRSA sticker. They should also be
‘flagged’ on the Patient Information Services computer, if possible.
If asymptomatic patients are found to be carriers of MRSA, it is worthwhile dischar-
ging them from hospital (if clinical condition permits) on an anti-staphylococcal
protocol (see page 125) for elimination of MRSA. If the patient requires treatment in
another hospital, the clinician and the member of Infection Control Team (ICT) at the
receiving hospital should be informed.
The number of staff caring for the patient should be kept to a minimum, if possible.
Staff with skin lesions, eczema or superficial skin sepsis should be excluded from
contact with the patient. As a general rule, patients with MRSA should be the last
seen on a ward round, if at all possible.
• All patients known to be infected or colonized with MRSA should be

admitted to a single room with its own bathroom facilities or cohorted
with patients with the strain. The patient should be advised that there is no
risk to healthy relatives or others outside the hospital. They should also be
given information and a fact sheet about MRSA.
• Single-use disposable plastic aprons should be worn for activities
involving contact with the patient or their environment. For extensive phys-
ical contact with the patient, non-permeable disposable gowns are required.
• The gown or plastic apron and gloves should be removed before leaving
room. When disposing of protective clothing, it is essential that it should not
come in contact with the environmental surfaces. Used plastic aprons/gowns
should be discarded into a yellow clinical waste bag before leaving the room.
• Single-use disposable gloves should be worn for handling contaminated tis-
sue, dressings or linen. Hands must be decontaminated after removing gloves.
• High efficiency filter type masks should be used for procedures that may
generate staphylococcus aerosols, e.g. sputum suction, chest physiotherapy
or procedures on patients with an exfoliative skin condition, and when
performing dressings on patients with extensive burns or lesions.
123
• Hands must be washed before and after contact with the patient or their
immediate environment. They should be washed thoroughly using an
antiseptic chlorhexidine/detergent or alternatively, physically clean hands
can be disinfected with an alcoholic hand rub.
• All single-use items must be disposed of as clinical waste. Clinical waste
bags must be sealed before leaving the room. Any reusable items should be
processed in accordance with the local disinfection policy.
• Use dedicated equipment, e.g. stethoscope, sphygmomanometer and
thermometer. Clean and disinfect before reuse.
• Instruments used for dressing changes should not be transferred from
patient-to-patient but should remain by the patient’s bedside. Consider the
surfaces and furniture within the rooms to be contaminated as well as the
patients themselves.
• All bed linen and clothing should be changed daily. Used linen must be
handled gently at all times and should be processed according to local
policy. Linen bags must be sealed at the bedside and removed directly to the
dirty utility area or to the collection point.
• After discharge of the patient, the room should be thoroughly cleaned using
detergents. Surfaces should be disinfected using appropriate disinfectant,
e.g. freshly prepared hypochlorite solution 1:100 dilution. Once the room is
dry it can be used for other patients.
Patient’s movement
Visits by patients with MRSA to other departments should be kept to a minimum. For
any treatment or investigations, prior arrangements must be made with the other
department. They should be seen immediately and not left in a waiting room with
other patients.
Within the hospital: Transfer of infected or colonized patients to other wards or depart-
ments should be kept to a minimum. If the patient is moved to a different ward, all
open lesions should be covered with an impermeable dressing during the transfer.
Inter-hospital transfer: Inter-hospital movement should be restricted where this is

possible. If transfer is necessary, then the ICT of the receiving hospital should be
informed. A letter should also be sent giving the relevant clinical details as to whether
the patient is infected or colonized with MRSA and the details of the treatment
protocol, so that a course of treatment can be completed.
Nursing or residential home: Continued carriage of MRSA is not a contraindication for

the transfer of the patient to a nursing or residential home. If the patient is discharged
to the residential or nursing home, the owner of the nursing home should be informed.
124
Decolonization therapy for MRSA

Treatment should be prescribed for 5 days at the advice of medical practitioner.
Nose: Apply 2% nasal mupirocin ointment three times a day for 5 days. A small
amount of ointment (about the size of a match-head) should be placed on a cotton
bud and applied to the anterior part of the inside of each nostril. The nostrils are closed
by gently pressing the sides of the nose together; this will spread the ointment through-
out the nares.
Body bathing: Shower: Wash vigorously with an antiseptic detergent (triclosan or

chlorhexidine), beginning with and paying particular attention to the hair, around the
nostrils, under the arms, between the legs (groin, perineum, and buttock area), feet
and working downwards. Rinse from head to toe and dry body with a clean towel.
For the bath add antiseptic (triclosan or chlorhexidine) bath concentrate to a bath full
of water immediately prior to the patient entering the water.
Body bathing or bed bathing: Patients confined to bed can be washed with an anti-
septic detergent (triclosan or chlorhexidine). Wet skin, apply about 30 ml of antiseptic
soap preparation directly onto the skin using a disposable cloth. Wash and rinse from
head to toe. Dry body with a clean towel.
Note: Triclosan should be in contact with the skin for about 1 min and then thoroughly
rinsed.
Hexachlorophane powder: Hexachlorophane 0.33% powder can be used to treat car-

rier sites. It should be applied to intact skin such as the perineum, buttocks, flexures
and axillae three times daily for 5 days. Do not use hexachlorophane powder on badly
excoriated or inflamed skin or during pregnancy. The product should be administered
to children less than two years of age on medical advice only.
Colonized lesions: Mupirocin ointment can be applied topically three times a day to
small lesions for 5 days. It should be used with caution if there is evidence of mod-
erate or severe renal impairment. Dressing containing chlorhexidine or povidone-
iodine may be applied to the infected wound.
Helpful hints
• Antiseptic detergents should be used with care in-patients with dermatitis and
broken skin and must be discontinued if skin irritation develops.
• Mupirocin ointment should be reserved for the treatment of MRSA. Prolong course
(more than 7 days) or repeated course (more than two courses per hospital admis-
sion) should be avoided to prevent emergence of resistant.
• Repeat swabbing is required at the advice of the ICT.
• Launder towels and cloths after use. Patient’s clothes (including undergarments/night
wear) should be changed on a daily basis and washed in hot water cycle. Dry clean
non-washable and woolen clothes. Bed linen should be changed at the beginning
of protocol and then every day until the end of protocol.
125
Ambulance transportation: The ambulance service should be notified in advance.

There is no evidence that ambulance staff or their families are at risk from trans-
porting patients with MRSA. The following infection control measures should be
taken:
• The patient should be given clean clothing before transport.

• A disposable plastic apron should be worn for patient contact.
• Physically clean hands can be disinfected with an alcoholic hand rub after
contact with the patient or the environment.
• The patient’s contact area, e.g. chair and the stretcher should be cleaned
and disinfected with a large alcohol impregnated wipe or disinfectant
solution after transport of an affected patient.
• Blankets and pillow cases should be placed in an appropriate bag for laun-
dering according to local protocol.
• The vehicle should be thoroughly cleaned with detergent and disinfected
with freshly prepared hypochlorite solution 1:100 dilution. The vehicle
may be used when all surfaces are dry. Fumigation and prolonged airing is
not necessary. Once the ambulance is dry it can be used for other patients.
Patient screening and microbiological surveillance

A swab moistened with sterile water should be used to sample carrier sites and
lesions. The screening swabs should be taken from the nose, perineum/groin, opera-
tive and wound sites, abnormal or damaged skin, insertion sites of IV lines, catheter
urine samples and sputum, if expectorating, at the advice of the ICT.
Once the patient is positive for MRSA, swabs from carrier and other sites should be
taken at least 3 days after stopping the MRSA treatment protocol. Three sets of nega-
tive screening swabs are required before the patient is considered to be ‘clear’, as
scanty colonization may not be detected with fewer screening specimens. Advice
should be taken from a member of the ICT regarding follow-up screening swabs. It is
important to note that relapses are particularly likely if the patient is receiving antibi-
otics and can occur after relatively long periods, such as 6–12 months. Carriage of
MRSA strains may persist for months or years and may reappear in an apparently
‘clear or cured’ patient.
Clearance of MRSA carriage

If considered appropriate, clearance of MRSA carriage should be carried out as
outlined on page 125. The treatment should only be prescribed on the advice of the
medical practitioner.
126
Topical nasal applications of antibiotics are usually ineffective in clearing throat or

sputum colonization. In addition, it is also often difficult to eradicate colonization
from chronic lesions such as pressure sores or leg ulcers in elderly patients. In these
situations, reliance must be placed on isolation procedures and early discharge.
Systematic therapy can be given as advised by the medical practitioner on an
individual patient basis. Certain body sites are more resistant to the eradication of
MRSA, e.g. tracheostomy sites, deep pressure sores and wounds, chronic leg ulcers,
rectal and perineal regions and colostomy sites.
Clearance of MRSA carriage should be attempted before surgery wherever possible.
These patients should be operated upon at the end of an operating list, if possible.
All lesions must be covered with an impermeable dressing during the operation and
the adjacent areas treated with appropriate antiseptic.
Health Care Workers

There is no evidence that MRSA poses a risk to healthy people. This includes HCWs
and their families. It is essential that HCWs must adhere to the recommended infection
control practice. Carriage by HCWs is usually transient, but some may harbour MRSA
in the nose or on the hands (contact dermatitis or eczema), and may act as primary
reservoirs. Therefore, it is important, that HCWs who have worked in a hospital or
health care facility where MRSA was endemic or who have reason to believe that they
may be carriers of MRSA, should inform their employer. HCWs who require treatment
for MRSA carriage should be referred to the occupational health department.

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129
VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE)

The first clinical strains of vancomycin or glycopeptide resistant enterococci (VRE or
GRE) were reported in 1988. Since then, the incidence of VRE (Enterococcus faecium
or Enterococcus faecalis) has been rising steadily. VRE do not generally appear to be
more virulent than sensitive strains but, because of their resistance patterns, are more
difficult to treat if infection occurs. In addition, these microorganisms have a high
propensity to become endemic.
Risk factors
The epidemiology of VRE has not been clarified. However, the following patient
populations are at increased risk of colonization and infection:
• Treatment with previous vancomycin and/or multiple broad-spectrum

antibiotic therapy.
• Presence of indwelling devices (peripheral IV and central lines, urinary
catheters, surgical drains, endotracheal tubes).
• Critically ill patients (e.g. patients in ICU, oncology or transplant wards).
• Patients who have had intra-abdominal, cardiothoracic, orthopaedic,
vascular and urology surgery.
• Severe underlying disease or immunosuppression.
Source of infection
E. faecium and E. faecalis are commensal bacteria in the gastrointestinal tract
of healthy individuals. However, these microorganisms are selected by the use of
broad-spectrum antibiotics. Most enterococcal infections have been attributed to
endogenous sources. However, in an outbreak situation or when the organism
is endemic in a health care institution, patient-to-patient cross-infection
can occur either through direct or indirect contact via the hands of personnel or from
contaminated patient-care equipment and environmental surfaces.
Mode of transmission
A major route of transmission of VRE within health care facilities is from patient-to-
patient via the hands of HCWs that acquire the organism after direct patient
contact or after handling contaminated materials. This is usually associated with
inadequate hand washing.
Infection control measures

The approach to management of these organisms depends on two factors, i.e.
endemicity of the organism in the institution, and vulnerability of the patients, largely
determined by the presence of risk factors (see above).
130
Elimination is usually achieved by discharging patients (colonized/infected). Patients

can remain colonized for a long time after discharge from hospital. An alert system
for re-admission of these patients is required so that these patients can be promptly
identified and placed on additional (contact) isolation precautions upon re-admission
to the hospital. If patients require transfer to another hospital, a member of the ICT
of the receiving hospital must be informed.
Where the organisms are not endemic to the institution, the object should be
elimination. Rigorous application of additional precautions (contact transmission)
has been shown to be effective in containing and eliminating the problem, although
this can be expensive and its cost-effectiveness is unclear. Eradication of VRE from
hospitals is most likely to succeed when infection or colonization is confined to a few
patients on a single ward.
If the VRE has become endemic on a ward, or has spread to multiple wards, eradica-
tion becomes difficult and costly. In these cases, the object should be minimization
of further transmission. Aggressive infection control measures and strict compliance
by hospital personnel is required to limit nosocomial spread. Application of addi-
tional precautions (contact transmission) is useful in both settings.
In addition to infection control following infection control measures, antibiotic policy

must be reviewed in an attempt to reduce use of all broad-spectrum antibiotics and
glycopeptides.
• Isolate all infected or colonized patients in a single room with its own
bathroom facilities or cohort them with other patients with presumed or
known same strain. Patients with VRE and diarrhoea or incontinence pose
a high risk of transmission to others and must be isolated in a single room.
• Appropriate protective clothing, i.e. gown/plastic apron should be worn

when entering room.
• Wear non-sterile disposable gloves when in contact with infected or colon-

ized patients or their environment. Hands are subsequently disinfected
with an antiseptic.
• Remove gown and gloves before leaving room and wash hands with anti-
septic solution or alcoholic hand rub. Ensure gown/plastic apron and
gloves do not contact environmental surfaces before disposal.
• Use a mask if the patient has colonized respiratory secretions.

• Use dedicated equipment, e.g. stethoscope, sphygmomanometer, rectal
thermometers.
• Use disposable equipment whenever possible. If not possible, clean and dis-
infect items and equipment before reuse. Standard sterilization procedures
for instruments will inactivate the organisms.
131
• Instruments used for dressing changes should not be transferred from

patient-to-patient but should remain by the patient’s bedside.
• Consider the surfaces and furniture within the rooms to be contaminated
as well as the patients themselves.
• Adequate cleaning and disinfection of re-usable devices should be carried
out if such devices are re-used on other patients.
• Enterococci persist in the environment. Disinfection with a high-level
disinfectant (e.g. freshly prepared hypochlorite solution 1:100 dilution)
should be undertaken in addition to standard cleaning and this should be
done on a regular basis.
• Transfer of patients to other high dependency units should be restricted, if
possible.
Screening of patients
The role of broader screening of risk groups on a routine basis is less clear, and costs
can be considerable. Therefore, it is not recommended as a routine procedure.
However, in high-risk patients and clinical areas (e.g. in ICUs), some form of ongo-
ing screening programme may be of benefit in identifying new admissions who are
colonized. In an outbreak situation, screening swabs for culture from multiple body
sites, i.e. stool or rectal swabs, perineal area, areas of broken skin (i.e. ulcer and
wound), urine from catheterized patients, colostomy site should be taken to identify
carriers. Since the most frequent site of colonization is the large bowel, a faecal
sample is the most useful screening specimen. It is important to emphasize that stool
carriage may persist for months or years and oral antibiotic therapy to eradicate the
carriage is not successful.

Bowler ICJ, Storr JA, Davies GJ, et al. Guidelines for the management of patients
colonised or infected with vancomycin-resistant enterococci. Journal of Hospital Infection
1998; 39: 75–82.
Boyce JM. Vancomycin-Resistant Enterococcus: Detection, Epidemiology, and Control

Measures. Infectious Disease Clinics of North America 1997; 11(2): 367–384.
Hospital Infection Control Practices Advisory Committee. Recommendations for pre-

venting the spread of vancomycin resistance entrococci. Morbidity and Mortality Weekly
Report 1995; 44: 1–13.
Murray BE. Vancomycin-resistant enterococcal infections. New England Journal of

Medicine 2000; 342: 710–721.
Nelson RRS. Intrinsically vancomycin-resistant Gram-positive organisms: clinical relevance

and implications for infection control. Journal of Hospital Infection 1999; 42: 275–282.
132
Nelson RRS. Selective isolation of Vancomycin-resistant enterococci. Journal of Hospital

Infection 1998; 39: 13–18.
Noshkin G, Bednarz P, Suriano T, et al. Persistent contamination of fabric-covered

furniture by Vancomycin-resistant enterococci: implications for upholstery selection in
hospitals. American Journal of Infection Control 2000; 28: 311–313.
Ridwan B, Mascini E, Van Der Reijden N, et al. What action should be taken to prevent
the spread of vancomycin-resistant enterococci in European Hospitals? British Medical
Journal 2002; 324: 666–668.
Spera RV, Faber BF. Multiply-resistant Enterococcus faecium. The nosocomial pathogen of
the 1990s. Journal of American Medical Association 1992; 268: 2563–2564.
Wade JJ, Uttley. Resistant enterococci – mechanisms, laboratory detection and control in
the hospitals. Journal of Clinical Pathology 1996; 49: 700–703.
133
MULTI-RESISTANT GRAM-NEGATIVE BACILLI

The first reports of extended-spectrum beta-lactamases (ESBLs) in Gram-negative
bacilli came from Europe and were followed quickly by reports in the US. This type
of antimicrobial resistance is now recognized worldwide. Although ESBLs are found
most frequently in Klebsiella pneumoniae, the elements conferring this
type of resistance are transferable to other genera, including Escherichia coli and
others.
These pathogens often occur in an outbreak setting and pose a therapeutic dilemma
due to resistance to multiple antimicrobials to beta-lactams and other agents, includ-
ing fluoroquinolones and gentamicin. These isolates also have a propensity for spread
by clonal strain-transmission from patient to patient, thereby posing an infection
control dilemma. Control interventions for these organisms involve choosing effective
therapy for infected patients and instituting infection control measures and antibiotic
utilization measures.
Risk factors for colonization or infection

Reported risk factors for colonization or infection from multiple outbreaks of ESBL-
producing organisms include: presence of IV catheters, emergency intra-abdominal
surgery, gastrostomy or jejunostomy tube, gastrointestinal colonization, length of hos-
pital or ICU stay, prior antibiotics (including third-generation cephalosporins), prior
nursing home stay, severity of illness, presence of a urinary catheter, and ventilator
assistance. In the majority of cases, these organisms affect severely ill patients in the
ICU setting as well as chronically debilitated patients in the long-term care setting.
Infection control precautions

In addition to the following infection control measures, excessive use of broad-
spectrum antibiotics (in particular the widespread use of ceftazidime) should be
avoided. Antimicrobial prophylaxis for surgery should be restricted to a maximum
of 24 h.
• Application of additional precautions (contact transmission) should be

instituted. Such precautions involve use of barriers, e.g. gloves, gowns for
contact with infected patients or their immediate environment. Hands
must be washed after removing gloves.
• Patients should not be transferred between wards or hospital unless it is
absolutely essential. If transfer is essential, the ICT of the receiving hospi-
tal should be informed in advance.
• Bedpans and urinals should be disinfected using heat treatment. If a
bedpan disinfector breaks down, it should be repaired as an emergency.
Disposable bedpans and urinals can be used, if available.
134
• Communal equipment (especially if wet) may act as a source for these

organisms, therefore ward equipment must be stored dry; soaking of instru-
ments in disinfectant solution must be avoided.
• Urinary catheters must be inserted under aseptic procedure. Urine drainage
bags must be emptied by the tap, for which single-use disposable gloves
should be used and hands must be washed after the procedure. Do not break
the circuit and reconnect the urinary system. A separate jug or container
should be used for each patient when emptying urinary drainage bags.

Garner JS. The Hospital Infection Control Practices Advisory Committee. Guideline for
Jacoby GA, Medeiros AA, O’Brien TF, Pinto ME, et al. Broad-Spectrum, Transmissible
Beta lactamases. New England Journal of Medicine 1988; 319: 723–724.
Karas JA, Pillay DG, Muckhart D, Sturm AW. Treatment Failure Due to Extended
Spectrum Beta-Lactamase. Journal of Antimicrobial Chemotherapy 1996; 37: 203–204.
Lucet JC, Chevret S, Decre D, et al. Outbreak of multiply resistant Enterobacteriaceae in

an intensive care unit: epidemiology and risk factors for acquisition. Clinical Infectious
Diseases 1996; 22: 430–436.
Monnet DL, Biddle JW, Edwards JR, et al. Evidence of interhospital transmission of
extended-spectrum beta-lactam-resistant Klebsiella pneumoniae in the United States,
1986 to 1993. Infection Control Hospital Epidemiology 1997; 18: 492–498.
Naumovski L, Quinn JP, Miyashiro D, et al. Outbreak of Ceftazidime resistance due to a

novel extended-spectrum beta-lactamase in isolates from cancer patients. Antimicrobial
Agents Chemotherapy 1992; 36: 1991–1996.
Pena C, Pujol M, Ardanuy C, et al. Epidemiology and successful control of a large

outbreak due to Klebsiella pneumoniae producing extended-spectrum beta-lactamases.
Antimicrobial Agents Chemotherapy 1998; 42: 53–58.
Rice LB, Willey SH, Papanicolaou GB, et al. Outbreak of Ceftazidime resistance caused by
extended-spectrum beta-lactamases at a Massachusetts chronic-care facility.
Antimicrobial Agents Chemotherapy 1990; 34: 2193–2199.
135
9
Prevention of Infection
Caused by Specific
Pathogens
TUBERCULOSIS (TB)
T his ancient disease, characterized in 1680 by John Bunyan as the ‘Caption of

all these Men of Death’ – has by no means been vanquished. According to
WHO estimates, 90 million new cases of TB will have occured in the 1990’s causing
30 million TB-related deaths, and 90% of these will have been in developing coun-
tries. Up to 40% of patients with TB will be co-infected with HIV.
TB is an infection caused by bacterium of the Mycobacterium tuberculosis complex

(M. tuberculosis, M. bovis, M. africanum). TB is usually a pulmonary disease.
Extrapulmonary TB is much less common, but infection may occur in any organ or
tissue including lymph nodes, meninges, pleura, pericardium, kidneys, bones, joints,
larynx, skin, peritoneum, intestines and eyes, M. tuberculosis and M. africanum, pri-
marily from humans and M. bovis primarily from cattle.
Clinical manifestations: Many initial infections with M. tuberculosis or related species

are asymptomatic. Approximately 90–95% of those infected with the bacterium
become latent carriers, with a lifelong risk of reactivation causing clinical (active)
disease. Approximately 10% of infected adults will develop such clinical disease in
their lifetime, about half of these in the first 5 years after infection (but predom-
inantly in the first year) and the other half later in life. The risk of developing disease
is much greater in infants and young children, and in those with impaired immune
function.
Early clinical symptoms include fatigue, weight loss, fever and night sweats. In more
advanced disease, hoarseness, cough with blood-stained sputum, and chest pain are
common. Once the individual has acquired the infection it may heal spontaneously
or, over weeks/months, become active disease. It may be contained and unapparent
137
TB bacilli
CLINICAL DISEASE Infection acquired through

Spread of disease from cavity respiratory infected droplets.
in lung parenchyma to other part
of lung. Sputum may become
positive for TB bacilli.
Lesion in lung
Lymph node
REACTIVATION PRIMARY INFECTION

Infection due to weakening of (“Ghon” focus, i.e. infection of
host defences which may lung parenchyma and
occur after months/years. involvement of mediastinal
lymph node.)
Figure 9.1 Acquisition and spread of pulmonary tuberculosis.
at the time but may cause active disease (reactivation) later in life because of old age
or other events that weaken the individual’s immunity.
Mode of transmission: TB is usually transmitted by exposure to airborne droplet

nuclei produced by people with ‘open’ pulmonary TB, during expiratory efforts such
as coughing and sneezing (Fig. 9.1).
138
Prevention of Infection Caused by Specific Pathogens
The infectious person with open TB usually produces aerosolized droplets of less
than 5 !m in diameter containing tuberculi bacilli. These droplets can remain afloat
and viable in the environment unless removed by planned infection control proced-
ures. When inhaled, these tuberculi bacilli can settle in the lungs, where they
may result in TB infection and may remain viable for the lifetime of the new host.
People with TB infection of this nature without evidence of clinical disease are not
infectious and are asymptomatic.
Prolonged close exposure may lead to infection in close contacts. Direct invasion
through mucous membranes or skin breaks may occur, but it is extremely rare.
Extrapulmonary TB is generally not communicable apart from exceptionally rare
circumstances where there is a draining abscess.
Infection by direct contact with mucous membranes or skin lesions is very rare.
Bovine TB may result from drinking unpasteurized infected milk or by aerosol trans-
mission from infected animals to farmers or animal handlers.
Either symptomatic or asymptomatic people with viable bacilli in their sputum may
be infectious. Untreated, or inadequately treated, patients may be sputum-positive
intermittently for many years, although children with primary TB are generally not
infectious. Patients usually become non-infectious after 2 weeks of beginning appro-
priate therapy.
Risk of acquisition: The risk of acquisition is related to the degree of exposure to the
aetiological agent. The greatest risk of disease occurs from 6–12 months after expos-
ure. For people with latent infection, susceptibility to reactivation is increased in
those with immunosuppression or debilitating diseases such as diabetes, cancer and
renal failure and in those who engage in substance abuse or are malnourished.
Reactivation of latent infection accounts for a large proportion of cases in elderly
people. Risk factors for acquiring TB include extremes of age, concomitant HIV
infection, ethnic group from high prevalence countries, chronic alcohol misuse, poor
socio-economic background and homelessness.
Incubation period: The incubation period from exposure to demonstrable primary

lesion or significant tuberculin reaction is in the range of 4–12 weeks. The subse-
quent risk of progressive pulmonary or extrapulmonary TB is greatest the first year
or two after infection with the greatest risk in the first 6–12 months, however, latent
infection may persist for a lifetime. The degree of communicability depends on the
number of bacilli discharged, the virulence of the bacilli, and opportunities for
exposure. Infection is transmissible from persons with TB, as long as viable tuber-
cle bacilli are being discharged in the sputum (smear positive on Ziehl Nielsen’s
stain).
Treatment: The treatment of tuberculosis is complex and lengthy. Inadequate treat-

ment and non-compliance with medication are the main causes of relapse and of the
139
emergence of drug resistant organisms. Therefore, the treatment should be super-

vized by a medical practitioner with expertise in the management of TB. Compliance
with treatment must be monitored. If there is any doubt, measures such as pill
counts, prescription checks or urine tests may be used. Individual plans for non-
compliant patients may involve arrangements for directly observed therapy. Most
patients with TB can be treated at home; a few require hospital admission for severe
illness, adverse effects of chemotherapy, or for social reasons. Effective treatment
with antimicrobial chemotherapy usually eliminates communicability within 2 weeks.
However, in some cases, especially in the case of multi-drug resistant tuberculosis
(MDR-TB), inadequate treatment or non-compliance with treatment, the patient
may remain sputum-positive or be sputum-positive intermittently for a lengthy
period of time.
Infection control precautions in hospital

Although the treatment of TB should be undertaken in the patient’s home whenever
possible, some patients will need admission because of the severity of illness, adverse
effects of chemotherapy, for social reasons, or for investigations to establish the
diagnosis.
Additional precautions (airborne transmission) should be observed. Health care

workers and visitors should wear a particulate filter mask when entering a TB
patient’s room if the patient cannot co-operate with personal risk reduction
measures, or where normal risk reduction measures are not effective (e.g. disease
due to drug-resistant strains of M. tuberculosis). Care should be taken to
ensure that all people who use masks are instructed in the correct fit and wearing
of the mask. When the patient is required to leave a TB isolation room (e.g. for
chest X-ray), then the patient should wear a mask if their TB is considered
infectious.
TB patients should be educated to cover their mouths and noses while coughing
or sneezing, and to dispose of used tissue paper in a closed container to be treated
as clinical waste. Medical procedures that present a particular risk of cross-
contamination from an infectious patient include bronchoscopy and the use of
respiratory and anaesthetic apparatus.
The following infection control measures should be observed:
• All suspected or confirmed pulmonary TB cases should initially be admitted

to a single room until their sputum status is known and risk assessments are
made. The door should be kept closed as much as possible.
• Adult patients with pulmonary TB with three negative smear samples

and patients with non-pulmonary TB infection caused by atypical
140
Mycobacterium spp. (with the exception of those with infected discharging

wounds) should be regarded as non-infectious and may be nursed in a
general ward.
• Patients whose bronchial washings are smear-positive should be managed

as if non-infectious unless the sputum is also smear-positive or becomes so
after bronchoscopy or they are on a ward with immunocompromised
patients, or they are known or suspected of having MDR-TB.
• No patient with suspected or confirmed respiratory TB, whatever the

sputum status, should be admitted to an open ward containing immuno-
compromised patients, such as HIV infected, transplant or oncology patients
until their infectivity is established because of the known possibility of trans-
mission of infection and the seriousness of MDR-TB.
• Patients in isolation should not visit wards, including communal washing

facilities, or public areas of the hospital and should not walk or be trans-
ported through open wards which may contain immunocompromised
patients, unless they are wearing a mask.
• All patients should be informed that their infection is spread to others by

the respiratory route. Routine surgical masks are recommended for
patients with uncontrolled cough or sneezing to reduce aerosol generation.
Other patients should be taught to cover the mouth and nose with dispos-
able paper tissue whilst coughing and to dispose of the tissues as clinical
waste.
• Visitors should, as far as possible, be limited to those who have already been
in close contact before the diagnosis. Contact with staff should be kept to a
reasonable minimum without compromising patient care.
• All children with TB and their visitors should be segregated from other
patients until the contacts have been screened and pronounced non-
infectious. It is possible that one of the visitors may have been the source of
the child’s infection and hence be a risk to other patients if the child is in
an open ward.
• The HCW should wear a mask if a patient with active pulmonary TB is

coughing and cannot be relied upon to cover his/her mouth. The patient
should also be advised to wear mask if he/she leaves the room.
In addition, the wearing of a mask is also recommended if direct exposure
to respiratory secretions is unavoidable, e.g. during bronchoscopy or pro-
longed care of a high dependency patient, after cough-inducing procedures
or when performing the last offices.
141
The surgical masks may not be effective in preventing the inhalation

of droplet nuclei. A high efficiency particulate air (HEPA) mask should
be used. Masks should be close fitting and filter particles of 1–5 microns (!).
In the US, use of particulate respirators (N95) are recommended.
Use of a mask is not a substitute for good infection control
practice.
• Risk assessments for the likelihood of infectiousness and MDR-TB should

be made taking into account the immune status of other patients on the
ward.
• Marked crockery and separate washing up facilities are unnecessary, and

no special precautions are needed for bed linen, books or other personal
property.
• Sputum specimens and other respiratory specimens should be sent to a

laboratory as outlined on page 103.
• HIV infected and tuberculosis patients should not be mixed. In settings

where other patients may be infected with HIV or otherwise immunocom-
promised, suspected or confirmed cases of pulmonary TB should be con-
sidered as potentially infectious on every admission until proved otherwise
and segregated accordingly. Patients with potentially infectious TB should
be segregated from other immunocompromised patients by admission to a
single room in a separate ward or to a negative pressure ventilation room
(see page 21).
• For all patients in a HIV ward, aerosol generating procedures such as

bronchoscopy, sputum induction, or nebulizer treatment should never be
performed in an open ward or bay and appropriate environmental controls
should be in place.
• When a patient is discharged home, the room should be terminally cleaned.

Fumigation of the room is not necessary.
• Termination of Infection Control Precautions: Isolation of patients should

commence on suspicion of infection and may only be discontinued in
untreated cases where three consecutive direct smears are negative for
AAFB (Acid & Alcohol Fast Bacilli). Uncomplicated sputum positive
TB will usually be non-infectious after 2 weeks compliance with standard
multi-drug chemotherapy and the patient may then be transferred to an
open ward but the results of any sputum tests and/or response to treatment
should be taken into account. However, in some circumstances, e.g. where
MDR-TB is suspected, three successive smear-negative sputum examin-
ations will be required.
142
Sputum smear
Yes positive 1 or No
more of 3 samples
on separate days
Risk Risk
for for
MDR-TB MDR-TB
No Yes No
Does Does Does

ward have ward have ward have
Yes* immunocompromised immunocompromised immunocompromised
patients? patients? patients?
Yes No Yes* No Yes No
Negative Negative Single Negative Single

Standard
pressure room pressure room on pressure room on
ward
(irrespective room† ward† room† ward†
of HIV status)
Figure 9.2 Risk assessment of infectivity and other factors. *Molecular tests for
identification of Mycobacterium tuberculosis and rifampicin resistance strongly
recommended. †If previous treatment for tuberculosis or contact with multi-drug
resistant tuberculosis (MDR-TB), molecular test for rifampicin resistance manda-
tory; if rifampicin resistance treat/isolate as MDR-TB.
Reproduced with permission from: Control and prevention of tuberculosis in the United Kingdom: Code of
Practice 2000. Thorax 2000; 55: 887–901.
Multi-drug resistant tuberculosis (MDR-TB)

MDR-TB is, by definition, TB resistant to two or more of the main line anti-
tuberculosis drugs (usually isoniazid and rifampicin with or without other drugs).
The implications are serious both for the individual and for public health because of
the limited number of the alternative anti-tuberculosis drugs available for treatment.
Additional precautions may be required for patients with MDR-TB which should be
considered on a case-by-case basis with the discussion of infection control team.
Drug resistant disease should be considered when there is:
• A history of previous drug treatment (usually incomplete treatment or

non-compliant patient).
• Contact with a patient with known MDR-TB.
• Patients infected with HIV.
• Prolonged sputum smear or culture positive while on treatment (smear
positivity at 4 months or culture positivity at 5 months).
It is preferable that cases of MDR-TB be managed at facilities with expertise in
such management. Because of the more serious consequences of infection, the
143
Yes Had No
BCG?†
Yes No
Age <16
Heaf* Heaf*
Chest
radiograph
No 3–4 Yes Yes 2–4 No
Normal Abnormal
Index
Yes smear No
positive
Advise and Advise and
inform# inform#
Repeat Heaf
Chest radiography at 6 weeks
clinical
examination
Yes No
2–4
Normal
Chest radiography
Yes No clinical Give BCG
examination if age <16
Abnormal Normal
Discharge Discharge Discharge
Investigate Investigate
Chemoprophylaxis if
Chemoprophylaxis** age <16 or convertor**
Figure 9.3 Contact tracing: examination of close contacts of patients with pul-
monary tuberculosis. Contacts of patients with non-pulmonary tuberculosis need
not usually be examined. Note: children under 2 years who have not had a BCG
vaccination who are close contacts of a smear positive index patient should receive
chemoprophylaxis irrespective of tuberculin status. †Previous BCG vaccination
cannot be accepted as evidence of immunity in HIV infected subjects. *A negative
test in immunocompromised subjects does not exclude tuberculosis infection.
#
Advise patient of tuberculosis symptoms and inform GP of contact. **Persons eli-
gible for, but not given, chemoprophylaxis should have follow-up chest radiographs
at 3 and 12 months.
Reproduced with permission from: Control and prevention of tuberculosis in the United Kindgdom: Code or
Practice 2000. Thorax 2000; 55: 887–901.
patient should be isolated in a negative pressure ventilation room. Their movement

around the facility should be minimized. HCWs and visitors should wear a 1 !m TB
particulate filter mask when entering the patient’s room. Care should be taken to
ensure that all people who use these masks are instructed in the correct fit and
144
wearing of the mask. When the patient is required to leave a TB isolation room
(e.g. for chest X-ray), then the patient should wear the mask if their TB is considered
infectious. He/she should be educated to cover their mouth and nose while coughing
or sneezing, and to dispose of used tissue paper as clinical waste. Medical procedures
that present a particular risk of cross-contamination from an infectious patient
include bronchoscopy and the use of respiratory and anaesthetic apparatus.
Contact tracing: Contacts should only be considered in the case of smear positive or
open pulmonary TB and in the first instance should be limited to close contacts,
i.e. household and close associates of patients with respiratory TB. If initial investi-
gation reveals a number of contacts with evidence of TB, consideration should be
given to widening the circle of contacts who may be offered screening. The person
responsible for local contact tracing should be named in the hospital policy.
• Staff: Contacts should only be considered significant if the source is smear

positive on direct sputum examination or on examination of bronchial
washings. Staff undertaking mouth-to-mouth resuscitation, prolonged
care of a high dependency patient or repeated chest physiotherapy should
be considered as close contacts. All members of staff should be seen in the
occupational health department and have their occupational health notes
reviewed to ascertain whether they have had a Heaf test, BCG vaccination
and BCG scar. Enquiries should be made as to any current illness or treat-
ment that might result in their immune system being compromised.
Those who have a previous history of BCG vaccination and/or were
previously positive on Heaf test, do not require further investigation but
should be advised of the possible symptoms of TB and the importance of
reporting such symptoms promptly.
• Patients: If an individual on an open ward is diagnosed as having infectious

TB, the risk of other patients being infected is likely to be small. Decisions
about appropriate action should take into account the degree of infectivity,
the length of time before the infectious individual is isolated, the proxim-
ity of contact, and whether other patients are unusually susceptible to
infection.
If the exposure of another patient is sufficiently extensive to be equivalent

to a household contact, or the exposed patient is known to be particularly
susceptible to infection, they should be managed in the same way as a
household respiratory contact.
In general, patients in the same bay (rather than the whole ward) should be
regarded as at risk, but only if the index case was coughing and was present
in the bay for more than 8 h before isolation. It is sufficient to document
the possible exposure in the patient’s records and the patient’s medical
practitioner should also be informed.
145

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146
Clostridium difficile INFECTION

Clostridium difficile is an aerobic, Gram-positive bacterium that was first identified
and characterized in 1935. C. difficile was accorded little interest until 1978 when
several reports identified its association with pseudomembranous enterocolitis.
Infection with C. difficile has now become the most frequent etiologic agent for
hospital-acquired diarrhoea, and the overall frequency of this nosocomial infection
appears to be increasing.
Clinical features: The symptom is mainly diarrhoea which usually starts 5–10 days
(range: few days to 2 months) after commencing antibiotic therapy. It ranges from
mild to severe foul smelling diarrhoea containing blood/mucus, fever, leucocytosis
and abdominal pain. In the majority of patients, the illness is mild and full recovery
is usual. Elderly patients may become seriously ill with dehydration. Occasionally,
patients may develop a severe form of the disease called pseudomembranous colitis.
Complications include pancolitis, toxic megacolon, perforation or endotoxin shock.
Risk factors: Risk factors for acquiring C. difficile-associated infection include:
1. Indiscriminate use and exposure to broad spectrum antibiotic therapy,

particularly "-lactam agents.
2. Gastrointestinal procedures and surgery.
3. Advanced age, i.e. common in elderly and debilitated patients; outbreaks
being more common in geriatric and long-stay wards.
Diagnosis: All suspected cases should be investigated by sending faecal specimens

to the microbiology laboratory for detection of C. difficile toxin. Usually, once the
diagnosis has been confirmed, repeat specimens need not be taken unless there is a
relapse following treatment. This is because it is not uncommon for the faeces to
remain toxin-positive for some time after the start of treatment even when the
patient’s symptoms have settled. Screening and treatment of asymptomatic patients is
not necessary. Routine stool culture for detection of C. difficile is not recommended but
can be considered in an outbreak situation for epidemiological investigations.
Management: Treatment of C. difficile enterocolitis focuses on three basic strategies.
• Firstly, the antibiotic therapy that has mediated the change in the patient’s
gut microflora should be discontinued or changed to an antibiotic which
has less of an association with enterocolitis.
• Secondly, antiperistaltic medication should be avoided. Diarrhoea is the
response of the infected host to expel pathogens responsible for entero-
colitis. Use of opiates and antiperistaltic drugs results in the retention of
pathogen, probably worsens enterocolitis-associated necrosis of the colonic
mucosa, and increases the risk of toxic megacolon. Rehydration of patients
147
usually results in rapid improvement. Loss of fluid and electrolytes must

be replaced using the intravenous route until diarrhoea has ceased and
effective oral intake has resumed.
• Thirdly, specific antibiotic therapy to treat the offending C. difficile
pathogen should be initiated. Oral metronidazole is administered 400 mg 8
hourly for 10 days, which should be given as a first choice. If metronidazole
is not effective then oral vancomycin 125 mg 6 hourly for 10 days should be
prescribed. Vancomycin should not be prescribed as a first line therapy
because of problem of emergence of vancomycin resistant enterococci
(VRE). The majority of patients improve within 2–4 days. However,
clinical relapse can occur in 15–25% of the cases usually within 1–3 weeks.
Control of antibiotic usage: Of all the measures that have been used to prevent the
spread of C. difficile-associated diarrhoea, the most successful has been the restric-
tion of the use of antimicrobial agents. Therefore it is essential that the use of inappro-
priate and broad spectrum antibiotics (especially oral) is avoided. The hospital
should have an antibiotic policy which must be reviewed on a regular basis. Narrow
spectrum antibiotics for a minimum duration are preferred if treatment is con-
sidered essential to deal with systemic infection. Antibiotics such as aminoglycosides
and some fluoroquinolones appear to have little propensity to induce C. difficile
infection, probably due to their lack of effect on the endogenous anaerobic gut
bacteria.
Infection control measures: C. difficile is normally fastidious in its vegetative state,

it is capable of sporulating when environmental conditions no longer support its
continued growth. The capacity to form spores enables the organism to persist and
survive in the environment (e.g. on dry surfaces) for extended periods of time. The
degree to which the environment becomes contaminated with C. difficile spores is
proportional to the number of patients with C. difficile associated diarrhoea.
Environmental contamination can be heavy, especially if the diarrhoea is severe or
accompanied by incontinence; asymptomatic patients after infection may continue
to shed organisms in their stools and serve as a source of contamination.
The following infection control precautions should be taken:
• All infected patients should be segregated from non-affected patients in a

single room with en suite toilet facilities or cohort all symptomatic patients.
• Additional (contact transmission) isolation precautions should be used.

• Hands can become contaminated by direct contact with patients who are
colonized or infected with C. difficile or by contact with spores contam-
inating environmental surfaces. Therefore, strict hand hygiene before and
after patient contact remains the most effective control measure to prevent
cross-infection.
148
• Proper use of non-sterile, single-use disposable gloves is an ancillary

measure that helps to further minimize transfer of these pathogens from
one surface to another. Hands must be washed after removing gloves.
• The patient’s immediate environment and other areas where spores may
accumulate (e.g. sluice, commodes, toilets, bedpans, sinks, high-touch
surfaces in patients’ bathrooms) and other soiled areas must be cleaned and
disinfected thoroughly and frequently. Separate cleaning equipment must
be reserved for this purpose. Mop heads should be disposable or laundered
after each use and single-use disposable cloths must be used. C. difficile
spores are highly resistant to most disinfectants.
• The recommended approach to environmental infection control is meticu-
lous cleaning and decontamination of surfaces. Chlorine-containing
(hypochlorite) chemicals 1,600 ppm of av Cl2 should be used for environ-
mental surface disinfectant.
Patients discharge: Patients can remain colonized for a long time after discharge
from hospital. If the patient is discharged or transfered to another hospital or long-
stay health care facility, appropriate personnel at the receiving health care facility
must be informed.

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of Clostridium difficile-associated diarrhoea in an acute care hospital and a skilled nurs-
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of diarrhoea due to Clostridium difficile. Journal of Hospital Infection 1994; 27: 1–15.
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antibiotic-associated colitis: Isolation of Clostridium difficile from the hospital environ-
ment. American Journal of Medicine 1981; 70: 906–908.
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1994; 7: 471–474.
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carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo con-
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from patients and the environment of hospital wards. Journal of Clinical Pathology 1983;
6: 88–92.
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and Clostridium difficile-associated diarrhea in a cohort of hospitalized patients. Journal
of Infectious Diseases 1990; 162: 678–684.
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An epidemiologic investigation of a cluster of cases. Journal of Infectious Diseases 1982;
145: 269–274.
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British Medical Journal 1995; 310: 1375–1380.
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associated diarrhoea during a hospital outbreak. Infection Control Hospital Epidemiology
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Clostridium difficile strains from patients and the hospital environment in Belarus.
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Infection: prevention and management. London: DoH, 1994.
Worsley MA. Infection control and prevention of Clostridium difficile infection. Journal
of Antimicrobial Chemotherapy 1998; 41 (Suppl. C): 59–66.
Yannelli B, Gurevich I, Schoch PE, Cunha BA. Yield of stool cultures, ova and parasite
tests, and Clostridium difficile determination in nosocomial diarrhoea. American Journal
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150
LEGIONNAIRES’ DISEASE
Legionellosis is a collective term describing infection produced by Legionella spp.
whereas Legionnaires’ disease is a multisystem illness with pneumonia. Legionnaires’
disease is caused by infection with Legionella spp. with Legionella pneumophila
responsible for 90% of infections. In all, about 35 species of legionella have been
recognized. The incubation period of Legionnaires’ disease is 2–10 days, most often
5–6 days.
Clinical features: Legionellosis is an acute bacterial pneumonia characterized

initially by anorexia, malaise, myalgia and headache. Within a day, there is usually a
rapidly rising fever associated with chills. A non-productive cough, abdominal pain
and diarrhoea are common. Chest radiograph may show patchy or focal areas of
consolidation that may progress to bilateral involvement. Severe infections may lead
to respiratory failure and death. The case-fatality rate has been as high as 40% in
hospitalized cases; it is generally higher in those with compromised immunity.
Unrecognized infections are common.
Pontiac fever is a clinical syndrome which may represent reaction to inhaled antigen
rather than bacterial invasion. It is not associated with pneumonia or death; patients
recover spontaneously in 2–5 days without treatment.
Risk factors: Legionellosis may occur as sporadic cases or outbreaks, and is more fre-
quently reported in summer and autumn. The incidence of infection increases with
increasing age (i.e. persons #50 years of age) and those who smoke are at highest
risk. Males are affected more commonly than females. The following groups of
patients are more susceptible to infections:
• Immunosuppressed patients, e.g. transplant patients, cancer patients,

patients receiving corticosteroid therapy, and
• Immunocompromised patients, e.g. surgical patients, patients with under-

lying chronic lung disease, dialysis patients, diabetes mellitus.
Source of infection: Reservoir and source of infection for Legionnaires’ disease

are hot and cold water systems (showers) particularly in hospitals and hotels,
air-conditioning and wet cooling system towers, evaporative condensers, humidi-
fiers, whirlpool and natural spas, respiratory therapy devices and decorative
fountains/sprinkler systems. In several hospital outbreaks, patients were con-
sidered to be infected through exposure to contaminated aerosols generated by
cooling towers, showers, faucets, respiratory therapy equipment, and room-air
humidifiers. Airborne transmission in water aerosols is believed to be the major,
if not sole, means of infection. Person-to-person transmission has not been
documented.
151
Case definitions for Legionnaires’ disease

Confirmed case: A clinical diagnosis of pneumonia with laboratory
evidence of one or more of the following:
• Isolation (culture) of legionella species from clinical specimens.

• Seroconversion (a four-fold or greater increase in titre) deter-
mined using a validated indirect immunofluorescent antibody
test (IFAT) incorporating a monovalent L. pneumophila serogroup
1 antigen.
• The presence of L. pneumophila urinary antigen determined using
validated reagents/kits.
Presumptive case: A clinical diagnosis of pneumonia with laboratory
evidence of one or more of the following:
• A single high titre of 128 using IFAT as above (or a single titre of 64 in
an outbreak).
• A positive direct fluorescence (DFA) on a clinical specimen using
validated monoclonal antibodies (also referred to as a positive result
by Direct Immunofluorescence (DIF).
Adapted from Public Health Laboratory Services Atypical Pneumonia Working Group.
Investigating a single case of Legionnaires’ disease. Communicable Disease and Public
Health 2002; 5(2): 157–162.
Diagnosis: The diagnosis of Legionellosis purely by clinical criteria can be

difficult and reliance is therefore placed on laboratory tests, which include
isolation of the causative organism on special media and its demonstration by direct
immunofluorescence (IF) stain of involved tissue or respiratory secretions. It can also
be diagnosed by detection of antigens of L. pneumophila in urine by RIA or by a four-
fold or greater rise in IFA titre between an acute phase serum and one drawn 3–6 weeks
later.
Prevention: Currently there is no vaccine against Legionellosis and since Legionella

is a very widespread organism, prevention must therefore focus on reducing the risk
of the organism being aerosolized. The prime aim must be to avoid creating condi-
tions favourable for the organisms to multiply in water and be disseminated in air
through droplets. Special precautions for the environment include adequate mainten-
ance of potential reservoirs of infection, such as hot water and air conditioning
systems, spa baths, humidifiers and respiratory therapy equipment.
152
Steps in an epidemiologic investigation for Legionellosis

• Review medical and microbiologic records.
• Initiate active surveillance to identify all recent or ongoing cases.
• Develop a line listing of cases by time, place, and person.
• Determine the type of epidemiological investigation, i.e. case-control
or cohort study.
• Assess risk factors among potential environmental exposures,
e.g. showers, cooling towers, respiratory therapy equipment.
• Gather and analyze epidemiological information.
• Collect water samples from environmental sources implicated by
epidemiological investigation.
• Subtype strains of Legionella spp. cultured from both patients and
environmental sources.
• Review autopsy records and include autopsy specimens in diagnostic
testing.
It is important to highlight that the following factors enhance colonization and

amplification of legionellae in water environments:
• Temperatures of 25–42°C [77–107.6°F]

• Stagnation of water
• Scale and sediment, and
• Presence of certain free-living aquatic amoebae that can support intracel-
lular growth of legionellae.
Therefore it is essential that health care facilities should either maintain potable
water at the outlet at #51°C (#124°F) or $20°C ($68°F) or chlorinate heated water
to achieve 1–2 mg/L (1–2 ppm) of free residual chlorine at the tap.
Adequate maintenance of wet cooling towers and hot water systems is essential
in control of legionella. It is important that the construction of new cooling towers
in the health care facilities must be located so that the drift is directed away from
the air-intake system. The cooling towers should be designed to minimize the
volume of aerosol drift. Infection control procedures must be implemented for
cooling towers.
153
Maintenance of cooling towers must be carried out according to manufacturers’ rec-

ommendations. A record of detailed maintenance and infection control measures,
including any environmental tests, must be kept.
If cooling towers or evaporative condensers are implicated in healthcare-associated

Legionellosis, decontaminate the cooling-tower system. It is important that cooling
towers should be drained when not in use. They should be mechanically cleaned to
remove scale and sediment at regular intervals. Appropriate biocides should be used
on a regular basis to prevent the growth of slime-forming organisms.
Tap water should not be used in respiratory therapy devices. Maintenance of hot
water system temperatures at %50°C may reduce the risk of transmission.
Decontamination of implicated sources by chlorination and/or superheating of the
water supply have been shown to be effective.
Surveillance and Notification: All laboratory confirmed cases of Legionellosis should

be reported to appropriate personnel. This is to ensure that appropriate control
measures are taken to ensure that the source of Legionella is removed. In the com-
munity, cases must be reported to the appropriate local health department (CCDC
in the UK). Isolated cases may be difficult to investigate. Hospital surveillance should
detect healthcare-associated Legionnaires’ disease.

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Brundrett GW. Legionella and Building Services. Oxford: Butterworth-Heinemann, 1992.
Fallon RJ. How to prevent an outbreak of Legionnaires’ disease. Journal of Hospital

Infection 1994; 27: 247–256.
Joseph CA, Watson JM, Harrison TG, Bartlett CLR. Nosocomial Legionnaires’ Disease in
England and Wales, 1980–1992. Epidemiology and Infection 1994; 112: 329–345.
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a single case of Legionnaires’ disease. Communicable Disease and Public Health 2002; 5(2):
157–162.
Sabria M, Yu VL. Hospital-Acquired Legionellosis: Solutions for a Preventable Infection.

The Lancet Infectious Diseases 2000; 2: 368–373.
UK Health and Safety Commission. Legionnaires’ Disease: the control of Legionella bacteria
in water system: Approved Code of Practice and Guidence. Suffolk: HSE Book, 2000.
UK Department of Health. Health Technical Memorandum 2040. The control of legionella

in healthcare premises – a code of practice. Part 1 Management Policy, Part 2 Design
Considerations, Part 3, Validation and verification, Part 4 Operational management.
London: HMSO, 1994.
154
GASTROINTESTINAL INFECTIONS AND FOOD

POISONING
Diarrhoea and vomiting may be caused by many agents, both infective and non-
infective. The World Health Organization (WHO) defined food poisoning as any
disease of an infectious or toxic nature caused by or thought to be caused by the
consumption of food or water.
The definition of diarrhoea varies but generally includes the passage of liquid or
watery stools, three or more times per day. In the health care setting it is important
to distinguish between infectious and non-infectious diarrhoea. Infectious diarrhoea
is caused by enteric pathogens while non-infectious diarrhoea is caused by cathartics,
tube-feeding, inflammatory bowel disease, surgical resection of the gastrointestinal
tract and anastomoses.
Infection control precautions: It is prudent to consider all cases of gastroenteritis as

potentially infectious until appropriate investigations are completed. Patients should
be isolated in a single room with toilet facilities. Contact infection control precaution
should be implemented. Hand hygiene must be emphasized. Appropriate protective
clothing, e.g. gloves, plastic aprons or gowns should be worn when handling con-
taminated material or the environment.
Clinical cases and suspected outbreaks of gastrointestinal infection among staff and
patients must be reported to a member of the Infection Control Team. In the com-
munity it is normal practice to exclude a patient with gastroenteritis from work or
school until the person is free of diarrhoea and vomiting and, if necessary, the appro-
priate clearance tests have been completed. Thereafter, it is particularly important to
assess the risk of spreading infection of persons in whom special action should be
considered.
In the UK, the Public Health Laboratory Services working party has defined four
groups of persons in occupations or circumstances where there is a special risk of
spreading gastrointestinal infection:
Group 1: food handlers,

Group 2: staff in health care facilities,
Group 3: children $5 years of age, and
Group 4: older children and adults who may find it difficult to
implement good standards of personal hygiene.
The circumstances of each case, excreter, carrier or contact in these groups, should be
considered individually and factors such as standards of personal hygiene be taken into
account. It is important to emphasize that the agents causing gastroenteritis may infect
without causing symptoms or be excreted for long periods after recovery from clinical
illness. Excretion of organisms may still occur intermittently and in small numbers.
155
156
Table 9.1 Acute bacterial diarrhoeas and ‘food poisoning’.
Organism Incubation Vomiting Diarrhoea Fever Microbiology Pathogenesis Clinical features and treatment
period (h)
Staphylococcus 1–8 rarely &&& & ' Staphylococci grow Enterotoxin acts Abrupt onset, intense vomiting
aureus up to 18 in meats and in on receptors in for up to 24 h, regular recovery
dairy & bakery gut that transmit in 24–48 h. Occurs in persons
products and impulses to eating the same food. No
produces medullary treatment usually necessary
enterotoxin. centers. except to restore fluids and
electrolytes.
Bacillus cereus 1–8 rarely &&& & ' Reheated fried rice Enterotoxins After 1–6 h, mainly vomiting.
up to 18 causes vomiting or formed in food After 8–16 h, mainly diarrhoea.
diarrhoea. or in gut from Both self-limited to less than

growth of 1 day.
B. cereus.
Clostridium 8–16 ( &&& ' Clostridia grow in Enterotoxin Abrupt onset of profuse
perfringens rewarmed meat produced in diarrhoea; vomiting
dishes and produce food and in gut occasionally. Recovery usual
an enterotoxin. causes hyper- without treatment in 1–4 days.
secretion in Many Clostridium perfringens in
small intestine. cultures of food and faeces of
patients.
Clostridium 24–96 ( Rare ' Clostridia grow in Toxin absorbed Diplopia, dysphagia, dysphonia,
botulinum anaerobic foods from gut blocks respiratory difficulty.
and produce toxin. acetylcholine at Treatment requires clear airway,
neuromuscular ventilation, and intravenous
junction. polyvalent antitoxin. Toxin
present in food and serum.
Mortality rate high.
Clostridium 5–10 days ' &&& & Associated with use Enterotoxin Abrupt onset of foul smelling
difficile (up to 2 m) of broad spectrum causes epithelial diarrhoea; Toxin in stool.
antibiotics. necrosis in colon; Oral metronidazole or
pseudomembranous vancomycin can be used for
colitis. treatment.
Escherichia coli 24–72 ( & (E. coli ' E. coli 0157 is Enterotoxin causes Usually abrupt onset of
Some strain 0157; associated with hypersecretion in diarrhoea; vomiting rare. In
bloody eating beef burger. small intestine. adults, ‘traveller’s diarrhoea’ is
diarrohea) Some strain invade usually self-limited to 1–3 days.
gut mucosa. Treatment with antibiotic is
usually not recommended for
infection caused by E. coli 0157.
Vibrio 6–96 & & ( Organisms grow in Hypersecretion in Abrupt onset of diarrhoea in
parahaemolyticus seafood and in gut small intestine; groups consuming the same
and produce toxin stools may be food, especially crabs and other
or invade. bloody. seafood. Recovery is usually
complete in 1–3 days. Food and
stool cultures are positive.
Vibrio cholerae 24–72 & &&& ' Organisms grow in Enterotoxin causes Abrupt onset of liquid
(mild cases) gut and produce hypersecretion in diarrhoea in endemic area.
toxin. small intestine. Needs prompt replacement
Infective dose: of fluids and electrolytes
107–109 intravenously or orally.
organisms. Tetracyclines shorten excretion
of vibrios. Stool cultures
positive.
Campylobacter 2–10 days ' &&& & Organisms grow in Invasion and Fever, diarrhoea and
jejuni (blood jejunum and ileum. enterotoxin fresh blood in stool, especially
may be production in children. Usually self-limited.
present) uncertain. Give erythromycin or
fluoroquinolone in severe cases
with invasion. Recovery in
5–8 days is usual.
157
158
Table 9.1 Continued
Organism Incubation Vomiting Diarrhoea Fever Microbiology Pathogenesis Clinical features and treatment
period (h)
Shigella spp. 24–72 ( & & Organisms grow in Organisms invade Abrupt onset of diarrhoea, often
(blood superficial gut epithelial cells; with blood and pus in stools,
may be epithelium and gut blood, mucus, and cramps, tenesmus, and lethargy.
present) lumen and produce PMNs in stools. Therapy depends on sensitivity
toxin. Infective dose: testing, but the fluoroquinolones
102–103 organisms. are most effective. Do not give
opiods. Often mild and
self-limited.
Salmonella spp. 8–48 ( & & Organisms grow in Superficial infection Gradual or abrupt onset of
gut. Do not of gut, little diarrhoea and low-grade fever.
produce toxin. invasion. Infective No antimicrobials unless
dose: 105 systemic dissemination is
organisms. suspected, in which case give

a fluoroquinolone. Stool
cultures are positive. Prolonged
carriage is common.
Yersinia ? ( & & Fecal-oral Gastroenteritis or Severe abdominal pain,
enterocolitica transmission mesenteric adenitis. diarrhoea, fever. PMNs and
(occasionally). Occasional blood in stool; polyarthritis,
Food-borne. bacteremia. erythema nodosum in children.
Enterotoxin If severe, give tetracycline or
produced. gentamicin.
Under these circumstances, transmission is unlikely providing that good personal

hygiene is practised.
Members of staff suffering from gastrointestinal or food poisoning infection should

inform their line manager. If the member of staff works in the kitchen or an area
where food and enteral feed are prepared or handled, he or she should be taken off
work and should be referred to the occupational health department.

Cáceres VM, Kim DK, Bresee JS, et al. A viral gastro-enteritis outbreak associated
with person-to-person spread among hospital staff. Infection Control and Hospital
Epidemiology 1998; 19: 162–167.
Consultants in Public Health Medicine (Communicable Disease and Environmental

Health Working Group). Scottish Centre for Infection and Environmental Health.
Guidelines for bacteriological clearance following gastroenteritic infection.
Communicable Disease (Scotland) Weekly Report 1994; 28(26): 8–13.
Dryden MS, Keyworth N, Gabb R, Stein K. Asymptomatic food handlers as the source of
nosocomial salmonellosis. Journal of Hospital Infection 1994; 28: 195–208.
Guerrant RL, Van Gilder T, Steiner TS, et al. Practice Guidelines for the Management of
Infectious Diarrhoea: Infectious Diseases Society of America. Clinical Infectious Diseases
2001; 32: 331–350.
Scottish Home and Health Department. The investigation and control of foodborne and
waterborne diseases in Scotland. Edinburgh: HMSO, 1995.
PHLS Working Group on the Control of Shigella sonnei. Revised guidelines for the
control Shigella sonnei infection and other infective diarrhoeas. Communicable Disease
Report 1993; 5: R69–R70.
Subcommittee of the PHLS Working Group on the Vero-cytotoxin producing Escherichia

coli (VTEC). Interim guidelines for the control if infections with Vero cytotoxin produ-
cing Escherichia coli (VTEC). Communicable Disease Report 1995; 6: R77–R81.
The prevention of human transmission of gastrointestinal infections, infestations, and

bacterial intoxication. A guide for Public Health Physicians and Environmental Health
Officers in England and Wales. A Working Party of the PHLS Salmonella sub-committee.
Communicable Disease Report 1995; 5: R158–R172.
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1994.
159
MENINGOCOCCAL INFECTIONS
Meningococcal disease is caused by N. meningitidis or meningococci. They are
Gram-negative diplococci which are divided into antigenically distinct groups. The
most common are B, C, A, Y and W135. They can cause meningitis and septicaemia.
Septicaemia without meningitis has the highest case fatality of 15–20% or more,
whereas in meningitis alone, the fatality rate is around 3–5%. Most cases are a com-
bination of septicaemia and meningitis. The disease can affect any age group, but the
young are the most vulnerable. Cases occur in all months of the year but the
incidence is highest in winter.
The nasopharyngeal carriage rate of all meningococci in the general population is

about 10%, although rates vary with age; about 25% of young adults may be carriers
at any one time.
Person-to-person transmission is mainly by droplets spread from the upper respira-

tory tract. There is no reservoir other than humans and the organism dies quickly
outside the host. The incubation period is 2–10 days but most invasive disease
normally develops within 7 days of acquisition. Therefore, for practical purposes
1-week period is considered sufficient to identify close contacts for prophylaxis. The
incubation period is 2–3 days, and the onset of disease varies from fulminant to
insidious with mild prodromal symptoms. Early symptoms and signs are usually
malaise, pyrexia and vomiting. Headache, photophobia, drowsiness or confusion,
joint pains and a typical haemorrhagic rash of meningococcal septicaemia may
develop. In its early stages, the rash may be non-specific. The rash, which may be
petechial or purpuric, does not blanche and this can be confirmed readily by gentle
pressure with a glass slide etc, when the rash can be seen to persist. Patients may
present in coma. In young infants particularly, the onset may be insidious and the
classical signs are absent. The diagnosis should be suspected in the presence of vomit-
ing, pyrexia, and irritability and, if still patent, raised anterior fontanelle tension.
Emergency action
Urgent admission to the hospital is a priority in view of the potentially rapid clinical
progression of meningococcal disease. Early treatment with benzyl penicillin is
recommended and may save life. Therefore, all general practitioners should carry
benzyl penicillin in their emergency bags and give it while arranging the transfer of
the case to the hospital. The only contraindication is a history of penicillin anaphyl-
axis. In these instances chloramphenicol (1.2 g for adult; 25 mg/kg for children under
age of 12 years) may be given by injection. Immediate dose of benzyl penicillin for
suspected cases are:
Adults and children (10 years or over) 1,200 mg

Children aged 1–9 years 600 mg
Children aged less than 1 year 300 mg
160
This dose should be given as soon as possible, ideally by intravenous injection.

Intramuscular injection is likely to be less effective in shocked patients, due to
reduced perfusion, but can be used if a vein cannot be found.
Management in hospital: On arrival in the hospital of a suspected case, doctors

should take blood for culture and give benzyl penicillin (or suitable alternative)
immediately if this has not already been done.
All patients with known or suspected meningitis must be isolated in a single room at
the time of admission. The patient should be isolated for a minimum of 24 h after the
start of appropriate antibiotic and a full course of chemoprophylaxis has been given.
Notification: In most countries, meningococcal infections are notifiable diseases.

Notification to appropriate local authorities is important to ensure prompt follow up
of close contacts. Close contacts should be offered chemoprophylaxis and immun-
ization where appropriate, which can be offered up to 4 weeks after the index case
became ill.
Chemoprophylaxis: Although penicillin and cefotaxime are the drugs of choice for
the treatment of meningococcal infection, they have no effect on the elimination
of nasopharyngeal carriage of the organism and are therefore not indicated for
prophylaxis. Rifampicin, ciprofloxacin and ceftriaxone (but not cefotaxime) are
effective in reducing the nasopharyngeal carriage rate and are therefore recom-
mended for chemoprophylaxis.
Rifampicin: In the absence of contraindications, the drug of choice is rifampicin,

which can be used in all age groups. It should preferably be taken at least 30 min
before a meal or 2 h after a meal to ensure rapid and complete absorption. Dosages
of rifampicin are as follows:
Adults: 600 mg every 12 h for 2 days.

Children:
Over 1 year 10 mg/kg every 12 h for 2 days
(up to a maximum of 600 mg per dose).
3 months to 1 year 5 mg/kg every 12 h for 2 days.
Rifampicin is contraindicated in the presence of jaundice or known hypersensitivity

to rifampicin. Interactions with other drugs, such as anticoagulants, should be con-
sidered. It also interferes with hormonal contraceptives (family planning
association advice for a ‘missed’ pill should be followed if rifampicin is prescribed to
an oral contraceptive user) and causes red coloration of urine, sputum and tears, (soft
contact lenses may be permanently stained). Side effects should be explained to the
patients and the information should be supplied with the prescription.
Ciprofloxacin: Ciprofloxacin can be offered as an alternative to rifampicin and is

given as a single dose of 500 mg orally in adults. It is useful when large numbers of
161
contacts need prophylaxis, such as in the management of outbreaks in colleges or

military camps or where compliance is in doubt.
Ceftriaxone: Although no drug is considered to be safe in pregnancy, all pregnant

women who are contacts should be counselled carefully about risks and benefits and
the option to give prophylaxis should be discussed. Ceftriaxone can be given as a first
choice in pregnancy. It can also be used as an alternative to rifampicin or where
compliance is in doubt. Dosages of ceftriaxone are:
Adults: A single dose of 250 mg intramuscular injection.

Children: A single dose of 125 mg intramuscular injection
(from 6 weeks to 12 years).
Ceftriaxone is contraindicated in patients with a history of hypersensitivity to

cephalosporins. It is not recommended for premature infants and full-term infants
during the first 6 weeks of life.
Management of contacts
After a single case: Chemoprophylaxis should be offered to all close contacts (defined
as people who had close, prolonged contact with the case) as soon as possible, i.e.
within 24 h after the diagnosis of the index case. Prophylaxis is recommended to the
contacts of confirmed or probable cases 7 days before the case became ill. Contacts
of possible cases do not need prophylaxis unless or until further evidence emerges
that changes the diagnostic category to confirmed or probable. It is recommended in
the following situations:
Household: Immediate family and close contacts, i.e. people sleeping in the same
house and boy/girl friends as the index case.
Kissing: Those people who have been mouth kissing contacts with the index case.
Index case: Index case should receive prophylaxis (unless they have already been
treated with ceftriaxone) as soon as they are able to take oral medication.
Health care worker: HCWs are advised to reduce the possibility of exposure to large
particle droplets nuclei (by wearing surgical masks and using closed suction)
when carrying out airway management procedures (i.e. endotrachael intubations/
management, or close examination of orophrynx), on all patients with suspected
meningococcal septicemia or meningitis.
Chemoprophylaxis is recommended only for those HCW who were in direct

contact with respiratory secretions (i.e. mouth or nose is directly exposed to large
particle droplets/secretions) and have not used appropriate barrier precautions. This
type of exposure will only occur among staff who are working close to the face of the
162
case without wearing a surgical mask. In practice, this implies a clear perception of
facial contact with droplet secretions and is unlikely to occur unless undertaking
airway management or being coughed at, directly in the face. General medical or
nursing care of cases is not an indication for prophylaxis.
Cluster of cases: A cluster is defined as two or more cases of meningococcal disease

in the same preschool group, school, or college/university within a 4-week period. If
two possible cases attend the same institution, whatever the interval between cases,
prophylaxis to household or institutional contacts is not indicated.
If two confirmed cases caused by different serogroups attend the same institution,
they should be regarded as two sporadic cases, whatever the interval between them.
Only household contacts of each case should be offered prophylaxis.
If two confirmed or probable cases who attend the same preschool group or school
arise within a 4-week period and are, or could be, caused by the same serogroup,
wider public health action in the institution is usually indicated.
The principle of managing such clusters is to attempt to define a group at high

risk of acquiring meningococcal infection and disease, and to target that group for
public health action. The target group should be a discrete group that contains the
cases and makes sense to staff and parents, e.g. children and staff of the same pre-
school group, children of the same school year, children who share a common social
activity, or a group of friends.
It is important to emphasize that chemoprophylaxis is effective in reducing the

nasopharyngeal carriage rates after treatment but does not completely eliminate
transmission between household members. Contacts should be reminded of the
persisting risk of disease, whether or not prophylaxis is given, and of the need to
contact their general practitioner urgently if they develop any symptoms suggestive
of meningococcal disease.
Immunization of contacts
Close contacts of cases of meningococcal meningitis have a considerably increased
risk of developing the disease in the subsequent months, despite appropriate
chemoprophylaxis. Therefore, immediate family or close contacts of cases of group
A or group C meningitis should be given meningococcal vaccine in addition to
chemoprophylaxis. The latter should be given first and the decision to offer vac-
cine should be made when the results of serotyping are available. Vaccine should
not be given to contacts of group B cases. The serological response is detected
in more than 90% of recipients and occurs 5–7 days after a single injection. The
response is strictly group specific and confers no protection against group B
organisms.
163

Cartwright K, ed. Meningococcal Disease. London: Wiley, 1995.
Hart CA, Rogers TRF, eds. Meningococcal disease. Journal of Medical Microbiology 1993;
39: 2–25.
Kaczmarski EB, Cartwright KAV. Control of meningococcal disease: guidance for micro-
biologist. Communicable Disease Report 1995; 5: R196–R198.
PHLS. Meningococcal Forum. Guidelines for public health management of meningo-

coccal disease in the UK. Communicable Disease and Public Health 2002;5(3): 187–204.
PHLS Meningococcus Working Group and Public Health Medicine Environmental

Group. Management of clusters of meningococcal disease. Communicable Disease Report
1997; 7: R3–R5.
UK Department of Health. Immunization against infectious diseases. London: HMSO,

1996.
164
VARICELLA ZOSTER VIRUS (VZV)

VZV causes chickenpox (varicella) as a primary infection. The virus persists in a
latent state within the host and can subsequently reactivate years or decades later to
cause shingles (zoster).
Clinical features: Chickenpox is an acute generalized illness with sudden onset of
mild fever and constitutional upset and a typical skin eruption that is maculopapu-
lar for a few hours, vesicular for 3–4 days, and leaves a granular scab in 4–7 days. The
vesicles are monolocular and collapse on puncture. Lesions commonly occur in
successive crops, often with several stages of maturity present at the same time; they
tend to be more abundant on covered than on exposed parts of the body. In some
cases, the lesions may be so few as to escape observation. Mild atypical and inappar-
ent infections may occur. The illness can result in complications such as pneumonia,
encephalitis, visceral dissemination or haemorrhagic varicella.
Zoster or shingles is a local manifestation of re-activation of latent varicella infection
in the dorsal root ganglia. Vesicles with an erythematous base appear, sometimes
in crops, in irregular fashion on the skin to areas supplied by sensory nerves of a
single or associated group of dorsal root ganglia. In the immunosuppressed or those
patients with malignancies, chickenpox-like lesions may appear outside the
dermatome.
Immunosuppressed patients, e.g. with cancer, especially of lymphoid tissue, with or
without steroid therapy, immunodeficient patients and those on immunosuppressive
therapy may have an increased frequency and severity of zoster, both localized and
disseminated. Neonates developing varicella between ages 5–10 days, and those
whose mothers develop the disease 5 days prior to or within 2 days after delivery, are
at increased risk of developing severe generalized chickenpox, with a fatality rate of
up to 30%. Infection in early pregnancy may be associated with congenital malfor-
mations in up to 2% of cases.
Period of infectivity: The incubation period ranges from 2–3 weeks (usually 13–17
days). In chickenpox VZV is shed from the nasopharynx for up to 5 (usually 1–2) days
before the rash appears and then from the skin lesions until the vesicles have dried to
a scab, usually about 4–7 days; during this time, the patient is considered infectious.
In shingles, the virus is shed from the skin lesion vesicles until they have dried to
form a scab, so the patient is considered infectious for approximately 1 week after the
appearance of the vesiculopustular lesions. It must be noted, however, that conta-
giousness may be prolonged in individuals with altered immunity.
Transmission: VZV is spread from person-to-person by direct contact or by the
respiratory route (droplet or airborne) from secretions of the respiratory tract or
vesicle fluid from chickenpox cases or the vesicle fluid of cases of herpes zoster. It can
also be transmitted indirectly through articles freshly soiled by discharges from
vesicles and mucous membranes of infected people.
165
About 5–8% of the adult population without a history of chickenpox do not have
detectable antibody to VZV and are susceptible. Non-immune hospital staff may
acquire VZV infection either in the hospital or from hospitalized patients and are at
risk of developing chickenpox. Chickenpox in late pregnancy can be particularly
severe, therefore pregnant staff who have no clear history of chickenpox must avoid
contact with patients and colleagues with VZV infection. VZV vaccine should be
offered to non-immune HCWs.
Infection control measures: The following measures should be considered in the

control of VZV infection in health care setting:
• All suspected or clinically confirmed cases of chickenpox must be nursed in

a side room with additional (airborne) isolation precautions (see page 102).
The room should preferably have negative pressure ventilation. Infected
patients may be cohorted together when necessary.
• Hands must be washed with antiseptic hand preparation or can be disin-
fected with an alcohol hand rub.
• Patients with varicella infection and susceptible (non-immune) persons
exposed within the previous 21 days should not be admitted to hospital
unless absolutely necessary.
• In-patients who develop varicella and susceptible patients (non-immune)
exposed in hospital should be discharged as soon as possible if clinical
condition permits.
• Exposed susceptible persons (non-immune), when they are hospitalized,
must be isolated in a side room with appropriate infection control meas-
ures from 10 days following their earliest varicella exposure until 21 days
after their most recent exposure. This period may be extended in cases
where varicella zoster immunoglobin (VZIG) has been administered or in
cases of immunosuppression.
• In the case of zoster infection, the patient should be nursed in a side
room with infection control precautions from the first appearance of the
vesiculopustular lesions until scab formation. Hands must be washed
with antiseptic hand preparation or can be disinfected with an alcohol
hand rub.
• In pregnant women the disease is more serious with a higher risk of fulmin-
ating varicella pneumonia. Therefore all pregnant patients who are
admitted should be isolated in a side room with full en-suite facilities using
the infection control precautions.
VZIG prophylaxis: VZIG prophylaxis is recommended in individuals with a signifi-

cant contact with a case of varicella or zoster where the clinical condition increases
the risk of severe complications of varicella. VZIG does not prevent infection even
166
when given within 72 h of exposure. However it may attenuate disease if given up to

10 days after exposure. Severe maternal varicella may still occur despite VZIG pro-
phylaxis. There is some evidence that the likelihood of fetal infection during the first
20 weeks of gestation is reduced in women who develop chickenpox under cover
of VZIG.
A significant contact is defined as being in the same room (e.g. house or classroom
or 2–4 bed hospital bay) for a significant period of time (15 min or more) or any face
to face contact.
The following patients are at risk of developing severe complications of varicella and
should be urgently tested for varicella immunity if significant exposure to varicella
or zoster occurs:
Pregnant women: The problems of varicella infection during pregnancy relate to

both the mother and fetus and also when infection takes place at term to the new
born child. If varicella occurs during pregnancy, the woman should be advised of the
likelihood of fetal involvement, with reference to the stages of the pregnancy that
the infection took place and the providers of her antenatal care should be informed.
If a pregnant woman has a significant contact with varicella or zoster and has no past
history of varicella or zoster, the woman’s susceptibility should be determined
urgently by taking a blood sample. If they are varicella IgG negative, they should be
offered VZIG if they are within 10 days of the exposure.
If the varicella infection occurs %8 days before delivery, inapparent or mild in-utero
infection may occur. If the infection occurs 7 days before to 28 days after delivery,
these women run a high risk of severe disseminated infection in the neonate and the
intervention with VZIG is recommended. This should be administered to the mother
before delivery and to the neonate after delivery. Varicella in the neonate should also
be treated with aciclovir.
Neonates: Babies born before 30 weeks of gestation or below 1 kg birth weight should
receive VZIG if exposed to varicella, irrespective of the immune status of the mother.
It is also given to VZV antibody negative infants exposed to chickenpox or herpes
zoster in the first 28 days of life. In neonates, VZIG is recommended in infants whose
mother developed chickenpox (but not zoster) in the period 7 days before to 28 days
after delivery. Prophylactic intravenous aciclovir should be considered for neonates
whose mothers develop varicella 4 days before to 2 days after delivery as they are at
the highest risk of fatal outcome despite VZIG prophylaxis. Mothers with
varicella should be allowed to breast-feed. If nipple lesions are present, then milk can
be expressed from the affected breast until the lesions are crusted. This expressed
milk can be fed to the baby if he/she is covered by VZIG.
Patients with poor immunity: Patients with cancer, especially of lymphoid tissue,
patients with leukaemia, organ transplant, AIDS and HIV infection and patients on
chemotherapy for malignant disease.
167
Patients on systemic steroid drugs: Patients (or parents of children) at risk who use
systemic corticosteroids should be advised to take reasonable steps to avoid close
contact with chickenpox or herpes zoster and to seek urgent medical attention if
exposed to chickenpox. Manifestations of fulminant illness include pneumonia,
hepatitis and disseminated intravascular coagulation; rash is not necessarily a prom-
inent features. Patients on steroids who are non-immune may require prophylactic
cover with VZIG following contact with chickenpox or zoster.
VZIG is given by intramuscular injection as soon as possible and not later than
10 days after exposure. It must not be given intravenously. If a second exposure
occurs after 3 weeks a further dose is required. VZIG does not prevent infection even
when given within 72 h of exposure. However it may attenuate disease if given up to
10 days after exposure. Severe maternal varicella may still occur despite VZIG
prophylaxis.

Enders G, Millar E, Cradock-Watson J, et al. Consequences of varicella and herpes zoster
in pregnancy: prospective study of 1739 cases. Lancet 1994; 343: 1548–1551.
Miller E. Varicella-zoster virus. In: Greenough A, et al. (ed). Congenital, perinatal and
neonatal infections. London: Churchill and Livingstone, 1992: 223–232.
PHLS Joint Working Party of the Advisory Committees of Virology and Vaccines
and Immunisation. Guidelines on the management of, and exposure to, rash illness
in pregnancy (including consideration of relevant antibody screening programmes in
pregnancy). Communicable disease and public health 2002; 5: 59–71.
UK Department of Health. Immunization against infectious diseases. London: HMSO,

1996.
168
CREUTZFELDT-JAKOB DISEASE (CJD)

CJD is classified as a transmissible spongiform encephalopathy (TSE) in human;
other TSEs in humans include Kuru, Gerstmann-Straussler-Scheinker syndrome,
and fatal familial insomnia.
CJD is a progressive degenerative disease of the brain which causes dementia

and death. At first, it was thought that the infectious agent was a virus or virus-
like particle. However, in the 1980s, it became clear that a normal host protein, prion
protein (PrP), was an important component of the infectious agent. The incubation
period of sporadic cases of CJD is unknown, but iatrogenic cases appear to have an
incubation period of 2 to 15 years or more, depending on the route of inoculation.
Mode of transmission: CJD has been transmitted accidentally in human sources

including growth hormones, dura mater preparation and transplantation of a
corneal graft donated by an affected patient. CJD patients should not be accepted as
blood donors, and none of their tissues used for transplant purposes. In the case
of corneal grafts, the member of the ophthalmic surgical team responsible for
collecting the corneas should be instructed to make specific enquiries to exclude such
cases. Corneas should not be taken from demented patients nor from those who die
in psychiatric hospitals, nor from patients who die from obscure undiagnosed neuro-
logical diseases.
The PrP protein is extraordinarily resistant to standard cleaning and inactivation

processes. It also has a high degree of resistance to physical and chemical procedures
employed for sterilization and disinfection. Complete inactivation requires a combin-
ation of chemical and heat treatment. It also survives formalin fixation, therefore all
formalin-fixed specimens should be regarded as being infective. Special care should
therefore be taken to avoid accidental inoculation or other contamination while
preparing the tissue for microscopy.
Clinical manifestations: New variant Creutzfeldt-Jakob Disease (vCJD) refers to a

manifestation of the disease that is believed to be causally related to the Bovine
Spongiform Encephalopathy (BSE) epidemic that has occurred in the UK and several
other European countries. Unlike classical CJD, the initial presenting features
of vCJD are usually psychiatric disturbances, such as depression and behavioural
changes. Over the following months, additional symptoms such as abnormal sensa-
tion, ataxia and myoclonus develop. Although the EEG is abnormal, typical periodic
complexes usually seen in classical CJD are absent in vCJD. Within about 12 months
of the initial symptoms, patients enter a state of akinetic mutism, and death usually
occurs within a few months. Neuropathlogical features differ markedly from those of
classical CJD. The most consistent pathological change in vCJD, which is generally
not seen in classical CJD, is the presence of PrP plaques. In most cases studied,
plaques are distributed extensively throughout the cerebrum and cerebellum, with
some plaques seen in the basal ganglia, thalamus and hypothalamus.
169
Diagnosis: There is no serological test available for the diagnosis of CJD and reliance
can only be made on clinical grounds based on the history of rapidly progressive
dementia, the presence of mycolonic movements and a characteristic electroencephalo-
gram. It can be confirmed by the histological examination of brain tissue after death.
Infection control precautions: It is important to emphasize that CJD is neither a con-

tagious nor communicable disease, but is transmissible under certain circumstance
(see page 169). Normal social and clinical contact and non invasive procedures do
not a present risk to HCWs, visitors, relatives and the wider community.
Isolation of CJD patients is not necessary. Patients can be nursed in an open ward
using standard precautions. Patients may need to be placed in a single room on
compassionate ground. When caring for patients with CJD, the HCW should wear
single-use disposable gloves and plastic apron and gloves when carrying out proced-
ures, e.g. lumbar punctures for radiological and other investigations, biopsies, dress-
ing wounds and venepuncture/administration of injections etc.
Although CJD is not transmissible by the respiratory route, it is recommended to use

single-use disposal instruments which are in direct contact with mouth, pharynx,
tonsils and respiratory tract by a method described. Destruction by incineration of
non re-usable equipment is recommended.
Surgical procedures: It is essential that the surgical procedure should be carefully

planned beforehand and appropriate personnel informed. Where the surgical proced-
ure involves the brain (e.g. cortical biopsy), spinal cord or eye, the following
additional precautions should be taken:
• Minimum number of staff should take part in the operation.

• Disposable instruments and equipment should be used wherever possible.
• Members of the operating team should wear appropriate personal equip-
ment, i.e. liquid repellent theatre gown over a plastic apron, gloves, mask
and visor or goggles.
• Disposable drapes and dressings should be used.
• Cover all non-disposable equipment.
• One-way flow of instruments should be maintained.
• All waste should be treated as clinical waste and disposed of by incineration.
• Specimens sent to a Pathology Laboratory should be put in an appropriate
container and be marked with a ‘Biohazard’ label.
• All surfaces should be cleaned and disinfected according to local protocol.
These precautions should also be observed when neurosurgical procedures are carried
out on patients in whom the possibility of CJD enters into the differential diagnosis.
170
Methods of decontamination
The decision on methods of instrument decontamination should be based upon the
infectivity level of the tissue and the way in which instruments will subsequently be
re-used. For example, where surgical instruments contact high infectivity tissues,
single-use surgical instruments are strongly recommended. If single-use instruments
are not available, maximum safety is attained by destruction of re-usable instruments.
Where destruction is not practical, re-usable instruments must be handled with care
and must be decontaminated. Do not mix instruments used on high and low infectivity
tissues. To avoid unnecessary destruction of instruments, quarantine of instruments
while determining the final diagnosis of persons suspected of CJD should be used.
High-risk tissues (see Table 9.2) from high-risk patients (e.g. those with known or
suspected CJD) and critical or semicritical items should be subjected to the follow-
ing decontamination measures:
• These devices must be thoroughly cleaned to ensure that all tissue is effect-
ively removed. To minimize drying of tissues and body fluids on the object,
instruments should be kept moist until cleaned and decontaminated.
Table 9.2 Distribution of infectivity in the human body.
Infectivity category Tissues, secretions and excretions
High infectivity Brain

Spinal cord
Eye
Low infectivity CSF
Kidney
Liver
Lung
Lymph nodes/spleen
Placenta
No detectable infectivity Adipose tissue Tears
Adrenal gland Nasal mucous
Gingival tissue Saliva
Heart muscle Sweat
Intestine Serous exudate
Peripheral nerve Milk
Prostate Semen
Skeletal muscle Urine
Testis Faeces
Thyroid gland
Blood
Adapted from Brown P, 1994 & 1996.

Notes: Assignment of different organs and tissues to categories of high and low infectivity is
chiefly based upon the frequency with which infectivity has been detectable, rather than upon
quantitative assays of the level of infectivity, for which data are incomplete.
171
• Equipment that requires special prion reprocessing should be tagged after

use according to local protocol. Those instruments should be placed
securely in a robust, leak-proof container labelled ‘Biohazard’.
• Surgical instruments can be cleaned and then sterilized by autoclaving at
134°C for %18 min in a prevacuum sterilizer.
• Those devices that are impossible or difficult to clean could be discarded.
Alternatively, contaminated items should be immersed in a container
filled with a liquid (e.g. saline, water or phenolic solution) to minimize
the adherence of material to the items. This should be followed by initial
decontamination by autoclaving at 134°C for 18 min in a prevacuum
sterilizer, or by soaking in 1 N NaOH for 1 h.
• Environmental surfaces (non-critical) contaminated with high-risk tissues
(e.g. laboratory surface in contact with brain tissue of a person infected with
CJD) should be cleaned and then spot-decontaminated with a 1:10 dilution
of sodium hypochlorite (i.e. bleach). To minimize environmental contam-
ination, disposable cover sheets could be used on work surfaces.
• Non-critical equipment contaminated with a high-risk tissue should be
cleaned and then disinfected with sodium hypochlorite (1:10 dilution) or
1 N NaOH, depending on material compatibility. All contaminated surfaces
must be exposed to the disinfectant.
Devices in contact with low or no risk tissues can be cleaned and either disinfected or
sterilized by use of conventional protocols of heat or chemical sterilization,
or high-level disinfection. Although CSF is classified as a low infectivity tissue it is
recommended that instruments contaminated by CSF should be handled in the same
manner as those contacting high infectivity tissues, that instruments used for lumbar
puncture be single-use disposable and that they must be discarded and destroyed by
incineration afterwards.
Post-mortem: Post-mortem examination of patients with CJD should be done by a

neuropathologist with access to a specialized mortuary. However, a general
histopathologist who has been asked to perform a necropsy on a case of possible or
probable CJD must follow suitable infection control precautions based on local
guidance. As few persons as possible should take part in the post-mortem. Personal
protective equipment must be worn. Great care should be taken to avoid cuts and
sharp injuries, particularly from contact with sharp bony edges and during sewing
up. Accidental injuries or inoculation wounds should be thoroughly washed
(without scrubbing) in running water immediately, and the incident should be
reported according to local protocol. The bodies of patients who have died as a
result of CJD must not be used for teaching anatomy or pathology.
Childbirth: CJD is not known to be transmitted from mother to child during

pregnancy or childbirth. In the event that a person with CJD becomes pregnant, no
172
particular precautions need to be taken during the pregnancy, except during invasive
procedures. Childbirth should be managed using standard infection control proced-
ures, except that precautions should be taken to reduce the risk of exposure to
placenta and any associated material and fluids. These should be disposed of by
incineration.
Occupational exposure
No known cases of human CJD have occurred through occupational accident or
injury. In the context of occupational exposure, the highest potential risk is from
exposure to high infectivity tissues through needle-stick injuries with inoculation;
however, exposure to either high or low infectivity tissues through direct inoculation
(e.g. needlesticks, puncture wounds, ‘sharps’ injuries, or contamination of broken
skin) must be avoided.
Unbroken skin which has been contaminated with internal body fluids or tissues
should be washed with detergent and plenty of warm water, rinsed and dried. Do
not scrub. Brief exposure (1 min to 0.1 N NaOH or a 1:10 dilution of bleach) can be
considered for maximum safety. If needlesticks or lacerations occur, gently
encourage bleeding and wash (without scrubbing) with warm soapy water, rinse, dry
and cover with a waterproof dressing. Further treatment (e.g. sutures) should be
appropriate to the type of injury. Splashes into the eye or mouth should be irrigated
with either saline (eye) or tap water (mouth). All occupational injuries should be
reported according to local policy and protocol and the records kept for no less than
20 years.

Advisory Committee on Dangerous Pathogens, Spongiform Encephalopathy Advisory
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Disinfection, sterilization and preservation, 5th edn. Philadelphia: Lippincott Williams &
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Brown P, Gibbs CJ, Rodgers-Johnson P, et al. Human Spongiform Encephalopathy: the

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Brown P. Environmental Causes of Human Spongiform Encephalopathy. Baker H,

Ridley RM, (eds), Methods in Molecular Medicine: Prion Diseases. Totowa, NJ: Humana
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Brown P, Gibbs CJ Jr, Gajdusek DC, et al. Transmission of Creutzfeldt-Jakob Disease from
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174
VIRAL HAEMORRHAGIC FEVERS (VHFs)

VHFs are a group of viral diseases which are endemic mainly in west and central Africa.
VHFs can present a significant risk to all countries due to the ease of international
travel. VHFs have a significant mortality rate and there is no vaccine available.
The most clinically important viruses are:
• Lassa fever virus: Nigeria, Sierra Leone and Liberia

• Marburg virus: Uganda, Kenya, Zimbabwe
• Ebola virus: Zaire and Sudan
• Crimean-Congo haemorrhagic fever virus: Former Soviet Union and east
and west Africa.
Clinical manifestations: VHFs usually present as a febrile illness with headache,

myalgia, sore throat, cough and vomiting. Some patients have a cough, chest pain,
abdominal tenderness and skin rash. In severe cases, patients may suffer extensive
haemorrhage, accompanied by a purpuric rash and bleeding from almost any part of
the body, including the intestine, eyes, gums, nose, mouth, lungs and uterus.
Encephalopathy and multi-organ failure are common in severe cases and the case
mortality rate is high.
History of adequate malarial prophylaxis must be taken. Malaria is a common con-

founding diagnosis and is suspected in patients who have failed to take adequate
malarial prophylaxis.
Diagnosis: A firm diagnosis is not always possible but both the clinical and the
epidemiological evidence need to be considered for any patient presenting with
undiagnosed fever within 3 weeks of return from an endemic area.
In the initial assessment of patients with suspected VHF, laboratory testing should be
kept to an absolute minimum to minimize the risk associated with the collection and
handling of laboratory specimens. Laboratory procedures must include a risk assess-
ment at each stage, including risks associated with the chosen techniques, recommen-
dations about training and surveillance measures, waste disposal and decontamination.
All patients with suspected VHF and their specimens and bodily secretions should be
handled at Physical Containment Level 4. All specimens must be handled with
appropriate safeguards. The specimens should not be sent through the normal courier
mechanisms (human or otherwise), to ensure that accidents do not occur as a conse-
quence of mishandling or misplacement. The laboratory staff and infection control
practitioner must be alerted immediately to ensure appropriate handling of specimens.
Notification: All suspected cases of VHF must be notified to the local officer (CCDC
in the UK) or other designated authority.
175
Incubation period: The incubation period of the infection is usually 7–10 days (ranging
from 3–17 days). For infection control purposes, if no infection has occurred in a period
of up to 21 days from exposure, a contact is usually taken to be free from infection.
Risk categories: The UK Advisory Committee on Dangerous Pathogens (1996) have

categorized patients in the following risk groups:
Minimum risk: Patients for whom the possibility of a VHF has been assessed but whose
history and clinical condition make the diagnosis unlikely. This category includes febrile
patients who were not in known endemic or outbreak areas before they became ill, or
who were in such areas but became ill more than 21 days after contact with a potential
source of infection, and patients whose risk category has been revised because of their
clinical condition or the results of laboratory tests. These patients can be managed using
standard isolation precautions. No special ambulance transport is necessary.
Moderate risk: Febrile patients who have been in an endemic area during the 21 days
before they became ill but who have no other risk factors, or who have not been in
an endemic area but may have been in adjacent areas or countries during the 21 days
before the onset of illness, and who have evidence of severe illness with organ failure
and/or haemorrhage which could be due to a VHF and for which no alternative
diagnosis is currently evident.
Few patients remain in this category for more than 48–72 h. These patients should be
admitted to a designated high security infectious disease (HSID) unit or to inter-
mediate isolation facilities and transported by a category ambulance. Malaria must
be excluded by sending blood films to the laboratory. The appropriate local officer
should be notified and contacts identified, but the contacts need not be placed under
surveillance unless the patient is reclassified as high risk.
High risk: Febrile patients who have been in an endemic area during the 3 weeks before
illness and have lived in or stayed in a house for more than 4 h where there were febrile
people known or strongly suspected to have a VHF or have cared for a febrile patient
known or strongly suspected to have a VHF, or have had contact with body fluids,
tissue, or a dead person or animal known to have had a VHF, or were previously
classified as moderate risk but have developed organ failure and/or haemorrhage. This
category also includes febrile patients who have not been in an endemic area, but have
cared for a patient or animal known or strongly suspected to have had a VHF during
the 3 weeks before they themselves became ill. High-risk patients should be admitted
to a HSID unit and all specimens (except the initial malaria test) must be handled in
a designated laboratory. The appropriate local officer (CCDC in the UK) should be
notified. All those who had close contact with the patient after the onset of illness
should have their temperatures taken daily for 21 days after their last contact.
Source of infection: Patients are infectious while they are symptomatic and until the
virus has been cleared from the blood and body fluids. Lassa fever virus has been
found in the respiratory secretions of a symptomatic patient and in urine during the
176
convalescent phase. Sexual transmission of Ebola virus and Lassa fever virus has been
recorded, and Ebola virus has been found in seminal fluid for up to 2 months after
the onset of symptoms.
Mode of transmission: Recent evidence on the mode of transmission of these viruses
indicates that the main risk of transmission in the health care settings is from mucosal
or parenteral exposure to contaminated blood or other body fluids. Lassa fever virus
may also be transmitted by exposure to aerosols of contaminated body fluids,
particularly nasopharyngeal secretions and urine.
Management
In general practice: If the General Practitioner has seen a patient at home and
suspects a diagnosis of VHF in a patient suffering from acute atypical fevers, (espe-
cially with any accompanying superficial haemorrhages or in patients who have
recently returned from endemic areas), he/she is advised not to move the patient
from home and to seek specialist advice.
In hospital: It is possible that the provisional diagnosis might first be made in a patient
attending hospital as an out-patient, e.g. in the Accident and Emergency department
or in a patient already in a general hospital ward. It is important to emphasize that
VHFs are containment 4 pathogens and appropriate procedures must be taken.
Infection control and precautions

The following action must be taken:
• The patient must be isolated in a single room with standard and contact
isolation precautions. Strict isolation precautions must be instituted. The
patient must not be moved from the suspected ward or department. It is
possible that the patient may require treatment in a high security desig-
nated infectious diseases unit.
• The absolute minimum of staff should have contact with the patient, i.e. one
doctor and one nurse. The doctor involved in making the initial
diagnosis should seek advice from the consultant physician in infectious
diseases. In such circumstances, no other hospital medical staff should
be invited to assist in confirming suspicions to minimize the risk to HCWs.
• Instruments, dressings, documents, clothing or any other items must not be
removed from the area.
• Staff already involved with the case must not resume other professional
duties and should remain, as far as possible, within the department, using
a designated staff room.
• Patients and their body fluids are highly infectious therefore appropriate
protective clothing must be worn, e.g. scrub suit, gown, apron, two pairs of
gloves, mask, headcover, eyewear, and rubber boots.
177
• Disposable equipment should be used whenever possible. Other instruments

should be heat disinfected.
• The environment must be decontaminated using hypochlorite solution
1:100 dilution. Fumigation of the room is necessary after the patient has
been discharged.
• All waste must be treated as clinical waste and must be disposed of by
incineration.
• VHFs are classified as dangerous biological agents (containment
4 pathogens). Therefore, transport and handling of specimens requires
special precautions.
If the diagnosis of VHF is confirmed, staff who have been in contact with the patient
may require continuing isolation and surveillance. This should be carried out by the
occupational health department. Assessment of any surveillance measures necessary
for patients may be needed for other patients who may have been in contact with
suspect case.

Cooper CB, Gransden WR, Webster M, King M, et al. A case of Lassa fever: experience at
St Thomas’ hospital. British Medical Journal 1982; 285: 1003–1005.
Holmes GP, McCornick JB, Trock CC, et al. Lassa fever in the United States: investigations
of a case and new guidelines for management. New England Journal of Medicine 1990;
323: 1120.
Isaäcson M. Viral Haemorrhagic Fever hazards for travellers in Africa. Travel Medicine,
McCormick JB, Webb PA, Krebs JW, et al. A prospective study of the epidemiology and
ecology of Lassa fever. Journal of Infectious Diseases 1987; 155(3): 437–444.
Management of patients with suspected viral haemorrhagic fever. Morbidity and

Mortality Weekly Report 1988; 37(Suppl.): 1–16.
Notice to Readers Update: Management of Patients with Suspected Viral Haemorrhagic

Fever-United States. Morbidity and Mortality Weekly Report 1995; 44(25): 475–479.
UK Advisory Committee on Dangerous Pathogens. Management and control of viral

haemorrhagic fevers. London: The Stationary Office, 1996.
UK Advisory Committee on Dangerous Pathogens. Categorisation of biological agents

according to hazard and categories of containment, 4th edn. London: HMSO, 1995.
WHO and CDC: Infection control for viral haemorrhagic fevers in the African health care
setting. Geneva: WHO, 1998. http://www.who.int/
178
RABIES
Human-to-human transmission of rabies is very rare and has been demonstrated in
patients who have received infected corneal grafts. Transmission is mostly from an
animal bite in countries where rabies is prevalent. The incubation period is usually
3–8 weeks, but may be as short as 9 days or as long as 7 years, depending on the
severity of the wound, the site of the wound in relation to the richness of the nerve
supply and its distance from the brain.
Rabies is transmitted when infected saliva contaminates mucous membrane or an

open wound. The following precautions are recommended:
• The patient should be isolated in a single room with standard infection

control precautions.
• The staff should wear appropriate protective clothing including gloves,
gown, goggles.
• Mouth-to-mouth resuscitation should not be used.
• Staff in contact with the patient should be minimized.
• Staff with open lesions should not be allowed to have contact with the
patient.
• Pregnant female staff should not attend the patient.
• Specimens from the patient should not be sent to routine diagnostic labora-
tories without prior consultation with the senior member of staff.
• Equipment soiled by secretions or excretions should either be single-use
disposable or sterilized using heat sterilization in the Sterile Supply
Department.
• Attendant staff and other close contacts should be offered immunization
and sometimes rabies-specific immunoglobulin at the advice of the
physician in infectious diseases.
• Post-mortem examination should not be undertaken. Where such examin-
ation may be of value, the indications and arrangements must be discussed
with the histopathologist.

Rabies Prevention – United States 1991. Recommendations of the Immunization
Practices Advisory Committee. Morbidity and Mortality Weekly Report 1991; 40: 1–19.
UK Department of Health. Memorandum on rabies. London: HMSO, 1977.
UK Department of Health. Immunization against infectious disease. London: HMSO, 1996.
179
INFESTATIONS WITH ECTOPARASITES

Humans are the only reservoir for these parasites, which are usually localized to a
specific site of the body.
Lice (Pediculosis)
There are many different species of lice but only three that are clinically important
from the family pediculidae. They can be caught only by close contact, i.e. close
enough for lice to walk onto another host. Lice can be found on the body, on
bedding, chairs, floor etc. They are either dead, injured or dying and not able to crawl
onto another host. Nits are the eggs of lice, which are firmly attached to hair and are
difficult to remove.
Infestations with lice may result in severe itching and excoriation of the scalp or
body. Secondary bacterial infection may occur due to severe itching resulting in
regional lymphadenitis (especially cervical).
Head louse (Pediculus humanus var. capitis): This species lives on the head and
eyebrow hair. The female louse lays eggs at the base of the hairs where it is warmest.
Transmission to another host occurs when two heads are in direct contact, allowing
lice to crawl on to a new head. Lice prefer clean hair where they can move around
easily. They are invariably acquired from family members or close friends who
should be checked for infection. Head lice cannot be transmitted to others on cloth-
ing or linen and therefore no precautions are necessary. Patients with head lice need
not be isolated, except in paediatric wards where close contact between children may
transmit the lice. Outbreaks of head lice are common among children in schools and
other institutions.
Pubic or crab louse (Phthirus pubis): They live on coarse body hair, usually the pubic
area; they may also infect facial hair (including eye lashes), axillae and body surfaces.
They are transmitted by close physical contact, frequently but not always, by sexual
contact. Children may acquire crab lice through close contact with their mother, e.g.
axillary hair. Crab lice on clothing or bedding are not transmitted to other people
and can be removed by washing clothes in a hot cycle.
Body louse (Pediculus humanus var. corporis): Body lice are still prevalent among
populations with poor personal hygiene, especially in cold climates where heavy
clothing is worn and bathing is infrequent. They live in clothing, rather than hair
and go to the body only to feed. Transmission occurs in overcrowded conditions
by contact with infested clothing. They are easy to eradicate, as they will die if the
clothing is not worn for 3 days.

• Carefully remove all clothing of patients with body or pubic lice and seal in
a bag. As lice dislike light, clothing should be handled in bright conditions.
180
Single-use non-sterile disposable gloves and a plastic apron should be

worn. In hospital, process linen as infected linen according to local policy.
• No special treatment of the environment is required as spread is by personal
contact. Body lice are capable of surviving for a limited time in stored
clothing, but head and pubic lice rapidly die when detached from their
host.
• Patients with body lice do not require specific treatment but should
be bathed. Infestation with head and crab lice should be referred to the
medical practitioner for appropriate treatment.
• Clothing, bedding and fomites should be treated with a hot water cycle
(60°C or more).
Fleas
Infestation is usually with dog, cat, or bird fleas, which will bite humans in the
absence of the preferred host. The human flea is rare. Fleas are able to survive for
some months in the environment without feeding. Elimination of the host or treat-
ment of pets and the use of suitable insecticides on environment surfaces and soft
furnishing is therefore essential.

• Remove all clothing and bedding. All laundry should be treated as infected
linen according to the local policy.
• Clothing not suitable for washing may be treated with low temperature
steam. Seek advice from the SSD manager.
• The laundry bag must be removed immediately from the ward. In the
laundry, the inner hot water soluble plastic bag will allow transfer to a
machine without handling.
• Identify the flea, and if possible, treat or remove the host. If it is a cat flea,
take steps to exclude feral cats from the site.
• Vacuum clean floors, carpets, upholstery, fabrics, etc.
• Contact your pest control officer to treat the environment, e.g. ducting,
hard surfaces, and under fixtures, with a residual insecticide if necessary.
Scabies
Scabies is caused by Sarcoptes scabiei. The severe itching is caused by an allergic reac-
tion to the presence of a small mite which burrows into the top layer of skin. Intense
itching occurs especially at night or after a hot bath or shower. The allergic reaction
does not appear immediately, but develops between 4 and 6 weeks after infection.
However, symptoms may appear earlier (1–4 days) if the patient has had previous
exposure.
181
‘Norwegian’ or ‘crusty’ scabies occurs in elderly or immunosuppressed patients, i.e.

patients on immunosuppressive therapy, with AIDS and with other malignancies.
Immunocompromised patients may suffer hyperinfestation. This form of scabies is
highly contagious because mites multiply rapidly and large numbers of the parasites
are present in the exfoliating scales.
Human beings are the only source of infection. Spread of infection from person-to-
person occurs through direct skin-to-skin contact, which is usually prolonged and
intimate.
Any person infested with either mites or eggs is infectious. In the health care setting,
it is transmitted primarily through intimate direct contact with an infested person,
even when high levels of personal hygiene are maintained.
Hand-holding or patient support for long periods is probably responsible for most
hospital-acquired scabies. Transmission to HCWs has occurred during activities such
as sponge-bathing patients or applying body lotions. Transmission between patients
may also be possible when patients are ambulatory. Transmission via inanimate
objects, such as clothing and bedding, is uncommon, and only occurs if contamin-
ated immediately beforehand, as the mites do not survive very long out of contact
with human skin. Spread from bedding, clothing or fomites is unlikely.

• Refer members of the family and those in close physical contact to their
general practitioner so that they can be treated if necessary.
• Treat bedding and clothing as infected linen according to the local policy.
• Protective long sleeved gowns and gloves should be worn. Prolonged
contact should be avoided.
• No special environmental control measures are necessary.
• For hospitalized patients, institute additional isolation precautions (contact
transmission) for 24 h after start of effective therapy. Consideration should
be given to extending the isolation period in the case of immunocomprom-
ised or heavily infested patients. In addition, staff with scabies should be
rostered to avoid patient contact for 24 h after appropriate treatment is
initiated.
• Patients with ‘Norwegian’ scabies are highly contagious and additional
isolation precautions (contact transmission) are recommended until the
treatment is completed.
182

Gooch JJ, Strasius SR, Beamer B, et al. Nosocomial outbreak of scabies. Archive of
Dermatology 1978; 114: 897–898.
Jimenez-Lucho VE, Fallon F, Caputo C, Ramsey K. Role of prolonged surveillance in the

eradication of nosocomial scabies in an extended care Veterans Affairs medical centre.
Lettau LA. Nosocomial transmission and infection control aspects of parasitic and
ectoparasitic disease. Part I. Introduction/Enteric Parasites. Infection Control and Hospital
Epidemiology 1991; 12: 59–65.
ectoparasitic diseases. Part II. Blood and Tissue Parasites. Infection Control and Hospital
Epidemiology 1991; 12: 111–121.
ectoparasitic disease. Part III. Ectoparasites/Summary and conclusions. Infection Control
and Hospital Epidemiology 1991; 12: 179–185.
Maunder J. Treatments for eradicating lice and scabies. Prescriber 1991; April 5: 27–48.
Maunder J. The scourge of scabies. Chemist and Druggist 1992; 11: 54–55.
Maunder J. An update of headlice. Health Visitor 1993; 66(9): 317–318.
183
10
Blood-borne Hepatitis and
Human Immunodeficiency
Virus (HIV) Infections
B lood-borne infections are those where infectious agents in a person’s blood can
be transmitted to another person giving rise to infection. Since the infectious sta-
tus of a patient is not always known it is essential that all Health Care Workers adopt
safe working practices at all times. Health care facilities should implement standard
infection control precautions as the primary basis of preventing transmission of
infection to Health Care Workers (HCWs).
Immunization against hepatitis B infection is an effective means of protection against

hepatitis B virus (HBV) but must not be used as a substitute for good clinical prac-
tice. The vaccine will protect against hepatitis B infection but will not protect against
hepatitis C, HIV and other viruses transmitted through the blood-borne route.
Viral hepatitis
To date, six types of viral hepatitis have been identified, i.e. hepatitis A, B, C, D, E and
most recently, hepatitis G. Hepatitis A and E are transmitted by the faecal-oral route
and therefore will not be discussed; hepatitis viruses B, C, D and G are transmitted
by the blood-borne route.
Hepatitis B virus (HBV)

HBV is a member of the Hepadnaviridae family of DNA viruses. The mean incuba-
tion period of acute HBV infection is 75 days but it may range from 45 to 180 days.
After exposure to the virus, most infected individuals recover completely from the
acute illness; however, inapparent infections are common, particularly among
children. A small, and variable, proportion of individuals do not clear hepatitis B sur-
face antigen (HBsAg), which is found circulating in blood during the latter part of
the incubation period and in the acute phase of HBV. They become carriers, (i.e.
individuals who shed HBsAg into the circulation for more than 6 months) following
185
acute infection. Some of these develop chronic hepatitis, cirrhosis or hepatocellular

carcinoma. The likelihood of a patient developing chronic hepatitis is inversely
related to age at the time of infection.
Jaundice
Symptoms
↑ALT
HBeAg Anti-HBe
HBV DNA
Titer
HBsAg
IgG anti-HBc
Anti-HBs
0 4 8 12 16 20 24 28 32 36 40 52
Weeks after exposure
Figure 10.1 The typical course of acute type B hepatitis.

HBsAg: Hepatitis B surface antigen; anti-HBs: antibody to HBsAg; HBeAg: Hepatitis
B ‘e’ antigen; anti-HBe: antibody to HBeAg; anti-HBc: antibody to hepatitis B core
antigen; ALT: alanine aminotransferase.
Chronic infection occurs in at least 90% of cases following neonatal infection, 25%
of children aged 1–10 years and 5% or less in adults. Of these, 5–10% have persistent
‘e’ antigenaemia hepatitis B ‘e’ antigen positive (HBeAg!ve), which correlates with a
high level of viral replication and heightened infectivity; these are regarded as high-
grade infections. Such high grade infections are generally associated with HBV DNA
levels of greater that 10,000 genomes/ml in serum. A patient who is in the early pro-
dromal or acute phase of hepatitis B should also be considered as high grade. Most
carriers, however, are ‘e’ antigen negative and can be classified as low grade with regard
to transmission of infection. However, carriers of HBV who are negative for ‘e’ antigen
can occasionally transmit infection. Some of these low-grade carriers have been asso-
ciated with the presence of a viral mutation, which stops the synthesis of ‘e’ antigen
but still allows production of infectious virus.
Hepatitis C virus (HCV)

HCV belongs to the flaviviridae family. Incubation periods range from 20 days to
13 weeks. The acute phase of HCV infection is usually asymptomatic or mild and
186
Blood-borne Hepatitis and HIV Infections
Table 10.1 Interpretation of the common patterns of serological markers of HBV

infection.
Interpretation HBsAg HBeAg Anti-HBe IgM* IgG Anti-
(Hepatitis (‘e’ anti- (‘e’ anti- (to core (to core HBs
B surface gen) body) Ag) Ag)
antigen)
Acute Hepatitis B ! ! or " ! or " ! ! "

Recovered from " " Usually ! " ! !
HBV
Chronic infection§
High infectivity ! ! " " ! "
Low infectivity ! " ! " ! "
HBV immunization " " " " " !
HBsAg: Hepatitis B surface antigen; HBeAg: Hepatitis B ‘e’ antigen; Anti-HBe: Antibody to
Hepatitis B ‘e’ antigen; Anti-HBs: Antibody to Hepatitis B surface antigen.
*Tests for IgM are usually strongly reactive during acute infection; weaker reactivity may also
be present in some chronic infections.
§
Someone with detectable surface antigen more than 6 months after acute hepatitis B or first
detection of antigen.
patients are often unaware of the infection. Patients may complain of fatigue but a
few have a history of acute hepatitis or jaundice. If it proceeds to chronic disease,
progression is usually indolent and the most common complaint is fatigue. Up to
80% of people who are anti-HCV positive may continue to carry the virus, which
may cause slow ongoing liver damage. It is thought that 10–20% of individuals
with chronic hepatitis will go on to develop cirrhosis over 20–40 years and an sig-
nificant proportion of those with cirrhosis go on to develop liver cancer.
Diagnosis of HCV is based on an enzyme immunoassay that detects antibodies to

hepatitis C virus (anti-HCV). In general, the diagnosis is confirmed by use of a sup-
plemental recombinant immunoblot assay (RIBA). However, detection of antibodies
to HCV alone does not distinguish between individuals who have been previously
exposed to the virus and those who continue to have viraemia. Most RIBA-positive
patients are potentially infectious, as confirmed by use of a polymerase chain
reaction (PCR) based-test. The PCR test detects small amounts of viral RNA and
indicates if there is circulating virus (Fig. 10.2).
Hepatitis D virus (HDV)

HDV, previously known as the ‘delta agent’ is a defective virus that requires the
presence and the helper activity of HBV to allow it to replicate. HDV virus can be
co-transmitted with hepatitis B infection or can superinfect chronic HBV carriers.
The mean incubation period is 35 days and transmission is mainly through par-
enteral routes. Hepatitis caused by HDV is usually severe and individuals with double
187
Anti-HCV
HCV RNA (PCR)
1 2 3 4 5 6 1 2 3 4 5 6
Months Years
Time after exposure
Figure 10.2 Serological markers of hepatitis C. Majority of patients with Hepatitis

are asymptomatic.
Anti-HCV: antibody to hepatitis C virus by enzyme immunoassay; HCV RNA
[PCR]: hepatitis C viral RNA by polymerase chain reaction.
infection, HBV and HDV, usually develop rapidly progressive disease and cirrhosis at
an earlier age than those with HBV infection alone.
Hepatitis G virus (HGV)

Hepatitis G is a flavivirus that can be transmitted parenterally. At present, the
epidemiology and clinical correlation of HGV infection are not well characterized.
HIV infection
HIV is a member of the retrovirus family and responsible for HIV infections and cases
of acquired immunodeficiency syndrome (AIDS). It was first isolated in 1983. Two
serologically distinct types, HIV 1 and HIV 2, have been recognized. HIV 2, isolated
in 1986, is prevalent in certain West African countries. The two types of HIV present
similar hazards and cause similar illnesses, except that there is some evidence that pro-
gression of disease is slower in a person infected with HIV 2. The term HIV used in
these guidelines covers both types of virus.
Clinical features
After exposure to HIV most individuals develop antibody within 3 months. During
the acute phase, (i.e. around the time when antibody first appears) there may be a
self-limiting illness resembling glandular fever (infectious mononucleosis), with
188
Phase of infection
I II III IV V
Incubation Acute Asymptomatic phase Symptomatic phase AIDS

phase phase (ARC)
(Seroconversion
illness)
Weeks Months Years
Viral load Anti-HIV antibody CD4 count
Figure 10.3 Typical course of HIV infection.
lymphadenopathy and rash. Later in the course of infection, non-specific illness

(including fever, night sweats, and lymphadenopathy) is associated with progressive
immune dysfunction. When AIDS develops fully it is characterized by the appear-
ance of opportunistic infections and tumors.
Infection with yeast, Candida spp., may cause persistent and severe thrush in the
mouth and oesophagus and there may be reactivation of common latent herpes
viruses. Invasion of the lungs by Pneumocystis carinii, a microorganism normally of
low virulence, often gives rise to a pneumonitis with shortness of breath and diffuse
shadowing sometimes seen on a chest X-ray. Some individuals may be infected with
Mycobacterium spp., i.e. M. tuberculosis, M. avium-intracellulare etc. Many other
infections may supervene, caused by bacteria such as Salmonellae, viruses including
cytomegalovirus and hepatitis B and protozoa such as Toxoplasma in the brain or
Giardia or Cryptosporidium in the bowel. Some patients develop Kaposi’s sarcoma,
an unusual tumor of the skin. This appears as characteristic discrete purple patches,
often affecting the extremities, although internal organs may also be involved. Still
others develop lymphoma, often in the brain.
HIV testing
Routine testing of patients for unidentified HIV is not recommended. Testing should
be undertaken only on the basis of clinical assessment or where it is in the interests
of both patients and HCWs. The provision of patient confidentiality, privacy, and
informed consent for testing are essential. The individual requiring an HIV test
should be offered appropriate discussion prior to testing, which should address the
189
specific needs of the individual. The patients should have information about HIV
transmission, the significance of a positive or a negative result and be able to discuss
their particular needs and concerns.
Laboratory diagnosis
HIV serology: HIV screening is undertaken by enzyme-linked immunosorbent assay
(ELISA), which detects antibodies to the virus. Positive specimens are then con-
firmed by a series of other tests. The seroconversion or ‘window period’, (i.e. the time
between exposure to HIV infection and the first detectable sign of antibody in
blood), is usually between 10–30 days but may last several months in some cases.
During this ‘window period’, the HIV antibody test will be negative; therefore a nega-
tive test is not an absolute exclusion of HIV infection.
CD4 lymphocyte count and HIV viral load: Several laboratory markers are available to
provide prognostic information and guide decisions on starting and changing therapy.
The most widely used marker is the CD4 lymphocyte count. Risk of progression to an
AIDS opportunistic infection or malignancy is high with the CD4 # 200 cells/gL.
While CD4 count measures immune dysfunction, it does not provide a measure of
how actively HIV is replicating in the body. HIV viral load tests assess the level of viral
replication and provide useful prognostic information, which is independent of the
information provided by CD4 counts. Patients vary in their level of viraemia. Rapid
progressors tend to have persistently high viral load whereas slow or non-progressors
have low viral load. In the early stages of infection (including the ‘window’ period) the
concentration of HIV in the bloodstream is very high. During this period the antibody
test is negative, although tests for HIV RNA are positive. After the resolution of the
seroconversion illness, the HIV viral load decreases due to the host immune responses
and stabilizes at a lower level. As immunodeficiency progresses and AIDS develops, the
HIV viral load rises again. Viral load is also influenced by antiretroviral therapy. Most
patients on combination antiretroviral therapy have a low HIV viral load.
Routes of transmission
Blood-borne viruses are transmitted through transfer of blood or ‘high risk’ body
fluids containing virus and may occur by:
• Unprotected penetrative sexual intercourse with an infected person

(between men or between a man and a woman).
• Skin puncture by sharps contaminated with blood, i.e.
– sharing used needles and syringes among intravenous drug users.
– receipt of tattoos, ear piercing, communal hair cutting, acupuncture,
dental treatment, electrolysis etc.
– inoculation injury to HCW from an infected individual.
190
General principles: control of infection

with blood-borne viruses
• Apply good basic hygiene practices with regular hand washing,
before and after contact with each patient, and before putting on and
after removing gloves. Change gloves between patients.
• For all clinical procedures, cover existing wounds,* skin lesions and
all breaks in exposed skin with waterproof dressings, or with gloves
if hands extensively affected.
• HCWs with chronic skin disease such as eczema should avoid those
invasive procedures, which involve sharp instruments or needles
when their skin lesions are active, or if there are extensive breaks in
the skin surface. A non-intact skin surface provides a potential route
for blood-borne virus transmission, and blood-skin contact is com-
mon through glove puncture that may go unnoticed.
• Use protective clothing as appropriate, including protection of the
mucous membrane of the eyes, mouth, and nose from blood and
body fluid splashes. Avoid wearing open footwear in situations where
blood may be spilt, or where sharp instruments or needles are han-
dled.
• Prevent puncture wounds, cuts, and abrasions and if present, ensure
that they are not exposed.
• Avoid sharps usage wherever possible and consider the use of alter-
native instruments, cutting diathermy, and laser.
• Where sharps usage is essential, exercise particular care in handling
and disposal, following approved procedures and using approved
sharps disposal containers.
• Clear up spillage of blood and other body fluids promptly and disin-
fect surfaces.
• Follow approved procedures for sterilization and disinfection of
instruments and equipment.
• Follow approved procedures for safe disposal of contaminated
waste.
* Staff with larger wounds, eczema or other skin conditions that cannot be adequately
protected by plastic gloves or impermeable dressings should seek advice from the
Occupational Health Department.
191
• Childbirth from an infected mother to her baby (intrauterine and peripar-

tum) or through breast-feeding.
• Via infected blood transfusion, blood products, donations of semen, skin
grafts, and organ transplants from someone who is infected.
Transmission through contamination of open wounds and skin lesions may also
occur, e.g. eczema, splashing the mucous membrane of the eye, nose or mouth and
through human bites when blood is drawn.
Blood is not the only concern, as various other ‘high risk’ body fluids, i.e. cere-
brospinal, peritoneal, pleural, pericardial, amniotic and synovial fluid, semen, vaginal
secretions and any other body fluids containing visible blood, and all tissues, organs
and parts of bodies which are unfixed, are also hazardous. Exposure to ‘low risk’ body
fluids such as urine, faeces, nasal secretions, tears, saliva (except in relation to dentistry),
sputum, and vomitus present a minimal risk of blood-borne virus infection unless con-
taminated with blood; although they may be hazardous for other reasons as they may
contain other pathogenic microorganisms. When blood is mentioned, it should be
taken to include blood and ‘high risk’ body fluids unless otherwise stated.
Occupational risks to HCWs

In the health care setting, the risk of acquiring blood-borne infection is proportional
to the prevalence of infection in the population served and the chance of inoculation
accidents occurring during procedures.
The risk of infection following percutaneous exposure to the blood from an infec-
tious source from hepatitis B patients is estimated to be between 5 and 30%. The risk
of hepatitis C infection after percutaneous exposure to a known infected source
appears to be intermediate between the risk of HBV and HIV, i.e. between 3 and 10%.
For a HCW, the average risk for HIV infection after a percutaneous needlestick injury
with HIV-infected blood is estimated to be 0.3% and the risk associated with mucous
membrane exposure is estimated to be about 0.09%.
Risks to patients from HCWs

Documented cases of hepatitis B and hepatitis C infections have occurred in patients
operated on by hepatitis B or C infected HCWs. Internationally, there have been only
two documented series of HIV transmissions from HCW to patient. One occurred in
the US, where six patients became infected with HIV from a Florida dentist. This
transmission was considered to be the result of a lapse in infection control proced-
ures. A second HIV transmission occurred in one patient following prolonged
orthopaedic surgery in France. No further cases of transmission of HIV from HCW
to patient have been detected, despite look back studies of large numbers of patients
cared for by HIV-infected HCWs.
192
Responsibility of HCWs
Since transmission of hepatitis B, C and HIV from infected HCWs to patients has
been documented, it is essential, that all HCWs have an overriding ethical duty to
protect the health and safety of their patients. They are strongly advised to follow
basic infection control precautions scrupulously and adopt safer working
practices.
All HCWs (including locum staff) who perform exposure-prone procedures should be
vaccinated against HBV and their serological response checked subsequently. Any
HCW who performs exposure-prone procedures and who has not yet been immun-
ized should be tested for evidence of current infection (the presence of hepatitis B
surface antigen), as soon as possible. This may mean testing before immunization has
been completed. Blood specimens for testing HCWs who perform exposure-prone
procedures should be collected directly by a member of the occupational health
service or a person commissioned by the service.
Those who are, or have reason to believe that they may have been exposed to these
infections in whatever circumstances, must seek medical advice from the occupational
health department. They must not perform exposure-prone invasive procedures (see
below). The occupational health department will advise the HCW on their work,
which may need to be modified or restricted to protect patients. It is extremely
important that the infected HCWs receive the same rights of confidentiality as any
patient seeking or receiving medical care.
Provided routine infection control measures are followed scrupulously, the circum-
stances in which a blood-borne infection could be transmitted from the HCW to a
patient are restricted to exposure-prone procedures, which must not be performed by
an infected HCW. HCWs who are infected with HIV, Hepatitis B or Hepatitis C
infection must seek advice from the occupational health department who will advise
the individual about the type of work to be undertaken.
The UK Department of Health recommends that HCWs who are hepatitis B

surface antigen positive (HBsAg !) and hepatitis B ‘e’ antigen negative (HBeAg ")
and currently perform exposure-prone procedures should have their viral load
(HBV DNA) measured. A HCW whose HBV DNA concentration in blood (viral
load) is less than 1,000 genome equivalents per ml will not be restricted but should
be advised by the occupational health department on minimizing the risk of
transmission both to patients and to other close contacts and be retested every 12
months. They should cease performing exposure-prone procedures if their viral
load exceeds 1,000 copies/ml or they are shown to have transmitted HBV to a
patient.
Health Care Workers should not be allowed to perform exposure-prone procedures

if they are hepatitis C RNA positive.
193
Exposure-prone procedures
All breaches of the skin or epithelia by sharp instruments are by definition invasive. Most
clinical procedures, including many which are invasive, do not provide an opportunity
for the blood of the HCW to come into contact with the patient’s open tissues. Provided
the general measures to prevent occupational transmission of blood-borne viruses are
adhered to scrupulously at all times, most clinical procedures pose no risk of transmis-
sion of HIV from an infected HCW to a patient, and can safely be performed.
Exposure-prone procedures are those invasive procedures where there is a risk that
injury to the worker may result in the exposure of the patient’s open tissues to the
blood of the worker (bleed-back). These include procedures where the worker’s
gloved hands may be in contact with sharp instruments, needle tips or sharp tissues,
(e.g., spicules of bone or teeth) inside a patient’s open body cavity, wound or con-
fined anatomical space where the hands or fingertips may not be completely visible
at all times. However, other situations, such as pre-hospital trauma care and care of
patients where the risk of biting is predictable (e.g. with a violent patient or a patient
having an epileptic fit) are also considered to be exposure-prone.
Normal vaginal delivery in itself is not an exposure-prone procedure. When under-

taking a vaginal delivery, an infected HCW must not perform procedures involving the
use of sharps, instruments such as infiltrating local anaesthetics or suturing of a tear
or episiotomies, since fingertips may not be visible at all times and the risk of injury to
the worker is greater. Neither can they perform an instrumental delivery requiring for-
ceps or suction if infiltration of local anaesthetic or internal suturing is required.
In practice, this means that an infected HCW may only undertake a vaginal delivery if
it is certain that a second midwife or doctor may also be present who is able to under-
take all such operative interventions as might arise during the course of delivery.
Procedures where the hands and fingertips of the worker are visible and outside the
patient’s body at all times, and internal examinations or procedures that do not
involve possible injury to the worker’s gloved hands from sharp instruments and/or
tissues are considered not to be exposure-prone provided routine infection control
procedures are adhered to at all times. Examples of such procedures include: taking
blood (venepuncture), setting up and maintaining intravenous lines or central lines
(provided any skin tunnelling procedure used for the latter is performed in a non-
exposure prone manner), minor surface suturing, the incision of external abscesses,
routine vaginal or rectal examinations and simple endoscopic procedures.
Surgical procedure
Each patient and each operation should be considered as a potential source of infection.
Therefore, it is essential that all the operating room HCWs demonstrate their knowledge
of potential risks by ensuring that a ‘confine and contain’ approach is implemented for
every procedure. All HCWs in the surgical team should be vaccinated against HBV.
194
Preoperative testing of a patient for infectious agents should be on the basis of clinical
indication, and medical practitioners should exercise their professional judgement in
ordering any clinically relevant test, with the patient’s consent. In the case of elective
surgery, any testing considered relevant should be completed before admission.
Discretion and patient confidentiality must be maintained in all circumstances.
Surgery lists should be scheduled on the basis of clinical urgency, and in such a way as
to allow ample time for adequate infection control procedures to take place. Operating
room and anaesthetic HCWs who may be exposed to infectious material in the course
of their duty should be informed of the patient’s infectious status prior to surgery.
In addition to the basic infection control precautions (see page 191), the patient with
a known blood borne viral infection may require the following additional precau-
tions for surgical operation:
• The consultant in charge of the patient is responsible for seeing that all mem-
bers of the team know of the infection hazards and appropriate measures to
be taken. The team should be limited to essential members of trained staff only.
The number of students allowed to attend the operation should be limited.
• It may help theatre decontamination if such cases are last on the list, but
this is not essential.
• Depilatory creams should be used for essential hair removal.
• Unnecessary equipment should be removed from the theatre in order to
reduce the amount of decontamination required after the operation.
Disposable items should be used wherever possible. If any item is not dis-
posable it must be decontaminated by the sterile supply department (SSD).
Special equipment reserved for these patients is not essential.
• Disposable drapes should be used and the mattress should be protected by
a plastic sheet.
• Diathermy and suction devices should be placed on the opposite side of the
table to the surgeon, thereby ensuring the assistant does not reach across
the table between the surgeon and nurse.
• Before any surgical procedure, the surgeon and scrub nurse should decide
on the routine for passage of sharp instruments during the procedure. This
may entail the designation of a ‘neutral zone’. The surgeon must avoid
placing his/her less dexterous hand in potential danger. Sharp instruments
should not be passed by hand. A specified puncture-resistant sharps tray
must be used for the transfer of all sharp instruments. Only one sharp must
be in the tray at any one time. If two surgeons are operating simultan-
eously, then each surgeon needs his/her own sharps tray.
• Variations in operative technique, such as a non-touch approach, the avoid-
ance of passing sharp instruments from nurse to surgeon and vice versa,
195
and new techniques of cutting (e.g. with lasers) or of wound closure that
obviate the use of sharp instruments and lessen the risk of inoculation are
recommended. Needles must never be picked up with the fingers, nor the
fingers used to expose and increase access for the passage of a suture in
deep tissues.
• Personal protective equipment
– Gowns: All staff in the theatre should wear a disposable plastic apron
under their gowns. A water-impermeable gown should be worn if gross
contamination with blood or body fluids is likely. Where waterproof
aprons are worn for procedures in which there is likely to be consider-
able dissemination of blood, it is essential that the aprons are of suffi-
cient length to overlap with protective footwear. This is especially
important for procedures carried out in the lithotomy position, since it
is common for blood accumulating in the worker’s lap to be channelled
down into the boots. Caps should cover the hair completely.
– Mask: The surgical team should wear a mask and two pairs of gloves
and skin lesions must be covered with waterproof dressings. Double
sterile gloving, i.e. a double glove with the larger size glove on the
inside is recommended for all surgeons involved in operating room
procedures. If a glove is torn or a needlestick or other injury occurs, the
gloves should be removed and hands washed when safety permits and
new gloves put on promptly.
– Eye protection: Spectacles or goggles should be worn by those taking part
in the operation to avoid conjunctival contamination or splashing.
– Footwear: Fenestrated footwear must never be worn in situations where
sharps are handled. For tasks involving likely dissemination of blood
it is recommended that Wellington boots or calf length plastic boots
are worn rather than shoes or clogs. Contaminated footwear must be
adequately decontaminated after use with appropriate precautions for
those undertaking it.
• Hand-held straight needles should not be used. Where practical, blunt
needles should be used to close the abdomen. When suturing, forceps or a
needle holder should be used to pick up the needle and draw it through the
tissue. Where practical, suture needles should be cut off before knots are
tied to prevent needlestick injury. Surgeons may use a sterile thimble on
the index finger of the less dexterous hand for protection when suturing.
Wire sutures should be avoided where possible because of the high injury
rate to the surgeon. After a surgical procedure, the skin should be closed
with staples whenever possible.
• Hands of assisting HCWs must not be used to retract the wound on viscera
during surgery. Self-retaining retractors should be used, or a swab on a
196
stick, instead of fingers. Certain instruments should be avoided unless

essential to the procedure, for example, sharp wound retractors such as
rake retractors and skin hooks.
• Closed wound drainage systems should be used, where appropriate. Wound
dressings with an impervious outer covering that will contain wound exud-
ates should be used. If drainage is considered necessary, closed rather than
open wound drainage is recommended. Blood should be cleaned off the
patient’s skin as far as possible at the end of the operation using suitable
antiseptic/detergents solution.
• Where practical, used instruments should be washed mechanically using an
ultrasonic washer rather than by hand. Surgical instruments and other
tools used in operations should be put in a robust puncture-resistant con-
tainer, labeled ‘Danger of Infection’ and returned to the SSD. Instruments
for reuse should, as soon as possible after use, be immersed in warm water
and detergent to prevent congealing or solidifying of blood and fatty mater-
ials, and must be thoroughly cleaned in the designated clean-up area before
sterilization.
• Infectious waste excluding sharps must be placed in an appropriate colour
coded infectious waste plastic bag, sealed and removed from the operating
room. Disposal of infectious waste must comply with local regulations.
• Needles, syringes, and disposable sharp instruments must be discarded into
approved sharps boxes. The sharps container must be closed securely when
three-quarters full. Scalpel blades and needles and all other non-reusable
sharps should be placed in a designated puncture-proof sharps container,
which should comply with local or international standard.
• Used linen and theatre clothing should be placed in a water soluble bag
which is then placed in a second plastic bag and marked as ‘Infected linen’.
It should be handled in accordance with local policy.
• Blood and other body fluid spills should be cleaned up immediately, using
absorbent material such as paper towelling that should then be discarded
into the infectious waste bag (see page 77). Gloves must be worn. The area
should then be cleaned with warm water and detergent. The area may be
treated with sodium hypochlorite (1% or 10,000 ppm available chlorine) or
other appropriate disinfectant, in accordance with the local protocol.
Disinfectant solutions should not be allowed to pool or remain on surfaces
for longer than is required to effect disinfection, usually about 3–5 min.
• Cleaning:
– Adequate time must be provided at the end of each case to allow for
thorough cleaning of the operating theatre and the appropriate dis-
posal of clinical waste.
197
– All surfaces (operating table, instrument table, equipment used and the
floor) should be carefully cleaned using warm water and detergent.
Walls and other surfaces do not require cleaning unless contaminated
with blood.
– Large volumes of fluid should be used for cleaning and gloves and a
plastic apron should be worn by the operator.
– Appropriate disinfectant, (e.g. sodium hypochlorite 1,000 ppm
available chlorine) may be used after removal of gross soil.
Surfaces should be cleaned and dried after applying disinfectants.
Thorough rinsing is necessary to minimize damage to surfaces from
the disinfectants.
Protection of the newborn

Hepatitis B infection: In high prevalence areas, hepatitis B immunization should be
given to all pregnant women. In other countries, those providing antenatal care will
need to take steps to identify infected mothers during pregnancy and make arrange-
ments to ensure that babies born to these mothers receive a complete course of
immunization against hepatitis B infection. This is best done by screening women
early in pregnancy. Where this has not been done, it should be possible to detect
carrier mothers at the time of delivery.
Specific hepatitis B immunoglobulin (HBIG) is available for passive protection while

hepatitis B vaccine confers active immunity and they are normally used in combin-
ation. Babies born to mothers who are HBeAg !, who are HBsAg ! without ‘e’ mark-
ers or where ‘e’ marker status has not been determined, or who have had acute hepatitis
during pregnancy, should receive specific HBIG as well as active immunization.
The newborn should be given 200 IU HBIG at birth or as soon as possible thereafter.
If immunization with the vaccine is combined with simultaneous administration of
HBIG, the injection must be given at a different site.
The first dose of vaccine should be given at birth or as soon as possible thereafter.
HBIG should be given at a contralateral site at the same time; arrangements for the
supply of HBIG should be made well in advance. The complete course of Hepatitis B
immunization regimen consists of a three-dose series of vaccine, with the first dose
at the time of birth, the second dose one month later and the third dose at six months
after the first dose. The vaccine should normally be given intramuscularly and the
anterolateral thigh is the preferred site in infants.
Hepatitis C infection: Currently, there is no therapy available for the prevention of

HCV infection in neonates born to mothers infected with HCV.
HIV infection: In order to prevent HIV infection in neonates, appropriate antiretro-

viral therapy can be given to both the mother before birth and to the neonate at birth
198
to reduce the risk of HIV transmission. It is usually appropriate to advise against

breast-feeding where the mother is known to be HIV positive.
Procedure after death

If a person known or suspected to be infected with a blood-borne virus (BBV)
dies either in hospital or elsewhere, it is the duty of those with knowledge of the
case to ensure that those who need to handle the body, including funeral person-
nel, post-mortem room and mortuary staff are aware that there is a potential risk
of blood-borne viral infection. Patients known or suspected to be infected with a
BBV should not be embalmed as embalming carries a significant risk for the
operator.
The principles of safe practice for the mortuary must be adhered to irrespective of
the infective state of the body. A full post-mortem should not be done merely to
confirm the cause of death. When a post-mortem is carried out on such patients, all
those concerned must be suitably informed and trained in safe procedures. They
must follow local written protocol.
The body should be placed in a disposable body bag; absorbent material may be
needed when there is a leakage from, e.g. surgical incisions or wounds. The bodies of
children of mothers with BBV infections should be treated as infected. The discreet
use of simple ‘Danger of infection’ labeling is appropriate and is attached in such a
way that it can be read through the cadaver bag.

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11
Protection for
H e a l t h C a r e Wo r k e r s
P rotection of health care workers (HCWs) should be an integral part of the Health
and Safety programme of health care establishments. Health care facilities have a
responsibility to ensure that all reasonably practicable steps are taken to ensure that
the risk of infection to health workers is minimized. Transmissible infections in
HCWs must be identified quickly so that they can be excluded from the work place
or from direct patient contact until they are no longer infectious.
Occupation Health Department

The roles and responsibilities of the Occupation Health Department described below
are mainly concerned with the risk of infection and are only a part of their work.
• Primary health screening of all staff by questionnaire and/or medical exam-

ination.
• Keeping accurate and up-to-date records of all members of staff.
• Immunization and vaccination of all existing staff at the required time
interval.
• Training of all grades of staff in personal hygiene with special precautions
for those particularly at risk of infection.
• Examination of staff returning to work after absence due to diarrhoea or
other infectious conditions, to ensure that the infection has cleared and to
give advice to the carrier.
• Determining staff contacts of the infectious disease, checking immunity
and follow-up if necessary. Arranging tests and possibly treatment for staff
with infectious diseases.
• Keeping records of all inoculation injuries, arranging post-exposure pro-
phylaxis following inoculation injuries and counselling of staff if necessary.
203
• Survey potential infective and toxic hazards (e.g. chemical disinfectant) to

staff in health care facilities.
Measures to protect HCWs

Measures to protect HCWs from infection fall mainly into three categories:
1. Immunization: All HCWs should be immunized against vaccine-preventable

diseases. Chickenpox (varicella) immunization should also be offered to
non-immune HCWs with no history of chickenpox or shingles. Hepatitis B
immunization should also be offered to all non-immune HCWs, particu-
larly those with potential exposure to blood or body substances, with post
immunization serology testing to identify non-responders. Refusal of vac-
cination by any HCW should be recorded together with a reason for such
refusal, if provided. Staff refusing immunizations may be prohibited from
working in certain areas and their work should be reviewed.
2. Education and training: All HCWs must be provided with appropriate
training and education in infection control as part of their orientation.
This must be reinforced through a regular continuing education pro-
gramme. They should be trained in the handling of blood and body fluids,
chemical disinfectants and should be aware of local policies and procedures
on infection control including waste disposal, dealing with contaminated
sharps, etc. They should also be provided with appropriate personal pro-
tective equipment. Work practices should be developed and implemented
to ensure compliance with infection control policies and procedure.
3. Reporting: HCWs must report any accidents or illness to their line manager
and, if appropriate, to the occupational health department. In addition, the
incident report process includes notes on remedial and follow-up action
taken before the process is considered complete.
Pre-employment assessment
HCWs should be assessed before employment with the aim of preventing disease in
the individual but a second and no less important function is to prevent transmis-
sion of infectious agents to patients. It is important that the employee must be given
assurance of the complete confidentiality of any health questioning and their occu-
pational health record.
It is important that all newly employed staff in the health care setting attend the occu-
pational health department. The screening process includes assessment by a health
questionnaire completed by the employee, covering questions related to general health,
history of infectious diseases and immunization status. It is also important to ascertain
immune status if the HCW has either had or been vaccinated against tuberculosis,
rubella, measles, mumps, chickenpox and hepatitis B virus (HBV). In addition, the
204
P r o t e c t i o n f o r H e a l t h C a r e Wo r k e r s
presence of skin disorders such as eczema, and a history of an underlying immuno-

suppressive disorder might require a reassessment of the staff member’s work practices.
Routine screening for staphylococcal, streptococcal and salmonella carriers is not

recommended. Screening may be instituted if an outbreak or epidemic occurs and if
HCWs are felt to be either at risk or potentially associated with spread of the infec-
tion. Agencies which provide temporary staff for the hospital should be informed of
the staff screening policy and, wherever possible, only those agencies with an effect-
ive screening programme should be used.
Health status of HCWs

There are certain medical conditions of HCWs that increase their predisposition to
infection if they come into contact with certain infectious patients, e.g. immune sta-
tus, certain skin conditions and pregnancy. There are many areas within health care
establishments where HCWs with these conditions can safely work and there are few
tasks that such HCWs are unable to perform safely. Health care establishments have
a responsibility to manage and supervise such HCWs in ways that both acknowledge
their right to work, and safeguard the welfare of both patients and HCWs. This
responsibility includes the need to identify such HCWs and inform them of the
problems they are likely to encounter in particular circumstances. It is important that
the occupational health department should liaise closely with the Infection Control
Team.
Staff should not work if they have acute or chronic diarrhoeal disease or febrile respira-
tory illness. Catering staff need to be carefully questioned about gastrointestinal
infection, history of enteric fever, skin conditions (e.g. allergic eczema, psoriasis and
exfoliative dermatitis), recurrent sepsis and tuberculosis. Staff with either shedding
and/or weeping skin conditions or damaged skin may readily be colonized by hospital-
associated microorganisms. These HCWs may not be harmed by the acquisition of
such microorganisms but may disseminate them widely. For example, placement of
such HCWs in wards containing patients with multi-resistant staphylococci is not
recommended. These employees should be identified by personal history screening
and advised of the problems posed by their condition.
Staff who are or have reason to believe that they may have been exposed to blood-
borne hepatitis (B and C) or HIV infection must declare this and discuss it in com-
plete confidence with the occupational health department, either at the initial
screening or when he or she first becomes aware of their infection. In general, such
staff may require a work assessment and must avoid exposure-prone procedures.
Management of sharps injury

All health care establishments should develop their own infection control proto-
cols for the management of blood-borne hepatitis (B and C) and HIV infection.
205
The protocols must include clear written instructions on the appropriate action to
take in the event of sharps injury and blood incidents involving either patients or
HCWs. The protocols must include the name of the physicians to be contacted, the
laboratory that will process emergency specimens, the pharmacy that stocks pro-
phylactic medication, and procedures for investigation of the circumstances of the
incident and measures to prevent recurrence. The protocols should also include
details for prompt reporting, evaluation, counselling, treatment and follow-up.
Treatment should be available during all working hours, e.g. through the occupa-
tional health department or, out of hours, the Accident and Emergency (A & E)
department. HCWs should report occupational exposures immediately after they
occur.
Occupational risks to HCWs

In the health care setting, the risk of acquiring blood-borne viral infection is pro-
portional to the prevalence of infection in the population served and the chance of
inoculation accidents occurring during procedures.
The risk of infection following percutaneous exposure to blood from an infectious

source from HBV patients is estimated to be between 5 and 30%. The risk of hepa-
titis C virus (HCV) infection appears to be intermediate between the risk of HBV
and HIV, i.e. between 3–10%. For a HCW, the average risk for HIV infection after a
percutaneous needlestick injury with HIV infected blood is estimated to be 0.3% and
the risk associated with mucous membrane exposure is estimated to be about
0.09%.
Risk factors for acquiring blood-borne viral infections

After percutaneous exposures, the following risk factors have been associated with an
increased risk for blood-borne viral infection.
1. Type of body fluid involved: The following body fluids pose a risk for blood-
borne transmission: blood, serum, plasma and all biological fluids visibly
contaminated with blood; laboratory specimens that contain concentrated
virus; pleural, amniotic, pericardial, peritoneal, synovial and cerebrospinal
fluids; and uterine/vaginal secretions or semen.
2. Quantity of blood: Larger quantities of blood, indicated by visible contam-

ination of the device. Usually associated with a procedure using a hollow
bore needle directly placed in a vein or artery.
3. Type of needle: Hollow bore needles have more risk of transmission than
suture needles because of the quantity of blood they carry.
4. Depth of injury: A deep penetrating injury is a risk factor because it is dif-

ficult to wash off blood from the wound.
206
5. Infectivity of source patient: Blood from patients with high infectivity, e.g.
patients with full blown AIDS, hepatitis B ‘e’ antigen (HBeAg) positive and
hepatitis C polymerase chain reaction (PCR) positive patients.
Management of the exposed person

Immediate care of the exposure site: In cases of exposure to blood or body fluids, the
following procedures should be followed:
• Encourage the affected area of skin to bleed for few seconds.

• Do not suck the puncture site.
• Rinse immediately under running water and wash with soap and water.
• Do not scrub. Rinse and dry.
If the spillage of blood and body fluid has occurred on intact skin, contaminated
clothing should be removed and the affected area should be rinsed immediately
under running water and washed with soap and water. Do not scrub. Rinse and dry.
Exposed mucous membrane or conjunctivae should be irrigated immediately with
copious amounts of water using either running tap water or an eyewash bottle.
Immediate contact procedure: The line manager or head of the department should
be informed of the incident. HCWs should be immediately referred to the
Occupational Health Department or, out of hours, the A & E department, according
to the local policy.
Evaluation of the exposure: The appropriate physician should assess the member of
staff and initiate investigation, treatment and counselling, where required.
Evaluation and testing of the exposed person: The exposed person should have a
medical evaluation, including information about medications they are taking and
underlying medical conditions or circumstances. All exposed people should be
assessed to determine the risk of tetanus.
The exposed person would normally be tested for HIV and hepatitis C antibody and
hepatitis B surface antigen (HBsAg) at the time of the injury to establish their sero-
logical status at the time of the exposure. If the source patient is found to be HIV,
HBV and HCV negative, no further follow-up of the exposed person is generally neces-
sary, unless there is reason to suspect the source person is seroconverting to one of
these viruses, or was at high risk of blood-borne viral infection at the time of the
exposure. Pregnancy testing should be offered to all women of childbearing age
whose pregnancy status is unknown.
In the event of seroconversion, all reasonable attempts should be made to confirm

that the virus strain transmitted is identical in both patient and the source of the
infected blood.
207
Management of occupational exposures to HIV,

hepatitis B and C virus
Provide immediate care to the exposure site:
• Wash wounds and skin with soap and water.
• Flush mucous membranes with water.
Determine risk associated with exposure by:
• Type of fluid (e.g. blood, visibly bloody fluid, other potentially infec-
tious fluid or tissue, and concentrated virus).
• Type of exposure (i.e. percutaneous injury, mucous membrane or non-
intact skin exposure, and bites resulting in blood exposure).
Evaluate exposure source:
• Assess the risk of infection using available information.
• Test known sources for HBsAg, anti-HCV, and HIV antibody (consider
using rapid testing).
• For unknown sources, assess risk of exposure to HBV, HCV, or HIV
infection. Do not test discarded needles or syringes for virus con-
tamination.
Evaluate the exposed person:
• Assess immune status for HBV infection (i.e. by history of hepatitis B
vaccination and vaccine response).
Give post-exposure prophylaxis (PEP) for exposures posing risk of infec-
tion or transmission:
HBV: PEP with hepatitis B immunoglobulin (HBIG) and/or hepatitis B
vaccine series should be considered for occupational exposures
after evaluation of the HBsAg status of the source and the vaccin-
ation and vaccine-response status of the exposed person.
HCV: PEP not recommended.
HIV: These steps are advised:
• Initiate PEP as soon as possible, preferably within hours of exposure.
• Offer pregnancy testing to all women of childbearing age not known
to be pregnant.
• Seek expert consultation if viral resistance is suspected.
208
• Administer PEP for 4 weeks if tolerated. Perform follow-up testing and

provide counselling. Advise exposed persons to seek medical evalu-
ation for any acute illness occurring during follow-up.
HBV exposure:
Perform follow-up anti-HBs testing in persons who receive hepatitis B
vaccine. Test for anti-HBs 1–2 months after last dose of vaccine. Anti-HBs
response to vaccine cannot be ascertained if HBIG was received in the
previous 3–4 months.
HCV exposure:
• Perform baseline and follow-up testing for anti-HCV and alanine
aminotransferase (ALT) 4–6 months after exposure.
• Perform HCV RNA at 4–6 weeks if earlier diagnosis of HCV infection
desired.
• Confirm repeatedly reactive anti-HCV enzyme immunoassays (EIAs)
with supplemental tests.
HIV exposure:
• Perform HIV-antibody testing for at least 6 months post-exposure (e.g.
at baseline, 6 weeks, 3 months, and 6 months).
• Perform HIV antibody testing if illness compatible with an acute retro-
viral syndrome occurs.
• Advise exposed persons to use precautions to prevent secondary
transmission during the follow-up period.
Evaluate exposed persons taking PEP within 72 h after exposure and moni-
tor for drug toxicity for at least 2 weeks.
Adapted from Centers for Disease Control and Prevention. Updated US Public Health Service guidelines for
the management of occupational exposures to HBV, HCV and HIV and recommendations for post-exposure
prophylaxis. Morbidity and Mortality Weekly Report 2001; 50 (RR-11): 1–42.
Source patients or individual

Reasonable efforts should be made to identify the source. The source individuals should
be evaluated for infection with HIV, HBV and HCV. Information available in the med-
ical record or from the source person may suggest or rule out infection with each virus.
If the source is known to have HIV infection, then information on the stage of infection
and current and previous antiretroviral therapy should be gathered and used in decid-
ing the most appropriate regimen of post-exposure prophylaxis (PEP). If the source
patient refuses testing and serum storage, he/she should sign a form to that effect.
209
If consent cannot be obtained, for example if the patient is unconscious, then proced-
ures should be followed which comply with guidelines in the relevant country. The
source individual should be tested at the time of injury for the HIV and hepatitis C
antibody and HBsAg. If the HCV antibody test is positive, then HCV PCR should be
performed to test for HCV RNA. Transmission is extremely unlikely to occur from a
source that is HCV PCR negative.
Post exposure prophylixis (PEP)

Human immunodeficiency virus (HIV)
This depends on the circumstances of exposure to HIV, and the characteristics of the
source.
• HIV PEP recommended for percutaneous exposure to potentially infectious

blood or body fluids where there is an increased risk of HIV transmission.
• HIV PEP offered but not actively recommended for ocular mucous mem-
brane or non-intact skin exposure to potentially infectious blood or body
fluids where there is less increased risk of HIV transmission.
• HIV PEP not offered for any exposure to non-bloody urine, saliva or faeces,
which are not potentially infectious for HIV. As only a small proportion of
occupational exposures to HIV result in transmission of the virus, the tox-
icity of PEP must be carefully considered against its efficacy. The exposed
person should be informed of these side effects, and that there are only
limited data on the efficacy of PEP. If the exposed person is pregnant, she
should be informed about the available limited data on the toxicity of these
drugs in pregnant women.
Antiretroviral drugs: Various antiretroviral combinations can be used. It is import-

ant that drug combinations should be guided by knowledge of the index patient’s
previous treatment and local knowledge and experience in treating HIV infection
and disease. Prophylaxis should be given ideally within 1 h of exposure; this requires
health care facilities to have a system in place to assist exposed HCWs which is
available 24 h a day. The risk of toxicity in each case must be balanced against the
relatively low rate of infection after the average percutaneous exposure. Therapy
should be continued for 4 weeks.
Hepatitis B virus (HBV)

If the source is positive for HBsAg, then HBV PEP may be considered if the exposed
person is not already immune. However, no further action is required if the person
is known to be immune to HBV (antiHBsAg ! 10 mIU/mL), or if testing within 48 h
of the injury showed the exposed person to be immune to HBV.
If the exposed person is not immune to HBV, or is of unknown immune status,

then HBV immunoglobulin should be given within 48 h of exposure. In addition,
210
Table 11.1 Recommended HIV post-exposure prophylaxis for percutaneous injuries.
Infection status of source
Exposure type HIV-positive HIV-positive Source of Unknown HIV-negative

class 1* class 2* unknown source§
HIV status†
Less severe¶ Recommend Recommend Generally, no PEP Generally, no PEP No PEP
basic 2-drug expanded warranted; warranted; warranted
PEP 3-drug PEP however consider however, consider
basic 2-drug basic 2-drug
PEP** for source PEP** in settings
with HIV risk where exposure to
factors†† HIV-infected
persons is likely
More severe§§ Recommend Recommend Generally, no PEP Generally, no PEP No PEP
expanded expanded warranted; warranted; however, warranted
3-drug PEP 3-drug PEP however, consider consider basic 2-drug
basic 2-drug PEP** in settings
PEP** for source where exposure to
with HIV risk HIV-infected
factors†† persons is likely
*
HIV-positive: Class 1: asymptomatic HIV infection or known low viral load (e.g. "1,500 RNA copies/ml). HIV-positive, Class 2: symptomatic HIV
infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of post-exposure
prophylaxis (PEP) should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counselling,
resources should be available to provide immediate evaluation and follow-up care for all exposures.
†
Source of unknown HIV status, e.g. deceased source person with no samples available for HIV testing.
§
Unknown source, e.g. a needle from a sharps disposal container.
¶
Less severe, e.g. solid needle and superficial injury.
**
The designation ‘consider PEP’ indicates that PEP is optional and should be based on an individualized decision between the exposed person and the
treating clinician.
††
If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.
§§
More severe, e.g. large-bore hollow needle, deep puncture, visible blood on device, or needle used in patient’s artery or vein.
Reproduced from CDC Guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. Morbidity and
Mortality Weekly Report 2001; 50 (RR-11): 1–42.
211
212
Table 11.2 Recommended post-exposure prophylaxis for exposure to HBV.
Vaccination and Treatment

antibody response status
of exposed workers* Source HBsAg† positive Source HBsAg† Source unknown or not
negative available for testing
Unvaccinated HBIG§ # 1 and initiate HB Initiate HB vaccine Initiate HB vaccine series

vaccine series¶ series
Previously vaccinated
Known responder** No treatment No treatment No treatment
Known non-responder†† HBIG # 1 and initiate No treatment If known high-risk source,
revaccination or HBIG # 2§§ treat as if source were
HBsAg positive
Antibody response Test exposed person for No treatment Test exposed person
unknown anti-HBs¶¶ for anti-HBs
1. If adequate,** no 1. If adequate,¶ no
treatment is necessary treatment is necessary
2. If inadequate,†† 2. If inadequate,¶
administer HBIG # 1 and administer vaccine
vaccine booster booster and recheck
titre in 1–2 months
*
Persons who have previously been infected with HBV are immune to reinfection and do not require post-exposure prophylaxis.
†
HBsAg: Hepatitis B surface antigen.
§
HBIG: Hepatitis B immunoglobulin; dose is 0.06 mL/kg intramuscularly.
¶
Hepatitis B (HB) vaccine.
**
A responder is a person with adequate levels of serum antibody to HBsAg, i.e. anti-HBs $ 10 mlU/mL.
††
A non-responder is a person with inadequate response to vaccination, i.e. serum anti-HBs " 10 mlU/mL.
§§
The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for non-responders who have not completed a second 3-dose
vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred.
¶¶
anti-HBs: Antibody to HBsAg.
Reproduced from CDC Guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. Morbidity and
Mortality Weekly Report 2001; 50 (RR-11): 1–42.
HBV vaccine should be started for HCWs who are susceptible and have not received
HBV vaccine. If the exposed person is a known non-responder to HBV vaccination,
then HBV immunoglobulin should be given within 48 h, with another dose in
1 month. Blood should be drawn for testing before HBV PEP is given.
Hepatitis C virus (HCV)

Current evidence suggests specific PEP for HCV is not warranted. The use of inter-
feron is not warranted because of the high level of side effects and a lack of studies
to suggest that its use in this situation is effective. However, treatment options may
change in view of further studies; expert advice should be sought on this issue fol-
lowing a needlestick injury.
Post-exposure counselling and follow-up

It is essential that health care organizations should provide support and expert coun-
selling on the implications of the event; post-exposure prophylaxis and appropriate
long-term follow-up should be offered. Ideally, people nominated to provide support to
affected individuals should have an appropriate knowledge of factors concerning trans-
mission of HIV, HBV and HCV, and have counselling expertise. Where this is not pos-
sible, then a person with appropriate knowledge of disease transmission should be used.
Follow-up should be undertaken by a specialist with knowledge of blood-borne
infections. If it is demonstrated that a person has been exposed to a blood-borne
pathogen, they should not donate blood, semen, organs or tissue for 6 months, and
should not share items that may be contaminated with even a small amount of blood
(e.g. razors or toothbrushes). For HIV and HBV, they should be informed of the risk
of transmission to sexual and injecting partners for a 6-month period, and be coun-
selled about issues of safe sex and safe injecting. Advice should also be offered on
pregnancy and breastfeeding based on an individual risk assessment.
If initial blood tests for HBV, HCV or HIV were negative, these tests should be
repeated at 1, 3 and 6 months.
Protection against tuberculosis

All staff in regular contact with patients, and especially those working in chest medi-
cine or investigation units, thoracic surgery units, infectious disease wards, labora-
tory staff working in microbiology, pathology and post-mortem room staff are at
potential risk of contracting tuberculosis. All staff, including agency staff and locums,
should be screened and offered protection with BCG vaccine pre-employment. Health
care facilities that have contracts with agencies, should specify that the agency only
supply staff that meets this requirement.
It is important that all prospective staff should undergo pre-employment health

screening. Enquiries about symptoms suggestive of tuberculosis should form part
of the pre-employment health questionnaire, which should be checked by the
213
Pre-employment
questionnaire
Suspicious
symptoms
Yes No
Medical
assessment
chest radiograph
No Yes
Normal
Working with
patients or clinical
specimens
Yes
No
Yes Prior BCG No

scar or document
Heaf test
Yes Grade No
0, 1
Further history
No Suspicious
symptoms
Yes
Chest radiograph and medical
assessment
Yes No
Normal
Chest No Give Inform and Chest

clinic action BCG advise clinic
Figure 11.1 Screening of HCWs for tuberculosis.

Reproduced with permission from: Control and prevention of tuberculosis in the United Kingdom: Code of
Practice 2000. Thorax 2000; 55: 887–901.
occupational health department. The results of Heaf testing and BCG vaccination
should be obtained when feasible.
The recommendations for new staff are summarized in figure 11.1. A Heaf test
should be carried out on those prospective employees who do not have a definite
BCG scar. A negative or grade 1 Heaf test in the absence of a definite BCG scar is an
indication for BCG vaccination. Those without a definite BCG scar should have Heaf
testing and those with a positive response (grades 2–4) should undergo clinical
214
examination and chest X-ray. Those with strongly positive Heaf tests (grade 3 or 4)
and/or relevant clinical findings should be referred to a respiratory physician for fur-
ther management. Asymptomatic individuals who have no BCG scar and on Heaf
testing have grade 2, 3 or 4 results should be advised that they have encountered
M. tuberculosis in the past and do not require BCG vaccination. Careful enquiries
must be made to ensure that they are truly asymptomatic and they must be advised
of the relevant symptoms and the need to report these immediately.
Staff with symptoms compatible with tuberculosis: It is the ethical duty of all HCWs
to protect the health of their patients. Staff with symptoms compatible with tubercu-
losis should seek advice either from the occupational health department or from
their own medical practitioner so that they do not expose patients to infection.
Post-exposure follow-up: Following exposure of staff to a patient with open pul-

monary (positive sputum smear for AAFB) tuberculosis, a list of staff at risk should
be drawn by the line manager (see page 145). This list should only include staff that
have had direct contact. The list should be sent to the occupational health department
who will assess the circumstances of the exposure incident and review the HCWs.
Pregnant HCWs
Certain infections can be a problem during pregnancy, some of which may, poten-
tially, be acquired at the workplace: for example cytomegalovirus (CMV), hepatitis
viruses, human immunodeficiency virus, parvovirus (erythrovirus) B19, rubella and
varicella. In general, adherence to standard precautions and maintaining high stand-
ards of general hygiene in the workplace will provide the HCWs with the necessary
protection against infection.
It is the responsibility of the pregnant HCW to advise their medical practitioner and
employer of their pregnancy. The employer should advise pregnant HCWs of the
special risks associated with pregnancy and give them an opportunity to avoid
patients with specific infections. All women of childbearing age should be counselled
regarding their immune status and, if necessary, should be offered immunization
before they become pregnant. All information about immune status and pregnancy
of HCWs must remain confidential.
The following information relates to infections that are both significant in pregnancy
and have some possibility of being acquired through patient care. It is not meant to
be a comprehensive account of all infections having relevance to pregnant women.
Rubella
Confirming rubella immunity is part of routine antenatal screening. However, serious
congenital abnormalities most commonly follow rubella infection occurring in the first
trimester. For this reason, rubella antibody status should be checked at employment in
215
all HCWs, particularly women of childbearing age. If rubella antibody is absent or

below protective levels, then the HCW should be offered vaccination on beginning
employment. Rubella vaccination should be avoided in early pregnancy, and concep-
tion should be avoided for 2 months following vaccination, although no case of con-
genital rubella syndrome has been reported following inadvertent vaccination shortly
before or during pregnancy. Where necessary, those vaccinated can be tested for sero-
conversion 2 months after vaccination, and be revaccinated if necessary.
PEP with normal immunoglobulin will not prevent infection in non-immune con-
tacts and is therefore of little value in the protection of pregnant women exposed to
rubella. It may, however, prolong the incubation period, which in turn may margin-
ally reduce the risk to the fetus. It may also reduce the likelihood of clinical symp-
toms in the mother. Normal immunoglobulin should only be used if termination of
pregnancy due to confirmed rubella infection is unacceptable. In such cases, it
should be given soon after exposure. Serological follow-up of recipients is essential,
and should continue for up to 8 weeks.
Hepatitis B
Routine antenatal screening to determine HBV immune status is commonly per-
formed in some countries. All HCWs should be screened by medical history and if in
any doubt about previous infection/immunization, they should be tested for anti-
bodies to HBsAg. All non-immune HCWs should be offered HBV vaccination as
soon as possible at the start of employment and should be tested for antibodies to
HBsAg 3 months after the third dose of vaccine. Those who do not respond should
be offered a fourth dose or a further three doses depending upon the antibody level.
Persistent non-responders should be informed about the need for HBIG with 48 h of
parenteral exposure to HBV. If a HCW has not been vaccinated or is not known to
be immune to HBV, then HBIG should be offered within 48 h of significant exposure
to blood or potentially blood-contaminated secretions from a known HBV carrier or
an unknown source. HBV vaccination should be offered at the same time. While the
safety of the HBV vaccine for the developing fetus has not yet been confirmed by a
large-scale trial, HBV infection in a pregnant woman may result in severe disease for
the newborn. Pregnancy should therefore not be considered a contraindication to the
administration of HBIG or HBV vaccination.
Cytomegalovirus (CMV)
While CMV may commonly be encountered in urine and saliva, surprisingly there is
little evidence that this virus has been acquired by women HCWs and, in particular,
has then resulted in fetal infection. However, infection of HCWs is largely preventable
by applying standard precautions, including the use of gloves and regular hand wash-
ing. Generally, CMV infection in HCWs, even those working in high-risk areas such
as neonatal units, transplant units and caring for HIV positive patients, is not signifi-
cantly more common than that in the general community.
216
After primary infection, young children excrete CMV in urine and saliva in larger
amounts and for longer periods than adults. There is a high incidence of asymp-
tomatic excretion of CMV among infants and toddlers. For this reason, isolation of
children known to be excreting CMV is not recommended. To avoid CMV infection,
washing hands after all patient contact and after contact with urine and saliva is
essential. Avoidance of direct contact with saliva (e.g. kissing toddlers on the mouth)
is also important. Pregnant HCWs should be informed of the risks of CMV infection
and provided with an opportunity to determine their susceptibility by performing
antibody testing. They should be counselled about hygiene to minimize contact with
known CMV-infected patients. Pregnant HCWs, or those contemplating pregnancy,
should be counselled regarding mode of transmission of CMV and safe work prac-
tices. Routine antenatal screening is not recommended even in HCWs in high-risk
areas, but can be offered on an individual basis. The implications of screening test
results should be clearly explained.
Evidence of past CMV infection is a good indicator that symptomatic infection or

congenital defects in the infant are unlikely to occur. However, it does not totally
exclude the possibility of congenital infection, because reactivation of a past infec-
tion can occur during pregnancy. Conversely, if a HCW is antibody negative, avoid-
ance of high-risk work areas will not eliminate the risk of primary CMV infection
during pregnancy, especially if the HCW has close contact with children or other
sources outside work. CMV seronegative women who care for children over the age
of 2 years have a lower risk of infection. Redeploying seronegative pregnant employ-
ees to care for older children may further minimize the risk of working in high-risk
areas. CMV immunoglobulin is available for the prevention and treatment of CMV
infection in certain individuals at high risk of infection. However, its value is
unclear.
Varicella-zoster virus (chickenpox and shingles)

Primary infection with varicella-zoster virus (VZV) causes chickenpox. The infection
is highly contagious and is spread via the respiratory route or by direct contact with
skin vesicles. The contagious period extends from 2 days before to approximately 5
days after the onset of rash. Crusted vesicles are no longer infectious. Infection of
adults is generally more severe than infection of children.
There is some evidence that the infection may be more severe in pregnant than in
non-pregnant women. Less than 5% of women of childbearing age do not have
immunity to VZV. Even individuals who cannot recall having had chickenpox have
an 80% chance of having had VZV infection. If chickenpox occurs during the first
20 weeks of gestation, intra-uterine fetal infection and occasionally fetal damage
can occur. The fetal varicella syndrome is rare ("2% of affected pregnancies) and
clues to its presence may be found at a 20-week ultrasound scan. The most dan-
gerous time in pregnancy to acquire chickenpox is at term or immediately after
term. This is because there is a high chance that the newborn infant may be
217
exposed and may have little or no immunity. The newborn may then become
seriously ill with VZV infection. For these reasons, non-immune pregnant women
should not care for patients who are infectious, such as patients with chickenpox
or shingles.
An enzyme-linked immunosorbent assay (ELISA) test reliably detects the presence of

serum antibodies to VZV after natural infection. If a HCW has a history of clinical
chickenpox, testing is not necessary since they will be immune. If the HCW is unsure
whether or not they have had chickenpox and they are pregnant or contemplating
pregnancy, then they may have their VZV antibody status checked. VZV vaccine is
recommended for non-immune HCWs, but is not recommended during pregnancy.
Vaccinees should not become pregnant for 1 month after vaccination. Pregnant
HCWs who are not immune should not care for patients with chickenpox or shin-
gles. If inadvertent exposure occurs, VZV immunoglobulin (ZIG) may be given to
the pregnant HCW as soon as possible but up to 7 days after exposure to the virus.
Aciclovir can be used for the treatment of acute VZV infection.
Parvovirus (erythrovirus) B19

Human parvovirus B19 is usually transmitted via the respiratory route, but the virus
is very resistant in the environment and in biological materials such as blood or
plasma. Diagnosis is by serology and/or viral DNA detection. At present there is no
vaccine. Nosocomial outbreaks of B19, involving infection of patients and HCWs,
including pregnant HCWs, have been reported. Infection early in pregnancy may
affect the fetus, causing aplastic anaemia that later becomes manifest as hydrops
fetalis. Pregnant HCWs should therefore avoid contact with patients who are infected
with human Parvovirus (erythrovirus) B19.
Table 11.3 Summary of suggested work restrictions for HCWs exposed to or infected
with infectious diseases.
Disease Work restrictions Duration
Conjunctivitis Restrict from patient Until discharge ceases.

contact and contact with
patients’ environment.
Cytomegalovirus No restriction.
infection
Diarrhoeal diseases
Acute stage Restrict from patient contact, Until symptoms resolve.
contact with patient’s
environment, and
food handling.
Convalescent stage Restrict from care of Until symptoms resolve;
(Salmonella spp.) high-risk patients. refer to local guidelines
regarding need for
negative stool culture.
218
Table 11.3 continued

Diphtheria Exclude from duty. Until antimicrobial

therapy completed
and two cultures
obtained $24 h
apart are negative.
Enteroviral Restrict from care of Until symptoms resolve.
infections infants, neonates or
immunocompromised patients
and their environments.
Hepatitis A Restrict from patient contact, Until 7 days after
contact with patients’ onset of jaundice.
environment, and
food handling.
Hepatitis B
HCW with acute or No restriction; standard
chronic hepatitis B precaution should always
(HBsAg positive) be observed.
who does not
perform exposure-
prone procedures.
HCW with acute or Do not perform exposure-
chronic hepatitis B prone invasive procedures.
(HBsAg positive) who Seek advice from Occupational
performs exposure- Health Department who will
prone procedures. review and recommend
procedures (see page 193).
Hepatitis C Do not perform exposure-prone
invasive procedures. Seek
advice from Occupational
Health Department who will
review and recommend
procedures (see page 193).
Herpes simplex
Genital No restriction.
Hands (herpetic Restrict from patient contact and Until lesions heal.
whitlow) contact with patient’s environment.
Orofacial Evaluate for need to restrict
from care of high-risk patients.
HIV infection Do not perform exposure-prone
invasive procedures. Seek advice
from Occupational Health
Department who will review
and recommend procedures
(see page 193).
Measles
Active Exclude from duty. Until 7 days after the
rash appears.
Post-exposure Exclude from duty. From 5th day after first
(susceptible HCW) exposure through 21st
day after last exposure
and/or 4 days after
rash appears.
219

Mumps
Active Exclude from duty. Until 9 days after
onset of parotitis.
Post-exposure Exclude from duty. From 12th day after
(susceptible HCW) first exposure through
26th day after last
exposure or until 9
days after onset of
parotitis.
Pediculosis Restrict from patient contact. Until treated and
observed to be
free of adult and
immature lice.
Pertussis
Active Exclude from duty. From beginning of
catarrhal stage through
3rd week after onset
of paroxysms or until
5 days after start of
effective antibiotic
therapy.
Post-exposure No restriction, prophylaxis
(asymptomatic HCW) recommended (see page 105).
Post-exposure Exclude from duty. Until 5 days after start
(symptomatic HCW) of effective antibiotic
therapy.
Rubella
Active Exclude from duty. Until 5 days after rash
appears.
Post-exposure Exclude from duty. From 7th day after first
day after last exposure.
Scabies Restrict from patient contact. Until cleared by
medical evaluation.
Staphylococcus
aureus infection
Active, draining skin Restrict from patient contact,
lesions contact with patient’s environment,
and food handling.
Carrier state No restriction, unless HCW is
epidemiologically linked to
transmission of the organism.
Streptococcal Restrict from patient contact, Until 24 h after
infection, group A contact with patients’ antibiotic therapy.
(Strep. pyogenes) environment, and food handling.
Tuberculosis
Active Exclude from duty. Until proven
non-infectious
(see page 143).
PPD converter No restriction.
220

Varicella
Active Exclude from duty. Until all lesions dry
and crust.
Post-exposure Exclude from duty. From 10th day after
(susceptible HCW) first exposure through
21st day (28th day if
VZIG given) after
last exposure.
Zoster
Localized in healthy Cover lesions, restrict from Until all lesions dry
person care of high-risk patients¶. and crust.
Generalized or Restrict from patient contact. Until all lesions dry
localized in and crust.
immunosuppressed
person
Post-exposure Restrict from patient contact. From 8th day after first
day (28th day if VZIG
given) after last
exposure or, if varicella
occurs, until all
lesions dry and crust.
Viral respiratory Consider excluding from the Until acute symptoms
infections, care of high-risk patients or resolve.
acute febrile contact with their environment
during community outbreak of
RSV and influenza.
HBsAg: Hepatitis B surface antigen; HIV: human immunodeficiency virus; VZIG: varicella
zoster immunoglobin; RSV: respiratory syncytical virus.
¶
Those susceptible to varicella or at increased risk of complication of varicella, e.g. neonates
and immunocompromised persons (see pages 167–168).
Modified from Bolyard EA, Tablon OC, Williams WN, et al. CDC Guideline for infection control in
healthcare personnel, 1998. American Journal of Infection Control 1998; 26 (3): 289–354.
221
222
Table 11.4 Post-exposure prophylaxis against infectious disease.
Disease Prophylaxis Indications Comments
Hepatitis A One IM dose normal immunoglobulin HCW exposed to faeces of infected Persons with IgA
given within 2 weeks of exposure. persons during outbreaks. deficiency, if administered
within 2 weeks after
MMR (Measles-Mumps-
Rubella) or within 3 weeks
after varicella vaccine then

the immune response to
these vaccines is likely to
be inadequate.
Hepatitis B See Table 11.2 HCW exposed to blood or body fluids

containing HBsAg and who are not
immune to HBV infection.
HIV infection See Table 11.1
Varicella zoster Varicella zoster immunoglobulin HCW known or likely to be See pages 217–218
susceptible (especially those at high
risk for complications, e.g. pregnant
women) who have close and prolonged
exposure to a contact case or an
infectious HCW/patient.
Diphtheria Benzathine penicillin 1.2 megaunit IM HCW exposed to diphtheria or
single dose or erythromycin 1 g per day identified as carrier.
orally for 7 days.
Meningococcal Rifampicin 600 mg orally every 12 h HCW with direct contact with See page 162
disease for 2 days, or respiratory secretions from infected
Ceftriaxone 250 mg IM persons without the use of proper
single dose or Ciprofloxacin 500 mg precautions, e.g. mouth-to-mouth
orally single dose. resuscitation, endotracheal intubation,
endotracheal management, or close
examination of oropharynx.
Pertussis Erythromycin 500 mg 6 hourly orally for HCW with direct contact with
14 days after exposure. respiratory secretions or large aerosol
droplets from respiratory tract of
infected persons.
223

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Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare

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Bell DM, Shapiro CN, Ciesielski CA, et al. Preventing blood-borne pathogen transmission
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Bronowicki JP, Venard V, Botte C, et al. Patient-to-patient transmission of hepatitis C

virus during colonoscopy. New England Journal of Medicine 1997; 337: 237–240.
Bolyard EA, Tablon OC, Williams WN, et al. CDC guideline for infection control in
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Cardo DM, Bell DM. Bloodborne pathogen transmission in health care workers: risks
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trol of hepatitis C virus (HCV) infection and HCV-related chronic disease. Morbidity and
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226
12
Hand Hygiene and Personal
Protective Equipment
M ore than 150 years ago Ignaz Semmelweis (1818–1865) demonstrated that
puerperal fever was a contagious disease caused by infectious organisms,
which were spread from patient to patient by the hands of health care workers
(HCWs). This led to the introduction of hand dips with chlorinated lime at Vienna
General Hospital. Since then, many studies have demonstrated that contaminated
hands are responsible for transmitting infections.
It has been estimated that up to 30% of nosocomial infections could be prevented

if HCWs thoroughly wash their hands before and after contact with body sub-
stances. Therefore, importance of regular hand hygiene must be emphasized as one
of the most crucial interventions in the prevention of cross-infection in health care
facilities.
It is the responsibility of health care establishments to ensure that adequate

numbers of hand washing facilities are readily available in all clinical areas (see
page 20). They should be of suitable types and be located in areas where there is
significant patient contact. The supply of soap and disposable towels should be
readily available.
Microorganisms present on the hands may be divided into two categories:
Resident organisms: These microorganisms are normal flora of the skin and include
coagulase-negative staphylococci (mainly Staphylococcus epidermidis), members of
the genus Corynebacterium (commonly called diphtheroids) and Propionibacterium
spp. They are usually deep seated in the epidermis and are not easily removed by a
single hand washing procedure. They rarely cause infection apart from during
implant surgery and at intravenous sites.
Transient organisms: These microorganisms are those that are not part of the nor-
mal flora and represent recent contamination, usually surviving only for a limited
period of time. They are acquired during contact with the infected/colonized patient
227
or the environment and are easily removed by hand washing. The transient flora
includes most of the organisms responsible for cross-infection, e.g. Gram-negative
bacilli (Escherichia coli, Klebsiella spp. and Pseudomonas spp.), Salmonella spp., Staph.
aureus and viruses, e.g. rotaviruses.
Methods of hand decontamination

Choice of method of hand decontamination will depend upon assessment of what is
appropriate for the episode of care, what is practically possible and, to some degree,
personal preference based on the acceptability of preparations or materials.
Hands must be decontaminated before every episode of care that involves direct
contact with patients’ skin, their food, invasive devices or dressings. The choice of
method is based on an assessment of the degree of risk which depends on the
following factors:
• Level of anticipated contact with patient or object.

• Extent of contamination that may occur with that contact.
• Patient care activities being performed.
• Susceptibility of the patient.
Routine hand washing: Routine hand washing will render the hands socially clean
and remove transient microorganisms provided that an effective technique is used.
Procedure
1. Wet hands and forearms.

2. Apply sufficient plain, non-microbial (bar or liquid) soap to the hands to
obtain good lather.
3. Rub vigorously to form lather on the surface of the hands for at least
10 seconds.
4. The hands should then be thoroughly rinsed under running water for a
further 10 seconds.
5. Dry thoroughly using good quality paper towels.
Hands should be washed:
• Before and after a work shift.
• Before and after each nursing contact.
• After contact with blood, body fluids, secretions and excretions.
• After handling soiled or contaminated equipment or linen.
228
Hand Hygiene and Personal Protective Equipment
1. Palm to palm
2a. Right palm over 2b. Left palm over

left dorsum right dorsum
3. Fingers interlace
palm to palm
4. Back of fingers to opposing palms
5a. Rotational rubbing of 5b. Rotational rubbing of

right thumb left thumb
6a. Rotational rubbing of 6b. Rotational rubbing of

left palm right palm
Figure 12.1 Figures showing steps in hand washing technique.
229
• Before eating, drinking or handling food (including serving meals) or

drinks or administering drugs.
• After using the toilet.
Hygienic hand disinfection: Hygienic hand disinfection will remove and kill most
transient microorganisms. An antiseptic hand wash preparation is used.
Procedure
2. Apply 3–5 ml of antiseptic solution into cupped hands.
3. Rub vigorously to form lather on all surfaces of the hands and forearms for
at least 1 minute.
4. The hands should then be thoroughly rinsed under running water for
10–15 seconds, applying friction over all hand surfaces.
5. Rinse and then dry thoroughly.
Hands should be disinfected:
• During outbreaks of infection where contact with blood and body fluids or
in situations where microbial contamination is likely to occur.
• In high-risk areas, e.g. patients in isolation, Intensive Care and Special Care
Baby Units.
• Before performing an invasive procedure.
• Before and after touching wounds, urethral or IV catheters.
• Before wearing and after removing gloves.
Hygienic hand rub: An alternative method of hand disinfection is the application of

3–5 ml of a fast-acting antiseptic alcoholic hand rub into cupped hands. Hands are
rubbed until they are dried using the defined technique. Alcoholic hand rub
containing an emollient (e.g. glycerol) should be used to prevent excessive drying of
hands. Alcoholic hand rubs do not cleanse and therefore it is important that hands
should be cleaned first in the presence of visible contamination. The hygienic hand
rub method is convenient, rapid and effective alternative to hand washing method
and is useful in areas where a hand washbasin is not readily available, e.g.
• Emergency situations where there may be insufficient time and/or
facilities.
• When hand washing facilities are inadequate.
• In the community or when return to a hand washbasin is impractical.
• During a ward round where there is a need for rapid hand disinfection.
230
FRONT BACK
Not Less frequently Most frequently

missed missed missed
Figure 12.2 Parts of the hands most frequently missed during hand washing.
Reproduced with permission from Taylor LJ. An evaluation of handwashing techniques. Nursing Times 1978;
74: 54–55.
Surgical hand disinfection: The first surgical scrub for the day should be for 3–5
minutes. Subsequent washes for 3 min between consecutive operations or application
of alcoholic-based products to clean the hands for 3 min (see page 252) should suffice.
Hand washbasin
The health care facilities should have adequate numbers of hand washbasins (see
page 20). They should be located conveniently (i.e. preferably near an entrance) for
easy access to the HCW.
Hand washbasin should be supplied with both hot and cold water, preferably with a
mixer tap to achieve correct temperature. The tap should be fitted with hands-off
control (e.g. elbow operated) to avoid contamination. Hand washbasin should ideally
be fitted with a soap dispenser. The water should be turned off using a paper towel
rather than bare fingers or hands to avoid recontamination of hands. Plugs are not
necessary, since hands should be washed only under running water.
Hand drying
Only good quality paper should be used. It should be within easy reach of a sink.
Cloth/fabric towels are not recommended for use in health care facilities as they are
231
recognized as a source of cross-infection. However if they are used, then they must be
single-use and sent to the laundry. Use of hot air dryers in health care facilities is not
recommended as they are noisy and slow and can be used by only one individual at
a time.
Hand cleaning preparations

Hand cleaning preparations are mainly available in three forms, i.e. plain soap (bar
or liquid), antimicrobial hand washes, and alcohol hand rubs. Various studies have
been published concerning the effectiveness of various hand cleaning preparations in
removing microorganisms from hands. Overall there was no evidence to favor the
use of one antimicrobial agent over another. The choice of which hand decontamin-
ation preparation to use must take into consideration the need to remove transient
and/or resident hand flora. Preparations with a residual effect are not normally
necessary for everyday clinical practice.
The acceptability of agents and techniques is an essential criterion for the selection
of preparations for hand hygiene. Acceptability of preparations is dependent upon
ease of use combined with their dermatological effects.
Soap: It is important to emphasize that soap and water is as effective as preparations

containing antimicrobial agents for decontaminating hands and removing transient
microorganisms. Therefore, for general patient care, a plain neutral pH soap (with-
out added substances that may cause irritation or dryness) should be used for
routine hand washing.
If bar soap is used then the bar should be small in size to allow frequent changing.
The soap should be kept dry (in a soap rack or on a magnet or ring) to promote
drainage of water and avoid contamination with microorganisms which grow in
moist conditions.
Liquid soap products should be stored in closed containers and dispensed from
disposable containers. The dispensers should be regularly cleaned and maintained.
If liquid soap is dispensed from reusable containers, these must be cleaned when
empty and dried before refilling with fresh soap to avoid contamination. Special
attention should be taken to clean pump mechanisms as these have been implicated
as sources of infection.
Antiseptics: Preparations containing antimicrobial agents are more effective in

removing resident microorganisms than those without an antimicrobial agent.
Preparations containing antimicrobial agents have different effects on specific
microorganisms (see Table 6.2, page 62).
A range of products is available, but chlorhexidine, povidone iodine, alcohol and

triclosan are commonly used. Examples include 4% chlorhexidine gluconate-
detergent, povidone iodine solution containing 0.75% available iodine, 0.5%
232
chlorhexidine gluconate with 70% isopropyl alcohol or 2% triclosan in a tenside

base. A similar concentration of the antiseptic agent in different products does not
necessarily imply similar effectiveness, therefore new products should be tested before
introduction. Any preparation used for hand washing or hand disinfection must be
acceptable to the user and must not damage the skin on repeated use. If staff do not
accept the preparation, it will not be used. Therefore, it is recommended that a trial
be undertaken before introduction of a new product in some areas to assess the
acceptability by staff.
Alcohol based hand rubs: Alcohol based hand rubs are more effective in decontamin-
ating hands than soap and water and antimicrobial handwashing agents. Their use
gives a greater initial reduction in hand flora. However they are not effective in remov-
ing physical dirt or soiling and should be used to disinfect physically clean hands.
Nailbrushes
Routine use of nailbrushes is not recommended because frequent and vigorous use of
a nail brush may damage the skin, encouraging the proliferation and persistence of
microorganisms on the skin. Soft nailbrushes may be used for cleaning the nails and
subungual spaces prior to the first operation of the day. In such circumstances, they
must either be sterile single-use disposable, or be supplied sterilized by the hospital
sterile service department. Nailbrushes must never be soaked in a disinfectant
solution.
Hand care
Skin damage is generally associated with the detergent base of the preparation and/or
poor hand washing technique. Hand care is important, because intact skin is a
natural defense against infection. Damaged skin may result in increased carriage of
pathogens responsible for hospital-acquired infection. In addition, the irritant and
drying effects of hand preparations have been identified as one of the reasons that
health care practitioners fail to adhere to hand hygiene guidelines. Therefore hand
preparations that contain emollients and moisturizers should be used. The following
points should be kept in mind:
• To minimize chapping of hands, use warm water and pat hands dry rather
than rubbing them.
• Apply an emollient hand cream regularly to protect skin from the drying
effect of preparations.
• Nails should be kept short to allow thorough cleaning of the hands and to
prevent tears in gloves. Artificial nails should be discouraged as they
contribute to increased bacterial counts.
• Cuts and abrasions should be covered by water-resistant occlusive dressings
that should be changed as necessary.
233
• HCWs who have skin problems such as exudative lesions or weeping

dermatitis must seek medical advice and should be removed from direct
patient care until the condition resolves.
• Repeated hand washing and wearing of gloves can cause irritation or sen-
sitivity, leading to dermatitis or allergic reactions. This can be minimized
by early intervention, including assessment of hand washing technique and
the use of suitable individual use hand care product.
Hand care products are used to help prevent excessive dryness. Some are also respon-
sible for skin sensitization. Therefore, only suitable hand creams or lotions should be
used and the following points should be considered in their choice:
• They should be supplied in small, individual use containers that are not
refilled.
• Some types of hand creams and lotions may interact with antiseptics
(e.g. chlorhexidine) and affect the integrity of gloves.
• Aqueous-based hand creams should be used before wearing gloves as oil-
based preparations may cause latex gloves to deteriorate.
Compliance
Although hand washing is considered to be the most important single intervention
for preventing nosocomial infections, studies have repeatedly shown poor compli-
ance with hand washing by hospital personnel. The problem has been highlighted
especially among doctors who frequently fail to wash their hands between patients.
Failure to comply is a complex problem that includes elements of lack of motivation
and lack of knowledge about the importance of hand washing. It may also be due to
real or perceived obstacles, such as understaffing, inconveniently located hand wash-
ing facilities, an unacceptable hand washing product or dermatitis caused by previ-
ous hand washing. A number of strategies have been suggested to improve
compliance. Long-term success will require development of programmes and sus-
tained efforts at promoting compliance with hand washing. Effective interventions
will probably be multidimensional, and will require the application of behavioural
science theory combined with engineering and/or product innovation.
234
PERSONAL PROTECTIVE EQUIPMENT

The primary use of protective clothing in health-care settings is:
• To protect the skin and mucous membranes of HCWs from exposure to

blood/body fluid.
• To prevent contamination of clothing and reduce the opportunity of spread of
organisms from patients or fomites to other patients or environments.
The decision to use and select appropriate personal protective equipment must be
based upon an assessment of the level of risk associated with contamination of
clothing and skin by blood and body fluids from a specific patient care activity or
intervention. The HCW must complete a similar exercise for all personnel visiting a
patient in isolation. When protective wear is considered necessary, he or she is
responsible for educating visitors and supervizing its use. Protective clothing which
conforms to appropriate standards should be used.
Gloves
Provided gloves are correctly used, they can perform the following functions:
• Provide a protective barrier and prevent gross contamination of the hands

when touching blood and body fluids, secretions, excreta, mucous mem-
branes and non-intact skin.
• Reduce the likelihood that organisms from the hands of personnel will be
transmitted to patients during invasive or other patient care procedures
that involve touching mucous membranes and non-intact skin.
• Reduce the likelihood that the hands of personnel contaminated with
organisms from a patient or a fomite can transmit these microorganisms to
another patient.
• Protect the skin against hazardous substances, e.g. chemicals.
HCWs need to be aware that the inappropriate use of gloves can be a hazard and has
been associated with cross-infection. Defects in gloves may be present and hands may
be contaminated during their removal. Therefore, it is important that hands must
always be decontaminated after using gloves. The use of gloves should never be viewed
as a substitute for appropriate hand washing.
Types of gloves
As with all items of personal protective equipment, the need for gloves and the
selection of appropriate materials must be subject to careful assessment of the task
to be carried out and its related risks. Having decided that gloves should be used,
HCWs must make a choice between the use of sterile or non-sterile gloves depend-
ing on the tasks being undertaken.
235
Donning technique
• Remove jewellery (wrist watches and rings) which may puncture the
gloves.
• Open the protective paper package containing the sterile gloves onto
a sterile surface.
• Unfold packaging by touching the corners only.
• Pick up the inside cuff using the non-dominant hand. Do not touch
the outside of the glove.
• Slide the dominant hand inside the glove with correct alignment of
thumb and fingers.
• Slip the fingers of the gloved hand under the cuff of the remaining glove.
• Slide the hand inside the glove with fingers and thumb correctly aligned.
• Avoid touching any part of the exposed hand with the gloved hand.
• Interlock fingers after the gloves are in place to ensure a comfortable
fit and free movement.
Note: No special technique is necessary for use of non-sterile gloves. Pull
gloves on in a convenient manner. Gloves should cover wrists.
Glove removal technique

• Grasp the palm of the first glove just below the wrist.
• Roll the glove towards the fingertips so that it turns inside out.
• Hold the removed glove by the fingertips of the remaining gloved hand.
• Place two fingers of the bare hand inside the cuff of the remaining glove.
• Roll the second glove towards the fingertips with the bare hand until
the first glove is inside the second glove.
• Continue to remove until both gloves are inside out.
• Dispose of used gloves into a yellow clinical waste bag.
• Wash and dry hands thoroughly.
Note: It is the outside of the glove which is in contact with potentially
infected material and the possibility of exposure to unprotected skin is at
its greatest when the gloves are removed.
236
1. Single-use gloves
Sterile gloves: Single-use disposable sterile gloves should be used during aseptic
procedures to prevent patients acquiring infection. They should not be washed or
disinfected and re-used.
Non-sterile gloves: Non-sterile gloves should be used for procedures involving contact
with blood, body fluids, excretions and secretions or non-intact skin or mucous
membranes where there is a risk of infection to the HCW.
Gloves must be changed both between patient contacts and between separate proced-
ures on the same patient. They should be changed if torn or punctured. Hands
should be decontaminated following the removal of gloves. Gloved hands should nei-
ther be wiped with any form of alcoholic substance nor washed. Single-use gloves
should be removed carefully to avoid contamination of hands or other surfaces. Keep
in mind that gloves may develop defects or tears after extended use; that is why it is
so important to wash your hands after removing your gloves. Gloves contaminated
with blood and/or body fluids must be treated as clinical waste and disposed of
accordingly.
2. General-purpose utility gloves

The use of heavy duty or household type gloves is required for environmental
cleaning and decontamination procedures because they are robust and offer greater
protection to the HCW. They should be washed in detergent and stored dried after
each use. They should be replaced if punctured, torn, cracked, or showing signs of
deterioration.
Glove materials
A number of materials are used in the manufacture of gloves. It is important that the
most appropriate material for the purpose should be selected (see Table 12.1). Latex
gloves are the most widely used, especially when dexterity is required, as they are the
most sensitive. Recently the quality of vinyl gloves has improved and providing the
type chosen reaches the specified standards, they can be considered suitable for
barrier protection. Polythene gloves are not suitable for clinical use due to their
permeability and tendency to damage easily. Synthetic materials are generally more
expensive than latex and due to certain properties may not be suitable for all
purposes. The problem of patient or HCW sensitivity to latex proteins must be
considered when deciding on glove materials.
Latex allergy
Latex protein is a natural component of rubber which tends to produce an imme-
diate hypersensitivity reaction (Type I) whilst other chemicals used in processing
latex products can cause delayed hypersensitivity responses (Type IV). The usual
route of exposure is the skin. To minimize the risk of allergy, latex gloves should
have low levels of extractable proteins and residual accelerators. Evidence
237
Table 12.1 Types of gloves and suggested uses.
Glove type Features Suggested use
Plastic/co-polymer • Cheap • Not recommended as there are

• Tear easily and often no agreed specific indication for
fit poorly infection control use
Latex • Strong • Use when delicate manipulation
(non-sterile) • Good fit is required
• Risk of • Use for protection against blood
sensitization and body fluids
Latex • Strong • Use for invasive procedures
(sterile) • Good fit requiring high levels of patient
• Prone to sensitization and user protection or prolonged
contact with body fluids
Vinyl • Less sensitive as fit is • Use for handling cytotoxic agents
not as good as latex
gloves
Rubber • Expensive • Use for environmental cleaning
• Strong
Nitrile • More expensive than • For individuals working with

latex glutaraldehyde or sensitive
• Not available as a to latex
surgical glove
Neoprene • More expensive than • For individuals sensitive
latex to latex
• Available as a surgical
glove
Adapted from Hospital Infection Control Working Party Report. Review of hospital isolation
and infection control related precautions, July 2001.
indicates that cornstarch glove powder aerosolizes latex proteins causing the
allergens to be inhaled by both the glove wearer and others in the immediate
environment. It is recommended that all latex gloves should be non-powdered and
that all patient-admission processes should establish whether there is a history of
allergy to latex. In addition to latex allergy, it is also associated with adhesions and
increasing risks of infection associated with invasive devices. Therefore it is
strongly recommended that powdered gloves should not be used in the health-
care setting.
Nitrile gloves have the same chemical range as latex and therefore may lead to sensi-
tivity problems. In order to minimize latex allergy it is important that gloves should
be worn only when necessary and be removed as soon as the activity is completed.
HCWs who develop sensitivity or allergy to latex should use another type of glove,
e.g. neoprene.
238
Protective eyewear
The aim of protective eyewear (glasses, goggles or face-shields) is to help guard the
mucous membranes of the eyes, nose, and mouth of the HCW from exposure to
blood or body fluids that may be splashed, sprayed, or splattered into the face during
the clinical procedures. Protective eye wear must be worn during procedures that are
likely to generate droplets of blood or high-risk body fluids. They should comply with
approved standards. They must be close fitting, optically clear, antifog and distortion
free, and shielded at the side.
Face mask
Masks in conjunction with eyewear should be worn during procedures that are likely
to generate aerosols or splashes of blood and body fluids to prevent contamination
of mucous membranes of the mouth, nose and eyes. The type of mask best suited to
a particular situation depends on the body substances likely to be encountered and
the nature of the activity. Wearing of masks during routine ward procedures such as
wound dressing or invasive medical procedures is not necessary.
Surgical masks may not be effective in preventing the inhalation of droplet nuclei.
When caring for patients with known or suspected infectious pulmonary or laryn-
geal tuberculosis, it is recommended that a high efficiency particulate air (HEPA)
mask should be used. Masks should be close fitting and filter particles of 1–5 !m. In
the US, use of particulate respirators (N95) are recommended. Use of a mask is not a
substitute for good infection control practice.
Dental procedures can generate large quantities of aerosols of 3 !m or less, and

therefore dental HCWs should wear masks or facial barriers that block particles of
this size. Masks should be changed after 20 minutes of continuous exposure to
aerosols in the environment or as soon as practicable after they become moist or
visibly soiled. If the masks are used then they should:
• Be fitted according to the manufacturer’s instructions.

• Be used only once and changed when moist or grossly contaminated.
• Not be touched by hand while being worn.
• Be removed by untying and handled only by the ties and never by the face cov-
ering part which may be heavily contaminated with the microorganisms.
• Not be worn loosely around the neck, but be removed and discarded as soon
as practicable after use.
Aprons and gowns

Apron: Single-use disposable plastic aprons are recommended for general use and
should be worn when there is a risk that clothing or uniforms may become exposed
to blood, body fluids, secretions and excretions. Plastic aprons should be worn as
239
single-use items for one procedure or episode of patient care only. They should be
removed immediately after use by tearing the neck strap and the waist tie and
discarded into clinical waste bag before they leave the room. Hands must be washed
immediately after removing and bagging the soiled plastic apron.
Gowns: Clean, non-sterile gowns should be worn during procedures which are likely
to expose HCWs with spraying or splashing of blood, body fluids, secretions, or
excretions. Gowns should be impermeable and water repellent. If the gown is
expected to become wet during the procedure and if a water repellent gown is not
available, a plastic apron should be worn over the gown. Grossly soiled gowns should
be promptly removed and placed in a designated leak proof laundry bag. Hands
should be washed immediately after removing and bagging of the soiled gown.
Plastic overshoes
The use of overshoes is not recommended, as it is an ideal way of transferring
microorganisms from floor and shoes to hands.

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244
13
Prevention of Surgical
Site Infections
D espite advances in operative techniques and a better understanding of the

pathogenesis of wound infection, post-operative wound infection continues to
be a major source of morbidity and mortality for patients undergoing operative
procedures. It can account for up to 15% of all nosocomial infections.
The most critical factors in the prevention of post-operative infections, although

difficult to quantify, are the sound judgement and proper technique of the surgeon
and surgical team, as well as the general health and disease state of the patient.
In order to minimize post-operative surgical wound infection, it is important to
create a safe environment by controlling four main sources of infection, i.e. personnel,
equipment, the environment and patient’s risk factors.
Surveillance
Surveillance of surgical site infection (SSI) is a useful tool to demonstrate the
magnitude of the problem. Regular feedback of SSI to the surgeon has been shown
to provide strong motivation and a reduction in infection rates in clinical practice.
For surveillance of SSI, it is important that internationally agreed definitions should

be followed, which must be agreed with the surgical team prior to embarking on the
surveillance programme. The most widely used definition of SSI (see pages 246–247)
is that employed by the Center for Disease Control’s National Nosocomial Infections
Surveillance (NNIS) system. They must be risk adjusted so that they can be compared
amongst surgeons or among facilities.
In recent years, the surveillance of SSIs has been complicated by changes in surgical
practice, the short duration of post-operative stay, outpatient procedures, and
laparoscopic procedures. SSIs are considered to be nosocomial if the infection occurs
within 30 days the operative procedure or within 1 year if a device or foreign material is
implanted.
245
CDC criteria for defining a surgical site infection (SSI)*

Superficial incisional SSI
Infection occurs within 30 days after the operation, and infection involves
only skin or subcutaneous tissue of the incision, and at least one of the
following:
1. Purulent drainage, with or without laboratory confirmation, from the
superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or
tissue from the superficial incision.
3. At least one of the following signs or symptoms of infection: pain or
tenderness, localized swelling, redness or heat and the superficial
incision is deliberately opened by surgeon, unless incision is culture-
negative.
4. Diagnosis of superficial incisional SSI by the surgeon or attending
physician.
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inflammation and discharge confined to the

points of suture penetration).
2. Infection of an episiotomy or newborn circumcision site.
3. Infected burn wound.
4. Incisional SSI that extends into the fascial and muscle layers (see deep
incisional SSI).
Note: Specific criteria are used for identifying infected episiotomy and
circumcision sites and burn wounds.**
Deep incisional SSI

Infection occurs within 30 days after the operation if no implant¶ is left
in place or within 1 year if implant is in place and the infection appears
to be related to the operation. Infection involves deep soft tissues (e.g.
fascial and muscle layers) of the incision and at least one of the
following:
1. Purulent drainage from the deep incision but not from the organ/space
component of the surgical site.
2. A deep incision spontaneously dehisces or is deliberately opened by
a surgeon when the patient has at least one of the following signs or
246
Prevention of Surgical Site Infections
symptoms: fever (!38°C), localized pain or tenderness, unless site is

culture-negative.
3. An abscess or other evidence of infection involving the deep incision
is found on direct examination, during reoperation, or by histopatho-
logic or radiologic examination.
4. Diagnosis of a deep incisional SSI by a surgeon or attending
physician.
Notes:
1. Report infection that involves both superficial and deep incision sites
as deep incisional SSI.
2. Report an organ/space SSI that drains through the incision as a deep
incisional SSI.
Organ/space SSI
Infection occurs within 30 days after the operation if no implant¶ is left
in place or within 1 year if implant is in place and the infection appear
to be related to the operation and infection involves any part of the
anatomy (e.g. organs or spaces) other than the incision which was
opened or manipulated during an operation and at least one of the
following:
1. Purulent drainage from a drain that is placed through a stab wound§

into the organ/space.
2. Organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space.
3. An abscess or other evidence of infection involving the organ/space
that is found on direct examination, during reoperation, or by
histopathologic or radiologic examination.
4. Diagnosis of an organ/space SSI by a surgeon or attending physician.
*Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definition of nosocomial
surgical site infections. 1992: a modification of CDC surgical wound infections. Infection
Control Hospital Epidemiology 1992; 13(10): 606–608.
**Gaynes RP, Horan TC. Surveillance of nosocomial infections. In: Mayhall CG, ed.
Hospital Epidemiology and Infection Control, Baltimore: Williams & Wilkins; 1996,
1017–1031.
¶
National Nosocomial Infection Surveillance definition: a non-human-derived implantable
foreign body (e.g. prosthetic heart valve, non-human vascular graft, a mechanical heart, or
hip prosthesis) that is permanently placed in a patient during surgery.
§
If the area around a stab wound becomes infected, it is not an SSI. It is considered a skin
or soft tissue infection, depending on its depth.
247
The traditional classification of surgical wound infection was based on the exposure
of the incision to bacterial contamination (see Table 13.1). In 1992, the NNIS system
(Horan TC, et al. 1992) attempted to redefine surgical wound infection. This system
has provided a greater discrimination for the patients at risk of developing wound
infection. The NNIS system includes:
• Contaminated or dirty wound class.
• High pre-operative risk as defined by the American Society of
Anesthesiologists (ASA) pre-operative assessment score.
• Duration of operation exceeding the 75th percentile for a given procedure.
Additional risk factors of developing SSI are summarized in Table 13.2.
Microbiology
The pathogens isolated from infections differ, primarily depending on the type of
surgical procedure. For example, in clean surgical procedures, Staphylococcus aureus
from the exogenous environment or the patient’s skin flora is the usual cause of
infection. In other categories of surgical procedures, including clean-contaminated,
contaminated, and dirty, the polymicrobial aerobic and anaerobic flora closely
resembling the normal endogenous microflora of the surgically resected organ are
the most frequently isolated pathogens.
According to data from the NNIS, there has been little change in the incidence
and distribution of the pathogens isolated from infections during the last decade.
However, more of these pathogens show antimicrobial-drug resistance, especially
methicillin-resistant S. aureus (MRSA).
Pre-operative patient care

Patient’s risk factors
These include extreme age, obesity, malnutrition, certain concurrent disease or con-
ditions, i.e. diabetes, malignancy, chronic chest or heart disease, and immunosup-
pression. Patients with pre-existing skin lesions or infection in another site, and
treatment with steroids and immunosuppressive drugs, are more prone to get surgi-
cal wound infection due to impaired host defense mechanisms. These should be
corrected or treated before an elective operation is planned. Cessation of tobacco use
30 days before surgery is also recommended.
Pre-operative showers
Pre-operative showers or baths on the night before an operative procedure using
antimicrobial agents have been suggested as a means of reducing SSI in certain
categories of patients. Several studies observed lower infection rates when the patient
showered preoperatively with antiseptic agents while other studies have failed to
248
Table 13.1 Wound classification based on estimation of bacterial density, contam-

ination and risk of subsequent infections.
Surgical procedure Definition Expected infection

rate (%)
Clean Non-traumatic, uninfected operative 1–3

wounds in which no inflammation is
encountered; there is no break in
technique; and the respiratory,
alimentary, or genitourinary tracts or the
oropharyngeal cavities are not entered.
Clean contaminated Operation in which the respiratory, 8–10
alimentary or genitourinary tracts
are entered under controlled conditions
and without unusual contamination.
Contaminated Operation associated with: 15–20
• Open, fresh trauma wounds
• Major breaks in a sterile technique
or gross spillage from the
gastrointestinal tract
• Acute, non-purulent inflammation
Dirty and infected Operation involving old trauma wounds 25–40

with retained devitalized tissue, foreign
bodies, or faecal contamination,
and those with existing infection.
Table 13.2 Risk factors associated with surgical site infections.
Risk factors
Host-related Procedure-related
Definite • Age • Pre-operative hair removal

• Obesity • Type of procedure
• Disease severity • Antibiotic prophylaxis
• ASA (American Society of • Duration of surgery
Anesthesiologists) Score
• Nasal carriage of Staph. aureus
• Remote infection
• Duration of pre-operative
hospitalization
Likely • Malnutrition and low serum • Multiple procedures
albumin • Tissue trauma
• Diabetes mellitus • Foreign material
• Blood transfusion
Possible • Malignancy • Pre-operative showers
• Immunosuppressive therapy • Emergency surgery
• Breast size in women • Drains
Reproduced from Smyth ETM, Emmerson AM. Journal of Hospital Infection 2000; 45: 173–184.
249
Table 13.3 Antibiotics prophylaxis for surgical procedures.
Surgical procedures Antibiotics
Cardiac surgery Cefuroxime or cefazolin (three doses)

Neurosurgery Cefuroxime or cefazolin (single dose)
Head and neck
(operation involving the Cefuroxime or cefazolin " metronidazole
mucous membranes and (up to three doses)
deep tissue)
Biliary tract surgery Cefuroxime or cefazolin or gentamicin
(single dose)
ERCP Cefuroxime or cefazolin (single dose)
Gastroduodenal Cefuroxime or cefazolin (single dose)
Appendectomy Cefuroxime or cefazolin or gentamicin #
(simple) metronidazole (single dose)
Colorectal surgery Cefuroxime or cefazolin or gentamicin #
metronidazole (single dose)
Orthopaedic surgery
• Insertion of prosthetic Cefuroxime or cefazolin. Substitute vancomycin
joints, open operation if history of penicillin or cephalosporin allergy
(single dose)
• Lower limb amputation Benzylpenicillin 2 mega units IV 6 hourly.
Metronidazole or clindamycin for patient
allergic to penicillin. All antibiotics should be
given for 24 h duration
Peripheral vascular surgery Cefuroxime or cefazolin (three doses)
Urological surgery IV antibiotic cover depends on sensitivity testing
of screening urine. In an emergency situation,
give gentamicin 2–3 mg/kg body weight
(single dose)
Hysterectomy Cefuroxime or cefazolin # metronidazole or
co-amoxiclav alone (single dose)
Caesarean section Cefuroxime or cefazolin or co-amoxiclav
after umbilical cord is clamped (single dose)
Helpful hints
• All antibiotics should be administered at the induction of anaesthesia. Repeat dose of
antibiotic should be given for the operations when the duration of operation exceeds 3 h
or in the case of massive haemorrhage ($2 litres of blood is lost in an adult). Do not give
prophylactic antibiotic for more than 24 h.
• Prophylactic antibiotic dosage for adults: cefuroxime, 1.5 g IV (750 mg if body weight
%50 kg); cefazolin 1–2 g; clindamycin 600 mg IV; metronidazole 500 mg IV and
co-amoxiclav 1.2 g IV.
250
show a reduction in the wound infection rate. Even though pre-operative showers
may reduce the skin’s microbial colony count, they have not definitively been shown
to reduce the infection rates.
Pre-operative hospitalization
Pre-operative stay in hospital should be kept to a minimum before operations
because the longer the patient stays in the hospital before an operation, the greater
becomes the likelihood of succeeding wound infection.
Pre-operative shaving
Pre-operative shaving should be avoided because shaving can cause small nicks
and breaks leaving the skin bruised and traumatized which increases the risk of
colonization and infection. If hair is to be removed from the operative site, only the
area needing to be incised should be shaved. This should preferably be done using
depilatory cream the day before operation. Depilatory cream should be used with
caution as it can cause serious skin irritation and rashes, which may lead to wound
infection. Alternately hair can be removed with clippers in the anaesthetic room
immediately before the operative procedure. If clippers are used, then the head must
be sterile. Razors and shaving brushes should not be used.
Antibiotic prophylaxis
The use of antibiotic prophylaxis before surgery has evolved greatly in the last 20
years. Improvements in the timing of initial administration, the appropriate
choice of antibiotic agents, and shorter duration of administration have defined
more clearly the value of this technique in reducing post-operative wound
infections. It is generally recommended that a single dose of cephalosporin, e.g.
cefuroxime or cefazolin (see Table 13.3) should be administered intravenously
with the induction of anaesthesia. For caesarean sections, IV antibiotic should be
given immediately after cord is clamped. Prophylaxis should not exceed 24 h
following surgery. Use of third generation cephalosporins for surgical prophylaxis
is not recommended because they are costly and promote emergence of bacteria
resistance. Routine use of vancomycin as surgical prophylaxis should be avoided.
Repeat doses of IV cefuroxime or cefazolin should be given in the case of massive
haemorrhage ($2 litres of blood is lost in an adult) or when the duration of oper-
ation exceeds 3 h.
Before elective colorectal operations, in addition to parenteral agent, mechanically

prepare the colon by use of enemas and cathartics. Administer non-absorbable oral
antimicrobial agents in divided doses on the day before the operation. Three regi-
mens of oral agents combine neomycin with erythromycin base, metronidazole, or
tetracycline. Mechanical cleansing for pre-operative preparation before elective colon
resection should be used.
251
Operative factors
The principles of surgical asepsis, which is the prevention of access of infectious
agents to a surgical field, must be used for all operating room procedures. This is
achieved by methods that destroy microorganisms (by use of disinfectants and
sterilization procedures) or that prevent them from contaminating objects that come
into contact with the surgical field (by use of barrier protection).
Modern surgery is aseptic in the use of sterile instruments, sutures and dressings and
in the wearing of sterile gowns and gloves by the operating team. All articles used in
an operation must be ‘sterile’. All members of the operating team who are ‘sterile’
must touch only sterile articles: persons who are ‘unsterile’ must touch only unsterile
articles. All sterile packs should be opened using a technique that will prevent
contamination of sterile instruments.
The surgeon in charge of the patient, the anaesthetist and the scrub nurse should be
responsible for ensuring that all members of the operating team know the operating
room procedures and infection control precautions that are to be taken, including
any additional precautions that may be required. Staff involved in cleaning and ster-
ilizing instruments and equipment used in the operating theatre should also be
informed of the need for any additional precautions.
Surgical hand scrub

Before surgical procedures, hands, nails and forearms should be washed
thoroughly with an appropriate skin disinfectant to reduce the number of
microorganisms that could be transferred from personnel to the patient. Rings,
watches and bracelets should be removed and fingernails should be kept short and
clean. The hands and forearms should be free of open lesions and breaks in the
skin.
The application time and volume of antiseptic used for surgical scrub must be in
accordance with the efficacy of antiseptic solution used. Any agent or method of skin
decontamination that causes skin abrasions (e.g. use of a brush on skin) must be
avoided. The first wash of the day should include a thorough clean under the
fingernails; a brush or a stick can be used if necessary.
There is no universal agreement either on the type of antiseptic or the optimum

duration of surgical scrub. From evidence, it appears that the first surgical scrub
of the day should be for 3–5 min with subsequent washes for 3 min between con-
secutive operations; alternatively, apply alcohol-based products to clean hands for
3 min. A European guideline recommends that the total application for surgical
scrub time must not be shorter than 2 min and a minimum of two applications are
necessary (Labadie JC, et al. 2002). Hands should be air dried before gloves are put
on. Care should be taken to ensure there is no hand contact with any non-sterile
object.
252
Theatre wear
Outside clothing must be changed for clean, laundered operating room attire of
loosely woven material. An impermeable, cuffed-wrist, sterile gown should be worn
by scrubbed health care workers (HCWs). Operating room gowns should be made of
waterproof fabric with an ability to breathe, and should be comfortable to wear.
Alternatively, plastic aprons should be worn under gowns and should be of sufficient
length to overlap with footwear.
Procedure for surgical scrub

Rings, watches and bracelets should be removed before surgical scrub.
The first surgical scrub for the day should be for 3–5 min with subsequent
washes for 3 min between consecutive operations.
1. Turn the taps on using the elbows and adjust the flow of water and
temperature of the water.
3. Apply an antiseptic (e.g. chlorhexidine or povidone iodine)/detergent

preparation from an elbow operated pump dispenser.
4. Lather hands, wrists and forearms, keeping them above elbow level
and rinse thoroughly under running water. Clean finger nails and
remove ingrained dirt with a manicure stick held under running water.
Sterile nail brush can be used to clean nails and subungual spaces but
not the skin to prevent skin damage. This should only be done at the
beginning of the operation list.
5. Repeat the handwashing procedure. Rinse the hands, wrists and fore-
arms thoroughly under running water, making sure that fingertips
always point upwards, with elbows down, to avoid recontamination
of clean fingers and hands by water running down from contaminated
proximal areas.
6. The technique of drying is very important. Use a separate, sterile

towel for each arm, moving from fingertips to elbow using a dabbing
action.
7. Discard the towel and repeat the procedure for the other arm.
8. When hands, wrists and forearms are thoroughly dry, the individual is
ready to gown and glove.
253
Theatre gowns: The operating team should wear sterile gowns at surgery. Operating
suite/operating room clothing should not be worn outside the operating room envir-
onment. Clothing contaminated with blood or body substances should be removed
as soon as possible and bagged for laundering.
Surgical face mask: All members of staff scrubbed and assisting at the operating table
must wear fluid repellent high efficiency filter masks. Wearing of masks by other
members of staff not assisting the operation is not necessary. A fresh mask must be
worn for each operation and care must be taken when the mask is discarded.
It should be tied securely to cover the nose and mouth, and should be changed
frequently.
Eye protection: Masks and protective eye wear or face shields should be worn during
procedures which are likely to generate droplets of blood or body fluids to prevent
exposure of the mucous membranes of the mouth, nose and eyes. Eye protection and
face shields are essential to avoid blood splashes to the conjunctiva.
Gloves: Using gloves during surgery serves two purposes: it protects the surgical team
from contamination by blood and exudates from the patient and prevents transfer of
microorganisms from the surgeon’s hands to patient. Single-use sterile disposable
gloves should be used. They should not be washed or disinfected and re-used.
Hair/beard cover: All members of staff entering the theatre must wear their hair in a
neat style. Long hair should be tied in such a way that when the head is bent forward,
hair does not fall forward. Hair must be completely covered by a close fitting cap
made of synthetic material. Beards should be fully covered by a mask and a hood of
the balaclava type, which is tied securely at the neck.
Footwear: This should be enclosed and capable of protecting HCWs from acciden-
tally dropped sharps and other contaminated items. If there is constant risk of
spillage then ankle length, antistatic waterproof overboots should be worn. Open
footwear must never be worn in the operating room.
Plastic overshoes: Plastic shoe covers can be replaced by ordinary shoes dedicated
exclusively to the operating theatre as no difference exists in floor contamination
whether personnel wear shoe covers or not.
Skin disinfection
It is essential that the operating site is well disinfected before incision. This is
achieved by application of skin disinfectants, e.g. 70% ethanol or 60% isopropanol,
preferably with 0.5% chlorhexidine or 10% povidone iodine. The use of antiseptic
with alcohol increases the risk of burns to the patient during diathermy, especially if
the alcohol is not allowed to dry and drapes are soaked with alcoholic disinfectant.
Therefore, if an alcohol preparation is used the area must be allowed to dry before
operating. Alternatively, 7.5% povidone iodine or 0.5% aqueous chlorhexidine may
be used.
254
The antiseptic skin preparation should be applied with friction in concentric circles
moving away from the proposed incision site to the periphery and well beyond the
operation site to accommodate an extension to the incision or new incisions or drain
site to be made.
Draping
To restrict the transfer of microorganisms to the wound and to protect the sterility of
the instruments, equipment, supplies, and gloved hands of personnel, a sterile field
must be established by placing sterile drapes around the wound. The use of plastic
incisional adhesive drapes is controversial and is not associated with a reduction in
infection rate. Sterile drapes used in operating rooms should be impervious. Drapes
should incorporate systems for the containment of blood and irrigation fluids.
Wound drains
It is generally accepted that wound drains provide access for bacterial entry via
colonization and hands. Drains should not be used as an alternative to good
haemostasis. The closed system of wound drainage is indicated where drainage is
essential; open wound drains are not considered appropriate.
Staff movement
Excessive presence and movement of staff contributes to an increase in airborne
bacterial particles. Staff with bacterial skin infections may cause dispersal of Staph.
aureus or Streptococcus pyogenes. Therefore it is advisable to keep operating theatre
staff to the essential minimum. Additional personnel who wish to view the operation
can be accommodated in surgical viewing suites, where available. Staff with a boil or
septic lesion of the skin or eczema colonized with Staph. aureus should not be allowed
in the theatre. The door to the operating room should be closed at all the times to
avoid mixing corridor air with the operating room air, which would increase the
number of microorganisms present.
Surgical technique
The skill of the surgeon has a central role in minimizing surgical wound infection. Bad
surgical practice must not be ‘covered up’ with antibiotics. Expeditious surgery, gen-
tle handling of tissue, reduction of blood loss or haematoma formation, elimination
of dead tissue, debridement of devitalized tissue, removal of all purulent material by
irrigation or suction, and removal of all foreign materials from the wound are
essential to minimize surgical wound infections in all patients.
Duration of operation
There is a direct link between the length of the operation and the infection rate with
a clean wound, which doubles every hour. This is because bacterial contamination
increases over time and the operative tissues are damaged by drying and other
surgical manipulations, i.e. use of retractor, diathermy, etc.
255
Post-operative factors
Wound dressing
Staff should be trained in the appropriate method of dressing the wound. Frequency
of dressing should be kept to a minimum and dressings should not be opened for
48 h after the operation unless infection is suspected. The longer a wound is open,
and the longer it is drained, the greater the risk of contamination.
Clean, undrained wounds seal within 48 h and are unlikely to be infected in the ward.
Ward-acquired infection is less common than intra-operative infection and is often
superficial. On the other hand, theatre-acquired post-operative infections are usually
deep-seated and often occur within 3 days of the operation or before the first dressing.
Many infections, particularly after prosthetic surgery, may not be recognized for
weeks or months.
Post-operative stay
Avoid post-operative stay and overcrowding in the ward and discharge the patient
as soon as possible. If this is necessary for medical reasons, keep the patient in a
clean environment to protect them from colonization with bacteria from infected
patients.
Other factors
In addition, the following practices do not reduce surgical wound infection:
• Provision of a transfer area in the operating theatre where patients are

transferred from ward trolleys to clean operating room trolleys.
• Routine microbiological sampling of the operating room or environment is
not recommended as inanimate objects and surfaces are seldom the cause
of surgical wound infection. Settle plates used to evaluate air-borne con-
taminants are not useful for the same reason.
• Routine screening of theatre personnel is not necessary, unless an outbreak
clearly links personnel to infected cases. Staff who are carriers/dispersers of
Staph. aureus (including MRSA) or with septic lesions should not work in
the theatre until the condition resolves.
• Scheduling ‘dirty’ cases at the end of the day is preferable but not
necessary.
• Using tacky mats and plastic overshoe covers in operating rooms and other
patient-care areas does little to minimize the overall degree of contamin-
ation of floors, and has little impact on the incidence rate of nosocomial
infections.
256
Environmental cleaning of operating theatre

The floor of the operating theatre should be cleaned at the end of each session and
scrubbed daily. Routine use of disinfectant is not required apart from their use in
removal and disinfection of blood and other high-risk body fluids. Spillages on the
floor should be disinfected and removed as soon as possible (see page 77). Walls and
ceilings are rarely heavily contaminated and for general housekeeping purposes they
should be cleaned twice a year. Lint free cloth is recommended for all operating
theatre cleaning.

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259
14
Prevention of Infection
Associated with
Intravenous Therapy
I ndwelling intravenous (IV) lines are an integral part of patient care. They provide
a route for administering fluids, blood products, nutrients and IV medications, for
monitoring haemodynamic function, for maintaining emergency vascular access and
obtaining blood specimens. Intravascular devices are usually inserted into veins but
can, on occasion, be intra-arterial (e.g. for blood pressure monitoring). Most venous
catheters are short (less than 5 cm) and are inserted into smaller peripheral veins in
the arms. An increasing number of central venous catheters (CVCs) are now being
inserted into larger veins of the body. CVCs are usually much longer (more than
15 cm) and remain in place for longer than peripheral venous catheters. Some CVCs
may be inserted via a peripheral vein site and their tip is advanced until it is situated
within a central vein.
Many patients with intravascular lines have serious underlying diseases, making
them more susceptible to infections. Among other complications, catheter-related
sepsis is one of the most important. The risk of infection associated with these devices
can be minimized by adherence to aseptic technique during and after catheter
insertion. In addition, since the risk of infection increases with the length of time of
catheterization, intravascular catheters should be used only when absolutely
necessary and must be removed when no longer needed.
Sources of infection (Fig. 14.1)

Intrinsic: Sources of contamination may be intrinsic, where the contamination
occurs before use. This contamination is due to faulty sterilization of fluids which may
occur during manufacturing. Contamination of infusion solutions is rare in developed
countries but more often encountered in developing countries. The microorganisms
are usually Gram-negative bacteria growing in the infusate, such as Klebsiella spp.,
Enterobacter spp. or Pseudomonas spp.
261
Intrinsic contamination
of infusion fluid
Port for Connection with

additives administration set
Insertion site
Injection ports
Administration set
connection with
intravascular catheter
Figure 14.1 Points of access for microbial contamination in infusion therapy.
Extrinsic: The source of infection may be extrinsic (introduced during therapy) and
can occur due to contamination of the intravascular catheter during the insertion,
administration of the fluid or from the hands of the operator. However, the most
important reservoirs of microorganisms causing catheter-related infection are the
insertion site and the hub. The microorganisms are usually Gram-positive ones resid-
ing on the patient’s skin, e.g. coagulase-negative staphylococci, occasionally
Staphylococcus aureus, and less frequently diphtheroids. In addition, metastatic
colonization from a distant site of infection (e.g. wound, lung, kidney) may occur.
Pathogenesis of infection
An intravascular catheter is a foreign body which produces a reaction in the host
consisting of a film of fibrinous material (biofilm) on the inner and outer sur-
faces of the catheter (see Fig. 14.2). This biofilm may become colonized by micro-
organisms and will be protected from host defence mechanisms. Infection usually
follows colonization of the biofilm causing local sepsis or septic thrombophlebitis.
In some cases, the microorganisms grow in the biofilm on the catheter surfaces and
may be released into the bloodstream causing systemic infection, e.g. bacteraemia
or septicaemia.
262
Prevention of Infection Associated with Intravenous Therapy
EXTRALUMINAL SPREAD
• Patient’s own skin micro flora
• Microorganism transferred by the hands of HCW
• Contaminated entry port, catheter tip prior or
during insertion
• Contaminated disinfection solutions INTRALUMINAL SPREAD
invading wound • Contaminated infusate
(fluid, medication)
Skin attachment
Skin
Fibrin Vein
HAEMATOGENOUS SPREAD
• Infection from distant focus
Figure 14.2 Sources of microbial contamination in patients with IV catheter.

Reproduced with modification from Bennett JV, Brachman PS. Hospital Infection 3rd edn. Boston,
Little Brown, 1992.
Education and training

The intravascular catheter should be inserted by designated trained personnel with
documented competence. Adequate supervision must be provided for trainees who
perform catheter insertion. Policies and procedures regarding the insertion and
maintenance of intravascular access devices should be written and reviewed on a
regular basis. These policies must be readily accessible.
Monitoring and surveillance of catheter-related

infection
Catheter sites should be monitored visually or by palpation through on intact dressing
on a regular basis for evidence of catheter-related complications (i.e. tenderness,
thrombosis, swelling, or signs of inflammation or infection). The frequency of exam-
ination will depend on the clinical situation for the individual patient.
Semi-permeable adhesive dressings have the advantage of allowing inspection of the

site without the removal of the dressing. If the patient has tenderness at the insertion
site, fever without an obvious source, or other manifestations suggesting local or
bloodstream infection, the dressing should be removed to allow thorough examination
263
of the site. It is also important that patients should be encouraged to report any
changes in their catheter site or any new discomfort.
It is essential that the surveillance of catheter-related infection should be conducted

in high risk patients/areas, e.g. ICUs. The following strategies should be adopted to
reduce catheter-related infections.
Intravascular catheters and parenteral solutions

Before use, intravascular catheter and parenteral solution must be checked for expiry
dates and the integrity of the packaging. Parenteral fluid must be checked for macro-
scopic contamination and clarity of solution, e.g. visible turbidity, leaks, cracks,
particulate matter. Do not use any solutions if they are not clear or if the manufac-
turer’s expiry date has passed. Sterile packs and parenteral solutions must be stored in
a clean area and condition to avoid damage.
Use single-dose vials for parenteral additives or medications whenever possible. If

multidose vials are used, make sure that they are refrigerated after they have been
opened, if recommended by the manufacturer. The access diaphragm of multidose
vials should be cleaned with 70% alcohol before inserting a device into a vial. Do not
touch the diaphragm after it has been disinfected. Multidose vials should be
discarded if their sterility is compromised.
Selection of catheter type

Polyurethane and silicone catheters have a lower risk of complication than other
types. The use of an antimicrobial/antiseptic impregnated CVC should be considered
for the following adult patients who require short term (!10 days) catheterization:
• If, despite full adherence to maximum infection control precautions, there

is still a high rate ("3.3/1000 catheter days) of catheter-related sepsis.
• In patients who are expected to be at high risk, e.g. patients that are
receiving total parenteral nutrition, neutropenics and patients in ICU.
When prolonged IV access via a CVC is likely, catheters such as the Hickman type,
which have a cuff and are tunnelled subcutaneously, should be used because they are
associated with a lower rate of sepsis than standard CVCs. Totally implantable access
devices should be considered for patients who require long-term, intermittent
vascular access.
Single-lumen CVCs should be used unless multiple ports are essential for the man-
agement of the patient. If total parenteral nutrition is being administered, use one
CVC or lumen exclusively for that purpose. Select a catheter with a smaller lumen
than that of the vessel to be entered to reduce the incidence of trauma and second-
ary infection.
264
Selection of insertion site

Select the insertion site and technique with the lowest risk of complications, both
infectious and non-infectious. Do not routinely use the cutdown procedure as a
method of inserting catheters. The catheter should not be inserted into an area of
inflammation or infection. Use of steel needles for the administration of fluids and
medication should be avoided because it may cause tissue necrosis if extravasation
occurs.
Peripheral intravascular lines: In adults, use an upper extremity site in preference

to a lower extremity for catheter insertion. Replace a catheter inserted in a lower
extremity site with one in an upper extremity site as soon as it is feasible. In paedi-
atric patients, insert catheters into a scalp, hand or foot site in preference to a leg,
arm or antecubital fossa site.
Central venous catheter (CVC): Subclavian rather than jugular or femoral sites
should be selected for catheter insertion of CVCs unless medically contraindicated.
Tunnelled catheters or implantable vascular access devices (e.g. Porta-A-Cath)
should be used for patients who require long-term ("30 days) vascular access.
Once the catheter is inserted, it is essential that the device must be stabilized with
tape to reduce catheter movement. This helps to prevent potential complications
such as phlebitis, subcutaneous infiltration or sepsis. The date and time of insertion
should be documented in a standardized fashion, e.g. patient’s progress notes, care
plans, etc.
Aseptic techniques
Adherence to aseptic techniques during catheter insertion and later during catheter
manipulation is essential to reduce the risk of infection. Intravascular catheter teams
should be appointed consisting of highly trained staff to ensure stringent adherence
to aseptic techniques. Admix to all parenteral fluids should be carried out (preferably
in the pharmacy) in a laminar-flow hood using an aseptic technique.
Hand hygiene: Hands must be disinfected prior to catheter insertion using either
conventional antiseptic hand preparation or waterless alcohol-based hand disinfec-
tion. Hand hygiene must be observed before and after insertion, before and after
palpation of catheter sites, as well as before and after replacing or dressing an
intravascular catheter. Remember that the use of gloves does not obviate the need
for hand hygiene.
Cutaneous antiseptic: Skin should be disinfected using an appropriate antiseptic

before catheter insertion and at the time of dressing changes. A 2% chlorhexidine or
0.5% alcholic chlorhexidine based preparation is preferred. Alternately, tincture of
iodine, an iodophor or an alcoholic povidone-iodine solution should be used for
patients with a history of chlorhexidine sensitivity. Before inserting the catheter, the
265
Procedure for insertion of peripheral IV lines

Ensure that the patient is in a comfortable position and aware of the
nature of the procedure as this will reduce anxiety. Avoid shaving the skin
site; use hair clipper instead.
Procedure
• Collect all necessary equipment.

• Operator should use an alcohol rub or antiseptic detergent to disinfect
hands or wash hands thoroughly for 20 s, if antiseptic is not available.
• Dry hands thoroughly on a paper towel or clean linen towel, unless
alcohol is used.
• Select an appropriate site, avoiding bony prominences and joints.
• Disinfect intravascular insertion skin site with 0.5% alcoholic
chlorhexidine, or 10% alcoholic povidone-iodine, or 70% isopropyl
alcohol impregnated swab for at least 30 s prior to venepuncture.
Allow the insertion site to dry before inserting the catheter.
• The venepuncture site should not be touched once the vein has been
selected and the skin prepared. Do not touch the shaft of the catheter
with the fingers during insertion.
• Select a catheter that will fit easily into the vein. The correct sized
catheter reduces trauma and congestion of the vein.
• Insert the catheter as swiftly and as aseptically as possible using a ‘no
touch’ technique. Do not attempt repeated insertions with the same
catheter. Seek help from a senior colleage. If the first insertion is not
successful the procedure should be repeated with a new catheter.
• Look out for flashback of blood and then advance the catheter slowly.
• Apply sterile dressing (gauze or equivalent, or clear semi-permeable).
• Secure catheter to avoid movement.
• Label the site with the insertion date.
• Connect up the IV administration set.
• Clean around the site with a 70% isopropyl alcohol impregnated
swab.
• Ensure that all sharps are safely discarded into a sharps bin.
• Wash and dry hands.
266
Procedure for insertion of central venous catheter

The insertion of a CVC is an aseptic procedure. The hands must be
washed with an antiseptic detergent hand wash preparation. Sterile
gloves, gowns and mask should be worn. Use large sterile drapes to cover
the area.
• Collect all necessary equipment.

• Wash hands using an antiseptic-detergent or an alcohol hand rub.
• Disinfect intravascular skin insertion site with 0.5% alcoholic
chlorhexidine, or 10% alcoholic povidone-iodine with friction for at
least 2–3 min prior to venepuncture.
• Allow the insertion site to dry before inserting the catheter.
• Surround the site with large sterile drapes.
• Insert the CVC as swiftly as possible, maintaining a ‘no touch’ tech-
nique throughout the procedure.
• Blood should be aspirated freely to ensure that the catheter is in a vas-
cular space before injecting fluid. Position of CVP lines must be
checked by X-ray.
• Leave the site clean and dry after insertion.
• Secure the catheter with an appropriate sterile or clear semi-permeable
dressing.
• Label the site with insertion date. Record insertion date in the patient’s
medical notes.
• Connect up the IV administration set.
• Ensure that all sharps are safely discarded into a sharps bin.
• Wash and dry hands.
antiseptic preparation should be allowed to remain on the insertion site till it dries.
If povidone iodine is used then it should remain on the skin for at least 2 min or
longer if it is not yet dry before inserting the catheter. Application of organic solvent
(e.g. acetone or ether) to the skin before insertion of catheters or during dressing
change should be avoided.
Intravascular injection ports: Before accessing the system, intravascular injection ports
should be disinfected with a 70% isopropyl alcohol impregnated swab or an iodophor.
They should always be kept clean and dry. Put a cap on all stopcocks when not in use.
267
Catheter site dressing regimens

Sterile dressings should be used to cover the catheter site. Either a gauze or sterile
transparent semi-permeable dressing should be used. If the site is bleeding or
oozing, a gauze dressing is preferred. Well-healed tunnelled CVC sites may not
require dressings.
The catheter site dressing should be replaced when the dressing becomes damp,
loosened, or soiled, or when inspection of the site is necessary. Clean or sterile gloves
must be worn when changing the dressing on intravascular catheters.
The dressing should be changed on a regular basis for adult and adolescent
patients; the frequency of such changes must be determined individually depend-
ing on the circumstances. For short term CVC, the gauze dressing should be
replaced every 2 days and the transparent dressings every 7 days, except in paedi-
atric patients because in these patients, the risk of dislodging the catheter out-
weighs the benefit of changing the dressing. For tunnelled or implanted catheters,
the dressing should be replaced no more than once per week, until the insertion site
is healed. The frequency of catheter dressing change over a well-healed site is an
unresolved issue.
In-line filters
In-line filters reduce the incidence of infusion-related phlebitis but there are no
data to support their efficacy in preventing infections associated with intravascu-
lar therapy. Manufacturer’s claim the following potential benefits of in-line
filters:
• Reduce the risk of phlebitis in patients who require high doses of

medication or in patients in whom infusion-related phlebitis has already
occurred.
• Reduce the risk of infection from contaminated infusate or proximal
contamination (i.e. introduced proximal to the filter).
• Remove particulate matter that may contaminate intravascular fluids.
• Filter endotoxin produced by Gram-negative organisms in contaminated
infusate.
However, infusate-related sepsis can be minimized if most of the medications or

infusates are carried out in the pharmacy under aseptic conditions. Furthermore,
in-line filters may become blocked, especially with certain solutions (i.e. dextran,
lipids, mannitol), thereby increasing the number of line manipulations and decreas-
ing the availability of administered drugs. Thus, for the purpose of reducing
catheter-related sepsis, the use of in-line filters is not recommended.
268
Antimicrobial prophylaxis
Topical antimicrobial ointments should not be used routinely prior to insertion or as
part of routine catheter site care because of their potential to promote fungal infec-
tions and antimicrobial resistance. Routine use of intranasal antibiotic ointment,
antibiotic lock solutions or systemic antimicrobial prophylaxis before insertion or
during use of an intravascular catheter as a method to prevent catheter-related sepsis
is also not recommended.
Anticoagulant flush solutions

Anticoagulant flush solutions are widely used to prevent catheter thrombosis. Since
thrombi and fibrin-deposits on catheters may serve as a nidus for microbial
colonization of intravascular catheters, the use of anticoagulants may have a role in
the prevention of catheter-related sepsis.
Replacement of intravascular set, tubings and

parenteral fluids
Administration sets, including secondary sets and add-on devices should be
replaced no more frequently than at 96 h interval unless catheter-related sepsis
is suspected or documented or when the integrity of the product has been
compromised.
IV tubing used to administer blood, blood products, or lipid emulsions should

be replaced at the end of the infusion or within 24 h of initiating the infusion.
Lipid emulsion infusion should be completed within 24 h and blood within 4 h of
hanging.
Replacement of catheters
The peripheral venous catheters should be removed if the patient develops signs of
phlebitis (i.e. warmth, tenderness, erythema, palpable venous cord), infection, or a
malfunctioning catheter. In adults, rotate peripheral venous sites every 96 h to min-
imize the risk of phlebitis. In paediatric patients, leave peripheral venous catheters in
place until IV therapy is completed, unless a complication occurs.
Do not routinely replace CVCs or arterial catheters solely for the purpose of reducing
the incidence of infection. Replacement of CVCs is necessary if the patient is haemo-
dynamically unstable and catheter-related sepsis is suspected.
Any catheter inserted when adherence to proper asepsis is not ensured (i.e. those
inserted in an emergency) should be removed and re-sited at the earliest oppor-
tunity, preferably within 48 h. Use clinical judgement to determine when to replace
269
a catheter that could be a source of infection. Do not routinely replace catheters in

patients whose only indication is fever. Venous catheters do not necessarily need to
be replaced routinely in patients who are bacteraemic or fungaemic if the source of
infection is unlikely to be the catheter.
Guidewire exchange
Guidewire technique to replace catheters for which there is a clinical suspicion for
catheter-related infection is not recommended. If continued vascular access is
required, remove the implicated catheter, and replace it with another catheter at a
different insertion site.
If catheter-related infection is suspected, but there is no evidence of infection

at the catheter site, remove the existing catheter and insert a new catheter over
the guide wire. If catheter-related infection is confirmed, the newly inserted
catheter should be removed and, if still required, a new catheter inserted at a
different site.
Guidewire exchange can be used to replace a malfunctioning non-tunnelled catheter

if there is no evidence of infection and the risk of inserting a new catheter into a new
site is unacceptably high, e.g. due to obesity or coagulopathy. A new set of sterile
gloves should be used prior to handling the new catheter when guidewire exchanges
are performed.
Catheter-related infections
Blood cultures, preferably two sets from peripheral veins, should be taken. Swabs
should be taken from the site of catheter insertion. If microbiological investigation
proves catheter infection then the catheter should be removed and an alternative site
chosen for re-insertion. In cases of proven catheter-related sepsis, the catheter should
be removed and treated with appropriate antibiotics. The choice of antibiotic will
depend on the sensitivity of the microorganisms. If the catheter is removed, then the
distal end of the catheter should be sent in a sterile container for culture. If there is a
strong suspicion of infection, the line should be removed. Routine bacteriological
sampling of catheter tips is not necessary.
Device reprocessing
Intravascular devices are single-use only and must not be reprocessed. The narrow
hollow lumens of catheters cannot be satisfactorily cleaned. In addition, the physical
characteristics of the plastic may not withstand cleaning and sterilizing. These items,
together with solution containers, are manufactured for single use only and must not
be reused.
270

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central venous catheters. Infection Control and Hospital Epidemiology 1999; 20: 101–105.
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Cook D, Randolph A, Kemerman P, et al. Central venous catheter replacement: Strategies:

a systematic review of the literature. Critical Care Medicine 1997; 25: 1417–1424.
Crnich C, Maki DG. The promise of novel technology for the prevention of intravascular
device-related bloodstream infection. II. – Long-term devices. Clinical Infectious Diseases
2002; 34: 1362–1368.
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Clinical Microbiology and Infectious Diseases 2000; 19: 1–8.
Dobbins B, Kite P, Wilcox MH. Diagnosis of central venous catheter related sepsis – a crit-
ical look inside. Journal of Clinical Pathology 1999; 52: 165–172.
Eggimann P, Harbarth S, Constantin M-N, et al. Impact of a prevention strategy targeted

at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;
355: 1864–1868.
Elliott TSJ, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in
central venous catheterization. Journal of Hospital Infection 1994; 28(3): 163–176.
Farr B. Preventing vascular catheter-related infections: current controversies. Clinical

Infectious Diseases 2001; 33: 1733–1738.
Goldmann DA, Pier GB. Pathogenesis of infection related to intravascular catheterization.

Clinical Microbiology Reviews 1993; 6: 176–192.
Goetz AM, Wagener MM, Miller JIM, Muder RR. Risk of infection due to central venous
catheters: effect of site of placement and catheter type. Infection Control and Hospital
Epidemiology 1998; 19: 842–845.
Hospital Infection Control Practices Advisory Committee. Intravascular device-related

infections. American Journal of Infection Control 1996; 24: 262–293.
Infection Control Nurses Association. Guidelines for preventing intravascular catheter-

related infection. UK: Infection Control Nurses Association, 2001.
Mado M, Martin CR, Turner C, et al. A randomized trial comparing Arglaes (a trans-
parent containing silver ions) to Tegaderm (a transparent polyurethane dressing) for
peripheral catheters and central venous catheters. Intensive Critical Care Nursing 1998;
14: 187–191.
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venous catheter-related infection. New England Journal of Medicine 1977; 296: 1305–1309.
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Infections, 3rd edn. Boston: Little Brown; 1993: 849–898.
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with indwelling medical devises. Washington DC: American Society for Microbiology,
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272
15
Prevention of Infections
Associated with Urinary
Catheterization
I t has been estimated that about 10% of hospitalized patients require urinary
catheterization. Urinary tract infections (UTI) following catheterization or other
instrumentation are the most common hospital-acquired infections, accounting for
approximately 30–40% of all nosocomial infections. The risk of acquiring bacteriuria
increases with time, from approximately 5% per day during the first week of hospi-
talization to nearly 100% in 4 weeks. It has been estimated that 1–4% of bacteriuric
patients will ultimately develop clinically significant bacteraemia with a case fatality
of 13–30%. Therefore, it is important that urinary catheterization should be avoided,
if possible, and only be used when there is a clear medical indication. They should not
be used solely for the management of urinary incontinence. Regular review should be
carried out regarding the patient’s clinical need for continuing urinary catheteriza-
tion. The catheter should be removed as soon as possible, preferably within 5 days.
Alternatives to indwelling catheters are intermittent catheterization with an associated
infection risk ranging from 0.5–8%.
Consideration prior to catheterization

Urethral catheterization should be considered as a minor surgical procedure.
Therefore urinary catheters must be inserted using an aseptic technique and sterile
equipment. Before the procedure, efficient and effective cleaning of the area and sur-
faces involved should be undertaken. Aseptic technique should be maintained
throughout the procedure. The administration of systemic antibiotics at the time of
catheter insertion is not recommended (see page 278–279). Only a closed urinary
drainage system should be used. It has been estimated that the risk of infection can
be reduced from 97% when an open system is used to between 8–15% when a
sterile, continuously closed system is employed.
Before the procedure, check the expiry dates, the integrity of containers or packaging and
the correct amount of sterile water required to be inserted if the device has a balloon.
273
Prior to insertion, the procedure must be explained to the patients to allay any fear
and anxiety they may have.
Catheter material
Choice of catheter material will depend on clinical experience, patient preference and
the anticipated duration of catheterization. Latex catheters are the least expensive,
but irritation and allergic reaction may occur. Silicone catheters are comfortable and
may be a better choice for long-term catheterization. Silicone catheters obstruct less
often than latex, Teflon, or silicone coated latex in patients prone to encrustation.
Catheters coated with silver alloy (but not silver oxide) should be considered for
patients at high risk of developing of catheter-associated bacteriuria. However, the
particular type of catheter material does not influence the incidence of catheter-
associated infection in the short term (!4 days).
Catheter size
Catheter size/gauge relates to the circumference of the catheter. Larger diameter
catheters block the urethral gland and put pressure on the urethral mucosa, which
may result in ischaemic necrosis. They are also resistant to bending and are more
likely to cause pressure necrosis, especially in males. In general, the smallest diameter
catheter (with a 10 ml balloon) that allows free flow of urine is the most desirable.
The smallest size/gauge catheter is also less likely to be associated with leakage.
Urological patients may require larger diameter catheters and these must be used at
the advice of the urologist.
Maintenance of catheter
After insertion, regular inspection of the catheter and drainage system must be
attended to and documented at least daily; the date and time of catheter changes
should be documented either in nursing or medical notes.
Meatal care
Meatal cleansing should be performed at intervals appropriate for keeping the
meatus free of encrustations and contamination. Meatal cleansing with antiseptic
solutions is not necessary. Applying antimicrobial ointment to the urethral meatus
has not reliably been shown to reduce the incidence of UTI. Daily routine bathing or
showering is all that is needed to maintain meatal hygiene. If faecal incontinence
occurs, the perineum must be cleaned and the catheter changed without delay.
Drainage bag
Reflux of urine is associated with infection. Therefore it is important that the sterile
drainage bags should be positioned in a way that prevents back-flow of urine.
The urinary drainage bags should be put on a holder attached to the bed frame or a
274
Prevention of Infections Associated with Urinar y Catheterization
Procedure for urinary catheterization

Catheters must be inserted using an aseptic technique and sterile equip-
ment. The procedure must be explained to the patient to allay fear and
anxiety. Aseptic technique should be maintained throughout the procedure.
1. All equipment used must be sterile. Lay out the top of the trolley
making sure all items required are open and accessible.
2. Hands must be washed thoroughly with an antiseptic hand wash
preparation.
3. Sterile gloves must be worn and a ‘no-touch’ aseptic technique
should be used. A second pair of gloves should be available should
contamination occur.
4. The peri-urethral area should be thoroughly cleaned. Wiping motions
should be carried out from front to back to avoid faecal bacteria being
transported to the urinary meatus. This cleaning should be done using
sterile water and saline and then dried. In a male, grasp the distal shaft
of the penis and retract the foreskin. Cleanse the glans with a
disinfectant/detergent preparation. In a female, separate the labia and
cleanse the vulva using front to back technique. Use antiseptic solu-
tion to clean the urethral meatus prior to the insertion of the catheter.
5. Single-use sachets of sterile (water-soluble) lubricant should be used
on the catheter prior to urethral insertion to reduce friction and
trauma to meatus. Alternatively sterile anaesthetic (1–2% lignocaine)
gel can be instilled into the urethra to minimize pain. If anaesthetic
gel is used, allow 3–5 min for it to take anaesthetic effect before
catheterization.
6. Gently insert the catheter and advance it by holding the inner sterile
sleeve, avoiding contact with non-sterile surfaces. Ideally, the
‘no-touch’ technique should be used in which the operator has no
contact with the sterile shaft of the catheter.
7. Inflate the balloon by instilling the manufacturer’s recommended
amount of sterile water. If the site is to be dressed (e.g. supra pubic)
the dressings surrounding the device must be sterile.
8. Connect catheters to a sterile, closed urinary drainage system.
9. Hang drainage bag below the level of the bed to stop reflux. The bag
must be supported in the drainage stand to allow free flow of urine
and prevent the bag from touching the floor.
10. Secure the catheter to the patient’s thigh or abdomen to prevent move-
ment and urethral meatal ulceration.
11. Hands should be washed after gloves are removed.
275
Urinary bladder
Urine sampling
post
3 Connection between
drainage tube and
1 Urethral meatus- collection bag
catheter junction
2 Connection
between
catheter and
drainage tube
4 Tap outlet of
drainage bag
Figure 15.1 The four main sites through which bacteria may reach the bladder of
a patient with an indwelling urethral catheter. The recommended measures of
prevention are listed in Table 15.1.
stand to prevent contact with the floor. The bag and tubing must at all times be below
the level of the bladder so that flow can be continuously maintained by gravity. Where
dependent drainage cannot be maintained, e.g. during moving and handling, clamp
the urinary drainage bag tube and remove the clamp as soon as dependent drainage
can be resumed. Routine use of antiseptics (e.g. chlorhexidine and hydrogen perox-
ide) in the drainage bag is not recommended, as they do not reduce the incidence of
bacteriuria.
Emptying the drainage bag

The drainage bag should be emptied regularly (i.e. 8 hourly or earlier if it fills rap-
idly) via the drainage tap at the bottom of the bag to maintain urine flow and to pre-
vent reflux. The spout from the tap must be completely emptied to minimize a
build-up of organisms in the stagnant urine. Extreme care must be taken when
emptying the drainage bag to prevent cross-infection. Hands must be disinfected and
non-sterile disposable gloves must be worn before emptying each bag. Alcohol
impregnated swabs may be used to decontaminate the outlet (inside and outside)
before and after emptying the bag. When the bag is empty, the tap should be closed
securely and wiped with a tissue. If the bag does not have a tap, replace it when full
276
Table 15.1 Prevention of bacterial colonization/infection of the bladder in patients

with indwelling urethral catheters.
Entry points for bacteria Preventative measures
1. External urethral meatus and

urethra
Bacteria carried into bladder • Pass catheter when bladder full for wash-out
during insertion of catheter effect.
• Before catheterization prepare urinary meatus
with an antiseptic (e.g. povidone iodine or
0.2% chlorhexidine aqueous solution).
• Inject single-use sterile lubricant gel
(e.g. 1–2%) lignocaine into urethra
and hold there for 3 min before
inserting catheter.
• Use sterile catheter.
• Use non-touch technique for insertion.
Ascending colonization/infection • Keep peri-urethral area clean and dry.
up urethra around outside • Secure catheter to prevent movement
of catheter in urethra; bladder washes and ointments
are of no value.
• After faecal incontinence clean area
and change catheter.
2. Junction between catheter and • Do not disconnect catheter unless
drainage tube (when absolutely necessary.
disconnected) • Always use aseptic technique for irrigation.
• For urine specimen collection disinfect
outside of catheter proximal to junction
with drainage tube by applying alcoholic
impregnated wipe and allow it to dry
completely then aspirate urine with a
sterile needle and syringe.
3. Junction between drainage tube
and collection bag
Disconnection • Drainage tube should be welded to inlet of
bag during manufacture.
Reflux from bag into tube • Drip chamber or non-return valve at inlet
to bag.
• Keep bag below level of bladder. If it is
necessary to raise collection bag above
bladder level for a short period, drainage
tube must be clamped temporarily.
• Empty bag every 8 h or earlier if full.
• Do not hold bag upside down when
emptying.
4. Tap at bottom of collection bag
Emptying of bag • Collection bag must never touch floor.
• Always wash or disinfect hands (e.g. with
70% alcohol) before and after opening tap.
• Use a separate disinfected jug to collect urine
from each bag.
• Routine instillation of disinfectant into bag
after each emptying is of no value.
Modified from Brumfitt W, Hamilton-Miller JMT, Bailey RR: Urinary Tract Infections. London: Chapman &
Hall Medical, 1998.
277
using an aseptic technique. Do not reconnect a used bag. Wash and dry hands
thoroughly after touching the drainage bag.
When emptying the drainage bag, use a separate container for each patient and avoid
contact between the urinary drainage tap and the container. Each bag should be emptied
separately as required. For the purposes of measuring urinary output, an integral meas-
uring device is necessary. The urine receptacle should be heat disinfected and stored dry
after each use. Single-use disposable receptacles may be used. After emptying the recep-
tacle, gloves should be discarded and hands washed and dried thoroughly.
Bladder irrigation
Routine bladder irrigation or washout with antiseptics (e.g. chlorhexidine) or anti-
microbial agents does not prevent catheter-associated infection and should not be used.
Introduction of such agents causes erosion of the bladder mucosa and promotes the
emergence of resistant microorganisms. They may also cause damage to the catheter.
If the catheter becomes obstructed and can be kept open only by frequent irrigation,
the catheter should be changed, as it is likely that the catheter itself is contributing to
obstruction. However, continuous or intermittent bladder irrigation may be indi-
cated during urological surgery or to manage catheter obstruction and should be
undertaken on the advice of a urologist.
Specimen collection
Obtain urine samples from a sampling port. Do not disconnect the drainage bag to
obtain a sample as this causes interruption to the closed drainage system and may
pose a risk of infection to the patient. If a sample of urine is required for bacterio-
logical examination, it should be obtained from a sampling port or sleeve using an
aseptic technique. Do not obtain a sample for bacteriological culture from the
drainage bag. The sampling port must first be disinfected by wiping with a 70%
isopropyl alcohol impregnated swab. The sample may then be aspirated using a
sterile small bore needle and syringe and transferred into a sterile container. Routine
bacteriological testing is not cost-effective.
Removal of catheter
The optimal time limit for replacing catheters depends upon individual circum-
stances and the type of catheter used. However, urinary catheters should not be
changed as long as they are functioning well. A catheter that requires frequent
irrigation for recurrent obstruction should be changed and replaced.
Use of antimicrobial agents

The administration of systemic antibiotics at the time of catheter insertion may
provide early benefit to prevent catheter-associated infections but it also exposes
278
the patient to a risk of antibiotic associated toxicity and subsequent development of

infections with resistant bacterial strains. Therefore, routine administration of
prophylactic antibiotic in catheterized patients is not recommended. It may be
reserved for patients who are at a high risk of developing infection.
Long-term antibiotic prophylaxis is ineffective and predisposes to infection with

resistant microorganisms and fungi. Treatment of asymptomatic bacteriuria (i.e.
significant bacteriuria in the absence of clinical symptoms) in patients who require
continued catheterization is also not indicated. Treat patients with antibiotics only
if there is evidence of clinical infection. Treatment of catheter-associated UTI in
patients with long-term catheters may be difficult without removal or changing of
the catheter because bacteria are embedded in the biofilm (or encrustation) on the
surface of the catheter and may be protected from the action of antibiotics. In add-
ition, the use of an antibiotic in the presence of the catheter often results in infection
with a more resistant strain of bacteria. After the catheter is removed, in most
patients the bacteriuria spontaneously resolves; if treatment is indicated, it is only
for those cases in which the bacteriuria has persisted after catheter removal and in
which there are no underlying anatomical or physiological barriers to eradication of
the bacteriuria.
Routine administration of prophylactic antibiotic at the time of catheter removal is

not recommended. Culturing of urine sampled after catheter removal is indicated
only for patients where there is a high degree of suspicion or symptoms suggestive of
infection.
Policy and staff training

Catheterization is an aseptic procedure. Ensure that health care personnel are trained
and competent to carry out urethral catheterization. Policies and procedures regard-
ing the insertion, maintenance and changing regimes of indwelling urinary devices
should be written and reviewed and updated on a regular basis. These policies should
be readily accessible.
Regular education as well as orientation programmes should be implemented to

include instruction on the importance and principles of catheterization and the care
of the patient with indwelling urinary devices.
Re-use of catheters
Indwelling urinary catheters have narrow hollow lumens and cannot satisfactorily be
cleaned. Also, the physical characteristics of the latex or plastics may not withstand
cleaning and resterilizing. These items, together with drainage/collection systems, are
manufactured for single use only and must not be reused.
279

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16
Prevention of Nosocomial
Pneumonia
N osocomial pneumonia is the second most common hospital-acquired infection

and has a mortality rate of 20–50%. Ventilator-associated pneumonia refers
specifically to nosocomial bacterial pneumonia that has developed in patients
receiving mechanical ventilation. Compared to non-ventilated patients, the risk of
pneumonia is increased at least 7–10 fold in patients following surgery or in inten-
sive care who require mechanical ventilation. It has been estimated that nosocomial
pneumonia typically lengthens a patient’s hospital stay by 4–9 days and is associated
with very high morbidity and mortality.
Ventilator-associated pneumonia that occurs within 48–72 h after tracheal intub-

ations is usually termed early-onset pneumonia and often results from aspiration,
which complicates the intubation process. They are usually caused by antibiotic
sensitive bacteria, e.g. Staphylococcus aureus, Haemophilus influenzae and Streptococcus
pneumoniae. Ventilator-associated pneumonia that occurs after this period is usually
considered late-onset pneumonia and is usually caused by resistant bacteria, e.g.
methicillin resistant Staph. aureus and Gram-negative bacilli, i.e. Pseudomonas
aeruginosa, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Citrobacter
spp., Enterobacter spp. and Acinetobacter spp.
Nosocomial pneumonia can be caused by Legionella which can be acquired from

hospital air conditioning systems or from water supplies, particularly in immuno-
compromised patients. Other organisms responsible for hospital-acquired pneumo-
nia are viruses and fungi, e.g. Candida albicans, Aspergillus fumigatus (acquired from
building work) and Mycobacterium tuberculosis and other atypical mycobacteria.
Pathogenesis
The pathogenesis of ventilator-associated pneumonia usually requires two import-
ant processes to take place, i.e. bacterial colonization of the aerodigestive tract,
and aspiration of contaminated secretions into the lower airway. Therefore, the
283
Risk factors for oropharyngeal colonization

and nosocomial pneumonia
Extreme age (elderly or neonate)
Chronic disease or impaired immunity
Chronic lung disease
Existing cardiopulmonary disease
Immunosuppressive or cytotoxic drugs
Mechanical ventilation
Major injuries
Upper abdominal and thoracic surgery
Severe illness, e.g. septic shock
Aspiration
Tracheostomy, tracheal intubation
Achlorhydria, H2 antagonist or antacid therapy
General anaesthesia
Depressed consciousness, e.g. coma, cerebrovascular accidents
Sedative or hypnotic drugs
Neuromuscular disease
Heavy smokers
Nasogastric tube
Prolonged hospitalization
Obesity or malnutrition
strategies aimed at preventing ventilator-associated pneumonia usually focus on

reducing the bioburden of bacterial colonization in the aerodigestive tract, decreas-
ing the incidence of aspiration, or both.
The presence of invasive medical devices is an important contributor to the

pathogenesis and development of ventilator-associated pneumonia. This is
because the presence of invasive medical devices causes mechanical and chemical
injury to the ciliated epithelium of the respiratory tract. The injury promotes
colonization and aspiration of bacteria from the oropharynx or stomach into the
tracheobronchial tree. In addition, the presence of a foreign body, e.g. an endotracheal
tube, facilitates bacterial colonization of the tracheobronchial tree. The presence of
nasogastric tubes predisposes to gastric reflux and increases the potential for
aspiration. Therefore, it is essential that nasogastric or endotracheal tubes should
be removed as soon as clinically feasible. Unnecessary reintubation should be
avoided to prevent injury. Adequate pressure should be maintained in the
endotracheal-tube cuff.
284
Prevention of Nosocomial Pneumonia
Host Surgery Medications Invasive Respiratory

factors devices therapy
equipment
Oropharyngeal Gastric
colonization colonization
Aspiration
Number of bacteria
virulence
Lung defenses
Translocation
Bacteraemia Mechanical
?
cellular/humoral
Pneumonia
Figure 16.1 Factors influencing colonization and infection of the respiratory tract.
Reproduced with permission from Craven et al. Nosocomial pneumonia in the 90’s: update of the
epidemiology and risk factors. Semin Respir Infect 1990; 5: 157–192.
Strategy for prevention

The following measures should be adopted to prevent nosocomial pneumonia in
hospitalized patients:
Surveillance: Surveillance of nosocomial infection in the intensive care unit (ICU)

should be introduced and infection rate should be presented to intensive care physi-
cians on a regular basis.
Infection control programme: An infection control awareness programme should

be introduced to promote hand hygiene after contact with patients and wearing of
gloves for contact with the respiratory secretions, devices, or environmental surfaces
and performing tracheostomy using aseptic techniques.
Education and training: Education and training of staff in cleaning, disinfection and
maintenance of respiratory equipment is essential.
Ventilator circuits: Routine changing of ventilator circuit tubing is not recom-

mended because of rapid bacterial colonization of tubing which usually occurs
285
within 24 h of its placement. However, ventilator circuits should be changed if there

is overt soiling (e.g. with vomit or blood) or mechanical malfunction. Since a high
concentration of pathogenic bacteria is found in condensate fluid, it is important
that ventilator circuits should also be monitored regularly and any accumulated con-
densate fluid in the tubing removed.
Nasogastric tube: A nasogastric tube for enteral feeding may erode the mucosal surface
or block the sinus ducts and is responsible for causing regurgitation of gastric contents
leading to aspiration. Therefore, nutritional status must be assessed on a regular basis
and removal of a nasogastric tube should be considered if clinically indicated.
Continuous subglottic suctioning: Secretions from the respiratory tract usually

pool above inflated endotracheal tube cuffs and may act as a source of aspirated
material. Endotracheal tubes with a separate dorsal lumen above the cuff to
suction pooled secretions from the subglottic space are now available. These special-
ized endotracheal tubes should be part of an organized approach to preventing
ventilator-associated pneumonia and should not be used in place of such efforts. The
pressure of the endotracheal tube cuff should be adequate to prevent the leakage of
colonized subglottic secretions into the lower airway.
Suction catheters: There are two types of suction catheter systems available, i.e.
open (single-use) and closed (multi-use). The risk of nosocomial pneumonia
appears to be similar in both systems. The main advantages attributed to the closed,
multi-use catheters are lower costs and decreased environmental contamination.
Daily changes of in-line suction catheters are not necessary, which is another advan-
tage of using closed, multi-use catheter systems instead of open, single-use systems,
especially for patients who require prolonged ventilatory support.
Humidification with heat and moisture exchangers: Heat and moisture exchangers
are attractive alternatives to heated-water humidification systems. In theory, heat and
moisture exchangers reduce the incidence of ventilator-associated pneumonia by
minimizing the development of condensate within ventilator circuits. However, they
should be considered primarily a cost-effective method of providing humidification
to patients receiving ventilation if there are no contraindications (e.g. haemoptysis,
copious or tenacious secretions, or difficulty discontinuing mechanical ventilation
because of increasexd airway resistance).
Respiratory filter: The use of respiratory filters in the breathing system for the pre-
vention of ventilator-associated pneumonia is an unresolved issue.
Postural changes: Patients who are confined to bed have an increased frequency of
pulmonary and non-pulmonary complications. Therefore it is important that the
patient should be turned to encourage postural drainage. They should also be
encouraged to take deep breaths and cough. The patient should be maintained in an
upright position (elevate patient’s head to a 30–45° angle) to reduce reflux and aspir-
ation of gastric bacteria.
286
Table 16.1 Methods of prevention of nosocomial pneumonia.
Procedure/device Intervention to decrease risk
Suctioning • Use single-use disposable gloves and wash

hands before and after the procedure.
• Use sterile suction catheter and sterile fluid to
flush catheter.
• Change suction tubing between patients.
Suction bottle • Use single-use disposable. Non-disposable

bottles should be washed with detergent and
allow to dry. Heat disinfect in washing machine
or send to SSD.
Ventilator breathing circuits • Replace mechanical ventilators circuit every
48 h or protect with filter.
• Periodically drain breathing-tube condensation
traps, taking care not to spill it down the patient’s
trachea; wash hands after the procedure.
Oxygen mask • Change oxygen mask and tubing between
patients and more frequently if soiled.
Nebulizers • Change and reprocess device between patients
by using sterilization or a high-level disinfection
or use single-use disposable item.
• Fill with sterile water only.
Humidifiers • Clean and sterilize device between patients.

• Fill with sterile water which must be changed
every 24 h or sooner, if necessary.
• Single-use disposable humidifiers are available
but they are expensive.
Ventilators • After every patient, clean and disinfect
(high-level) or sterilize re-usable components
of the breathing system or the patient circuit
according to the manufacturer’s instructions.
Surgical patients: Pre-operatively, patients should be encouraged to stop smoking

and any existing infection should be treated. Post-operatively, coughing exercise and
breathing techniques should be taught. Early mobilization is essential and post-
operative pain should be controlled with judicious use of analgesics.
Stress-ulcer prophylaxis: Patients receiving mechanical ventilation are at high

risk for upper gastrointestinal haemorrhage from stress ulcers. Bacterial coloniza-
tion of the stomach, enhanced by the administration of pH-lowering drugs (e.g.
H2-receptor antagonists and antacids), is thought to be an important source of
pathogens that can cause pneumonia. The administration of sucralfate into the
stomach, which acts as a cytoprotective that does not block or significantly
neutralize gastric acid secretion, has been found to prevent bleeding or stress
287
In Out
Air
Patient
(Air saturated with
water vapour)
Water
Figure 16.2 In a humidifier, gas bubbles through water, enabling it to pick up vapour
but not actual droplets.
In Out
Air Patient
(Air mixed with
small droplets
of water)
Water
Figure 16.3 In a nebulizer, gas passes rapidly through a tube which is immersed in
solution creating small droplets of fluid.
Expiration
tubing
Endotracheal
tube or Inspiration
tracheostomy tubing
Medication
nebulizer Ventilator
Patient Humidifier
Figure 16.4 Patient on a continuous-volume ventilator, showing the location of

humidifier and nebulizer.
Reproduced from Castle M and Ajemian E. Hospital Infection Control: Principles and Practice. New York, John
Wiley & Sons, 1987.
288
ulcers without lowering gastric pH. Several randomized trials have found that
sucralfate is associated with lower rates of ventilator-associated pneumonia than
antacids or H2-receptor antagonists.
Selective decontamination therapy: When ventilator-associated pneumonia occurs,

treatment usually consists of supportive care and the administration of antibiotics.
Widespread use of broad spectrum antibiotics in the ICU should be avoided. In add-
ition, routine administration of oral or parenteral antibiotics as part of selective
decontamination of the oropharynx and gastrointestinal tract in critically ill patients
is controversial and should be avoided to prevent problems of widespread bacterial
resistance.

Bonten MJM, Bergmans DCJJ. Nosocomial pneumonia. In: Mayhall CG (ed), Hospital
Epidemiology and Infection Control, 2nd edn. Baltimore: Williams & Wilkins, 1999:
211–238.
Craven DE, Driks MR. Nosocomial pneumonia in the intubated patient. Seminars in
Respiratory Infections 1987; 2(1): 20–33.
Craven DE, Barber TW, Steger KA, Montecalvo MA. Nosocomial pneumonia in the 90’s:
update on epidemiology and risk factors. Seminars in Respiratory Infection 1990; 5:
152–172.
Das I, Fraise AP. How useful are microbial filters in respiratory apparatus? Journal of
Harmanci A, Harmanci Ö, Akova M. Hospital-acquired pneumonia: Challenges

and options for diagnosis and treatment. Journal of Hospital Infection 2000; 51:
160–167.
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Koerner RJ. Contribution of endotracheal tubes to the pathogenesis of ventilator-

associated pneumonia. Journal of Hospital Infection 1997; 35: 83–89.
Kollef MH. The prevention of ventilator-associated pneumonia. The New England Journal
of Medicine 1999; 340(8): 627–633.
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Clinics of North America 1997; 11(2): 427–457.
Tablan OC, Anderson LF, Arden NH, et al. Guideline for prevention of nosocomial
pneumonia. Infection Control and Hospital Epidemiology 1994; 15: 587–627.
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Ward V, Wilson J, Taylor L, Cookson B, Glynn A. Preventing Hospital acquired infection:

clinical guidelines. London: Public Health Laboratory Services. 1997: 31–35.
Webb CW. Selective bowel decontamination in intensive care – a critical appraisal.

Reviews in Medical Microbiology 1992; 3: 202–210.
Wiblin RT. Nosocomial Pneumonia In: Wenzel RP (ed), Prevention and Control of
Nosocomial Infections, 3rd edn. Baltimore: Williams & Wilkins, 1997: 807–819.
290
17
Hospital Support
Services
FOOD AND CATERING SERVICES
F ood service establishments are frequently identified as places where mishandling

of food has led to outbreaks of foodborne disease. Hospitals and other health care
facilities represent a special case of food service operation. The need for adequate
food hygiene facilities is of paramount importance, since the consequences of an
outbreak of food poisoning in a health care facility can be life threatening for
patients. Therefore, particular care must be taken to minimize the risk of infection or
intoxication through the food service system. Preparation of food requires attention
to raw materials, personal hygiene, kitchen hygiene, and especially time/temperature
control of all food-handling operations including cooking, cooling, reheating and
distribution. Assuring safe food requires management and control of microbio-
logical, chemical and physical hazards.
It is recommended that food service departments in health care establishments take

the HACCP (Hazards Analysis Critical Control Point) approach to the food safety
programme instead of the traditional approach based only on cooking procedures
(recipe-based), as the latter may not address all the steps that a food product passes
through, including receipt of goods, meal service and distribution.
The HACCP approach has been used widely in the food industry. The HACCP con-
cept evolved at the NASA (National Aeronautics and Space Agency) laboratories with
the aim of guaranteeing that the food provided for space travellers was not contam-
inated microbiologically, chemically, or physically in a way that would lead to either
a space mission failure or catastrophe. HACCP is a powerful process which focuses
control at seven points in a process which are critical to the safety of the end prod-
uct. The systematic approach of HACCP helps analyze potential hazards and identify
the points where hazards may occur. Once the changes are implemented, it must be
reviewed periodically. An integral part of a properly constructed HACCP plan is the
291
Table 17.1 The commonest causes of food poisoning.
• Preparing food too long in advance.

• Storing food at ambient temperatures.
• Cooling food too slowly before placing in refrigerator.
• Not reheating food to temperatures at which food poisoning bacteria can be
destroyed.
• Using contaminated food.
• Undercooking meat, meat products and poultry.
• Not thawing frozen poultry and meat for long enough.
• Cross-contamination between raw and cooked food.
• Keeping hot food below 63°C.
• Infected food handlers.
Reproduced with permission from Barrie D. The provision of food and catering services in hospital. Journal
existence of good manufacturing practice throughout the food service chain. This
includes factors that have become known as prerequisite or support programmes,
including supplier control, cleaning and sanitation, personal hygiene and staff train-
ing. All food must comply with relevant local food safety acts and the food hygiene
regulations of the country involved.
Staff health/hygiene
Although catering staff are mainly responsible for providing food in hospitals,
nursing and domestic staff are also involved in distributing or serving meals to
patients. Everyone who handles, prepares, processes and distributes food must
understand the principles of basic food hygiene and should be trained in personnel
and catering hygienic methods.
Cook-chill food production systems

There has been an increasing trend in health care establishments to use ‘cook-chill’
food service systems to extend the life of prepared food products. The time and tem-
perature control of product chilling and subsequent storage and handling is critical
in cook-chill systems because bacteria can grow in the extended time between food
production and consumption. The storage temperature for cook-chill systems
should be 0°C, which is lower than that required for conventional cold storage. The
storage time (shelf life) also needs to be closely monitored and may vary according
to the production method used as well as the storage temperature (storage below 0°C
controls the growth of most pathogenic bacteria).
292
Hospital Support Services
Table 17.2 General rules of food hygiene.
Delivery • Accept frozen food below !18°C

• Accept chilled food below "13°C
• Check ‘within date’ code
• Check state of packaging
Storage • Practise stock rotation
• Provide clean, dry, pest-free conditions
• Keep at correct temperatures
• Keep covered until required
• Keep raw food separately from cooked items
• Use separate utensils, surfaces
• Wash hands between different food
Thawing • Thaw below 15°C
• Thaw completely
• Cook within 24 h
Cooking • Ensure centre of food reaches 70°C for 2 min

• Cook on the day of consumption or chill rapidly and
refrigerate within 1½ h. Consume within 3 days
• Hold below 10°C or above 63°C
Reheating • Avoid, if possible

• Reheat rapidly
• Attain 70°C (use temperature probe)
Distribution • Hot food above 63°C

• Cold food below 10°C
• Check with temperature probe
Waste • Discard unwanted food after 1 h

• Always cover food waste
Cleaning maintenance • Observe schedules for all items

• Ensure good state of service and repair
Reproduced with permission from Barrie D. The provision of food and catering services in hospital. Journal
Texture modified products

Texture modified meals, which are provided to people with chewing and/or swal-
lowing problems, also have a greater risk of bacterial contamination. This includes all
food that has been pureed or minced after cooking. Where possible, food should be
pureed before cooking. Where this is not possible, for example with pureed fruit,
particular care must be taken to minimize cross-contamination. Strict time and
temperature control must also be maintained.
Food trolleys
In hospitals and large health care establishments, mechanical transport can make
it easier to distribute equipment and also reduce the movement of people, thus
293
minimizing the spread of infection. Trolleys should be of suitable height to allow

good visibility during use, be appropriate for the type of transport, and should be
enclosed or draped. They should be cleaned daily or more frequently if contamination
occurs.
Refrigerators
Refrigerators used by health care workers for storage of food items should be used
neither for storage of contaminated material, including clinical specimens, nor for
storage of medical products such as drugs, vaccines or blood, under any circum-
stances. Medications and vaccines should be stored in accordance with the manufac-
turer’s instructions. Vaccines (and other medications) requiring refrigeration should
be stored in a refrigerator dedicated to vaccine storage. Blood and other clinical speci-
mens requiring refrigeration should also have a dedicated refrigerator for storage.
Inspection
The catering manager has the responsibility for catering services. Daily inspection of
kitchens and all food-handling areas are necessary by catering managers and super-
visory staff with the aid of check-lists. Hospital administrators are responsible for
food hygiene in hospitals and should ensure that a full inspection is carried out
at least twice yearly. Full reports of these inspections should be submitted to the
hospital administrator and the hospital Infection Control Committee.
Food handlers
All food handlers should complete a pre-employment questionnaire, which should
be reviewed by a person competent to assess the implications of any positive answers
and decide if examination of faecal specimens is necessary. Pre-employment stool
testing is not generally required in the absence of a history of enteric fever. All food
handlers with infections, diarrhoea or suspected gastrointestinal infection must stop
working and report to their manager. Return to work depends on whether it is con-
sidered safe, usually by the occupational health department, but the opinion of the
microbiologist or infection control doctor may also be sought.
Hospital kitchen
The kitchen should have an agreed cleaning procedure. Methods, materials and fre-
quency should be defined. Cleaning materials should be stored in a designated area.
Good practice includes the use of separate bays for each task, colour coded cloths,
and satisfactory cleaning knives, preparation surfaces and chopping boards/blocks.
Food stores should be generally clean, uncluttered and with good access for cleaning.
Shelving should be easy to clean. Any food capable of supporting microbial growth
should be stored either below 8°C or above 63°C. Cook-chilled food should be stored
294
below 3°C. Deep frozen food should be at !18°C or below; chilled food should be
between 0°C and "3°C.
Ward kitchens
Ward kitchens or food-handling areas and the staff using them should observe the
same levels of food and personal hygiene as other food handlers. There should be
specific written cleaning and waste disposal policies. These should comply with writ-
ten codes of practice for food-handling in ward kitchens.
Ward refrigerators, dishwashers, microwave ovens and ice-making machines are used
by nursing staff, domestic staff and visitors, and are often used incorrectly. Ward
kitchen refrigerators should be used solely for patients’ food and never for medicines,
units of blood or pathology specimens. Ice-making machines should be purchased in
consultation with the infection control team (ICT) and a planned maintenance and
cleaning protocol should be drawn up.
Ice machines
Ice from contaminated ice machines has been associated with patient infection.
Microorganisms may be present in ice, ice storage chests and ice-making machines.
The two main sources of microorganisms in ice are the potable water from which it
is made and a transfer of organisms from hands.
Currently, there are no microbiological standards for ice, ice-making machines, or ice
storage equipment. However, it is important to clean ice storage chests at least
monthly, with more frequent cleanings recommended for open chests. Portable ice
chests and containers require cleaning and low-level disinfection before the addition
of ice intended for consumption. Ice-making machines may also be contaminated via
improper storage or handling of ice by patients and/or staff. Suggested steps to avoid
this means of contamination include:
• Minimizing or avoiding direct hand contact with ice intended for

consumption.
• Using a hard-surface scoop to dispense ice.
• Installing machines that dispense ice directly into portable containers at the
touch of a control.
Culturing of ice machines is not routinely recommended but may be useful as part of
an epidemiologic investigation.
If the source water for ice in a health care facility is not faecally contaminated, then
ice from clean ice machines and chests should pose no special hazard for immuno-
competent patients. Some waterborne bacteria found in ice could potentially be a
295
General steps to maintain ice machines

• Disconnect the ice machine from the power supply.
• Remove and discard the ice.
• Disassemble the removable parts of the machine that make contact with water
to make ice.
• Thoroughly clean the machine and the parts.
• Check for any needed repair.
• Ensure the presence of an air space in the tubing that leads from the water inlet
into the water distribution system of the machine.
• Inspect for rodent or insect infestations under the machine and treat if
necessary.
• Check door gaskets (open compartment models) for evidence of leakage or
dripping into the storage chest.
• Clean the ice-storage chest.
• Disinfect the machine by circulating with a diluted hypochlorite (50–100 ppm
av Cl2) solution through the ice-making and storage systems (suggested
contact time: 4 h for 50 ppm av Cl2 solution, 2 h for 100 ppm av Cl2 solution).
• Drain the chlorine solution, and flush with fresh tap water.
• Allow the ice-storage chest to dry, and return to service.
risk to immunocompromised patients if they consume ice or drink beverages with

ice. It may therefore be prudent to protect the immunosuppressed.
All ice machines must regularly be maintained. The following steps should be taken
to clean and disinfect the ice machines:
• Disconnect the machine from the power supply.

• Remove and discard the ice.
• Allow the machine to warm to room temperature.
• Clean the machine with fresh water and detergent.
• Rinse with fresh tap water.
• Wipe dry with clean materials.
• Rinse with diluted hypochlorite solution (100 ppm av Cl2).
• Air dry all surfaces before returning the machine to service.

Barrie D. The provision of food and catering services in hospital. Journal of Hospital
Infection 1996; 33: 13–33.
296
Bryan FL. Hazard Analysis Critical Control Point Evaluations. Geneva: World Health
Organisation, 1992.
Richards J, Parr E, Risborough P. Hospital food hygiene: The application of hazard

analysis critical points to conventional hospital catering. Journal of Hospital Infection
1993; 24: 273.
Mortimore S, Wallace C. HACCP – A Practical Approach, 2nd edn. Maryland: Aspen

publishers, 1998.
UK Department of Health. Health Service Catering Hygiene. London: Department of

Health and Social Security, 1986.
UK Department of Health. Chilled and Frozen. Guidelines on Cook-Chill and Cook-Freeze

Catering systems. London: HMSO, 1989.
UK Department of Health. Management of outbreaks of food borne illness. London: DoH,

1994.
UK Department of Health. Food handlers: Fitness to work. London: DoH, 1995.
UK Department of Health. NHS Management Executive. Hospital catering – delivery of a

quality service. EL (96)37, 1996.
UK Department of Health. NHS Executive. Management of food hygiene and food services
in the National Health Service, London: DoH, 1996.
297
LINEN AND LAUNDRY SERVICE

Although soiled linen may be contaminated with organisms, the risk of disease trans-
mission is negligible if it is handled, transported and laundered in a manner that
avoids dispersal. Infection in laundry workers after handling soiled linen has only
rarely been reported, and is usually ascribed to improper handling practices.
Inadvertent disposal of objects (sharps and personal property) in linen is a common

problem. Therefore all staff are urged to remove these objects which not only endan-
ger staff in the laundry from sharps injuries but can cause extensive damage to expen-
sive laundry machine.
General principles to prevent infection

Common sense, basic principles of infection control and accepted recommendations
for handling and processing procedures must be adhered to to minimize the risk of
infection. These recommendations must be adhered to regardless of the use of
in-house or off-site contractors. Management should ensure that all staff and laundry
contractors responsible for handling or laundering linen are appropriately trained.
The following principles should be followed for safe handling of laundry:
Laundry staff: All personnel involved in the collection, transport, sorting, and wash-
ing of soiled linen should be adequately trained and wear appropriate personal
protective equipment. All workers must cover all lesions on exposed skin with water-
proof plasters and wear appropriate gloves. Gloves used for the task of sorting laun-
dry should be of sufficient thickness to minimize sharps injuries. They must have
access to hand washing facilities.
Sorting: After removal, soiled linen must be handled with care at all times. It should
be placed into bags (or other appropriate containers) at the point of generation as
soon as possible. Bags must be securely tied or otherwise closed to prevent leakage.
Rinsing soiled laundry at the point of generation should not be done.
Infectious linen: Only linen visibly contaminated with blood and/or body fluids
should be viewed as potentially infectious. Within infectious linen, it is possible to
identify a ‘high risk’ group where the diseases involved are transmitted through a low
infectious dose of organisms, e.g. Escherichia coli 0157, shigellosis etc.
Infectious linen should be segregated at the point of use and care should be taken to
ensure that only this type of linen is placed in the container. Bags containing infec-
tious linen should be sealed, with an appropriate biohazard label indicating the point
of origin attached, and should be of a material which either dissolves, or has stitching
which dissolves, in the wash. A red plastic or other appropriately colour coded bag
should be used as an impervious outer container. The plastic bag should be discarded
as clinical waste immediately before the linen is placed in the wash. Alternatively a red
298
textile bag may be used. This should be removed prior to placing the inner bag into
the wash and then it should be laundered.
Laundry bags: Single bags of sufficient tensile strength are adequate for containing
laundry; leak-proof containment is needed if the laundry is wet and can soak
through a cloth bag. Bags containing soiled laundry should be clearly identified with
labels; colour-coding should meet the local policy so that HCWs may handle these
items safely, regardless of whether the laundry is transported within the facility or
destined for transport to an off-site laundry service.
Transport of soiled linens: Soiled linen in bags can be transported by cart or chute.
Loose, soiled pieces of laundry should not be tossed into chutes.
Transport and storage of cleaned linens: Clean laundry should be transported separ-
ately from contaminated laundry. Clean linen must be wrapped prior to transport to
prevent inadvertent contamination from dust and dirt during loading, delivery, and
unloading. Clean linen should be stored in a clean area of the ward or department
until it is distributed for patient use.
Laundry contract: It is important that the ICT should be involved in the contract-
setting process for laundry services. Care must be taken to ensure that any contract
change occurs only after a full appraisal of the above issues.
Laundry process
Linen and clothing used in health care facilities are disinfected during laundering
and generally rendered free of vegetative pathogens (hygienically clean), but they are
not sterile. Washing machines in health care facilities can be either washer/extractor
units or continuous batch machines. A typical washing cycle consists of three main
phases, i.e. pre-wash, main wash and rinse cycle.
The antimicrobial action of the laundering process results from a combination of

physical and chemical factors. Dilution and agitation in water removes significant
quantities of microorganisms. Soaps and detergents loosen soil and also have some
antimicrobial properties.
High-temperature wash
Hot water provides an effective means of destroying microorganisms. A temperature
of at least 71°C (160°F) for a minimum of 25 min is commonly recommended
for hot-water washing. Water of this temperature can be provided by steam jet or
separate booster heater. Chlorine bleach provides an extra margin of safety. A total
available chlorine residual of 50–150 ppm is usually achieved during the bleach cycle.
The last action in the washing process is the addition of a mild acid to neutralize any
alkalinity in the water supply, soap, or detergent. The rapid shift in pH from approxi-
mately 12 to 5 may also inactivate some microorganisms.
299
Chlorine bleach is a cheap broad-spectrum chemical disinfectant that enhances

the effectiveness of the laundering process. However, chlorine bleach is not an appro-
priate laundry additive for all fabrics. Bleach was not recommended in the past for
laundering fire-retardant fabrics, linen and clothing because its use diminished the
flame-retardant properties of the treated fabric. Some modern flame-retardant
fabrics can now tolerate chlorine bleach and chlorine alternatives such as activated
oxygen-based laundry detergents.
Low-temperature wash
Although hot-water washing is an effective laundry disinfection method, the cost can
be significant. Laundries are typically the largest users of hot water in hospitals,
consuming between 50–75% of the total hot water. Several studies have shown that
lower water temperatures can satisfactorily reduce microbial contamination when
the cycling of the washer, the wash-detergent, and the amount of bleach are carefully
monitored and controlled.
Low-temperature laundry cycles rely heavily on the presence of chlorine or oxygen-

activated bleach to reduce the levels of microbial contamination. Regardless of
whether hot or cold water is used for washing, the temperatures reached in drying
and especially during ironing provide additional significant microbiocidal action.
Dry cleaning
The dry cleaning process involves organic solvents such as perchloroethylene for soil
removal and use for linen that might be damaged in conventional water and deter-
gent washing. A number of studies have shown that dry cleaning alone is relatively
ineffective in reducing the numbers of microorganisms on contaminated linen.
Although a number of microorganisms are significantly reduced when dry cleaned
articles are heat pressed, dry cleaning should not be used routinely. It should be
reserved only for fabrics which cannot be safely cleaned with water and detergent.
Microbiological sampling
In the absence of agreed standards, routine microbiological sampling of cleaned
linen is not recommended. Sampling may be used as part of an outbreak investiga-
tion if epidemiological evidence suggests linen or clothing as a vehicle for disease
transmission.
Hygienically clean linen is suitable for neonatal intensive care units. The use of ster-
ile linen in burns units remains unresolved.
Staff uniforms
Uniforms without blood or body substance contamination presumably do not dif-
fer appreciably from street clothes in the degree and microbial nature of soilage.
300
Home laundering would be expected to remove this level of soil adequately. However,
if health care facilities require the use of uniforms, it would seem reasonable that they
provide workers with clean uniforms.
Mattresses and pillows

Standard mattresses and pillows can become contaminated with body substances
during patient care. Mattress covers should be replaced when torn. The practice of
sticking needles into the mattress should be avoided. Visibly stained mattresses should
be replaced.
Wet mattresses, in particular, can be a significant environmental source of micro-

organisms. Infection and colonizations due to Acinetobacter spp., methicillin-resistant
Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa have been described,
especially among burn patients.
Air-fluidized beds
Air-fluidized beds are used for the care of patients immobilized for extended periods
of time, e.g. decubitus ulcers, burns. These specialized beds consist of a base unit
filled with microsphere beads fluidized by warm, dry air flowing upward from a
diffuser located at the bottom of the unit. A porous, polyester filter sheet separates the
patient from direct contact with the beads but allows body fluids to pass through to
the beads. Moist beads aggregate into clumps which settle to the bottom where
they are removed as part of routine bed maintenance. Because the beads become
contaminated with the patient’s body substances, concerns have been raised about the
potential for these beds to serve as an environmental source of pathogens. Pathogens
such as Enterococcus spp., Serratia marcescens, Staph. aureus, and Streptococcus faecalis
have been recovered either from the microsphere beads or the polyester sheet after
cleaning.
Reports of cross-contamination of patients, however, are few. Nevertheless, rou-

tine maintenance and between-patient decontamination procedures are import-
ant to minimize potential risks to patients. Regular removal of bead clumps,
coupled with the warm, dry air of the bed can help minimize bacterial growth in
the unit. Beads are decontaminated between patients by high heat (range 45–90°C
[113–194°F]), depending on the manufacturer’s specifications for at least 1 h; this
is especially important for the inactivation of Enterococcus spp. which are rela-
tively resistant to heat. It is essential that the bed is thoroughly cleaned and disin-
fected, especially between patients. The polyester filter sheet requires regular
changing.
301

Barrie D. How hospital linen and laundry services are provided. Journal of Hospital
Infection 1994; 27: 219–239.
Department of Health NHS Executive. Hospital laundry arrangements for used and
infected linen. Heywood: Health Publications Unit, 1995.
McDonald LL, Pulgiese G. Textile processing service. In: Mayhall CG (ed). Hospital
epidemiology and infection, 2nd edn. Baltimore, MD: Williams and Wilkins, 1999: 1031–1034.
NHS Executive. HSG (95)18. Hospital laundry arrangements for used and infected linen.
London: 1995.
Standeert SM, Hutcheson RH, Schaffner W. Nosocomial transmission of salmonella to

laundry workers in a nursing home. Infection Control and Hospital Epidemiology 1994;
15: 22.
302
MANAGEMENT OF CLINICAL WASTE

The most practical approach to clinical waste management is to identify wastes that
represent a sufficient potential risk of causing infection during handling and disposal
and for which some precautions appear prudent. It is essential that all health care
facilities should have clearly defined guidelines to ensure the safe identification, pack-
aging, labelling, storage, transport, treatment and disposal of waste, from the point
of generation to the point of final disposal. Management of clinical and related
wastes must conform to the appropriate national and international guidelines.
It is essential that all employees who are required to handle and move clinical waste
should be adequately trained in safe procedures. They must be provided with appro-
priate protective equipment e.g. water-repellent clothing, heavy-duty gloves and pro-
tective footwear. Spillages and other incidents must be dealt with according to
written protocols. All accidents and incidents involving clinical waste, particularly
those resulting in injury to or contamination of handlers, must be dealt with accord-
ing to local policy.
Definition and categorization of clinical waste

The definition and categorization of clinical or medical waste varies from country to
country. Terms such as ‘hospital waste’, ‘clinical waste’, ‘infectious waste’, ‘medical
waste’, ‘biomedical waste’ and ‘biohazard waste’, have been used synonymously and
often inappropriately in many situations.
Clinical waste: Clinical waste has been defined as all types of waste (clinical, related
and general) arising from medical, nursing, dental, veterinary, pharmaceutical or
similar practices and waste produced in hospitals or other facilities during the inves-
tigation or treatment of patients and in research projects.
Non-clinical: Non-clinical or household waste is defined as other waste not in the

categories of either clinical waste or special waste. It is non-toxic, non-infectious or
its basic nature is unlikely to prove a health hazard or give offence in its existing form.
Special waste: Special waste is defined as waste that is dangerous to life and difficult
to dispose of by its nature. Some clinical waste is also classified as ‘special waste’, and
is subject to control under the special waste regulations. This waste includes waste
originating from patients with Hazard Group 4 biological agents (e.g. viral haemor-
rhagic fevers), which has not been autoclaved.
303
Categorization of clinical waste

Group A: Includes the following items: identifiable human tissue,* blood, animal
carcasses and tissue from veterinary centres, hospitals or laboratories. Soiled
surgical dressings, swabs and other similar soiled waste. Other waste materials,
for example from infectious disease cases, excluding any in Groups B–E.
Group B: Discarded syringe needles, cartridges, broken glass and any other
contaminated sharp instruments or items.
Group C: Microbiological cultures and potentially infected waste from pathol-
ogy departments and other clinical or research laboratories.
Group D: Drugs or other pharmaceutical products.
Group E: Items used to dispose of urine, faeces and other bodily secretions or
excretions that do not fall within Group A. This includes used disposable bed
pans or bed pan liners, incontinence pads, stoma bags and urine containers.**
*All identifiable human tissue, whether infected or not, may only be disposed of by
incineration.
**Where the risk assessment shows there is no infection risk, Group E wastes are not
clinical waste as defined.
Adapted from UK Health and Safety Commission. Safe disposal of clinical waste.
Norwich: HMSO, 1999.
Methods for safe handling of clinical waste

Clinical waste should be disposed of in a plastic bag (yellow with a black biohazard
symbol). The thickness should meet the appropriate local standard. It is recom-
mended that the clinical waste bag should be a minimum gauge of 225 (55 #) if high
density, or a minimum gauge of 100(25 #) if low density. Plastic bags should be
secured in a foot-operated lidded bin or carrier frame.
• Clinical waste should be placed into the plastic waste bag at the point of
generation.
• Bags should be replaced daily or when three-quarters full. Bags should be
securely closed by tying or sealed by plastic closures or heat sealers,
purpose-made for clinical waste bags. Staples must not be used as they
do not provide secure closure. They may puncture the bag and/or cause a
sharps injury to the handler.
• Bags should be suitably identified with the name of the health care facility
and the department concerned, which clearly identifies their point of ori-
gin. Closing the bag with pre-printed coded clips should be considered.
• Bags should be handled by the neck only and kept upright. To avoid
injuries, the hand should not be put underneath the waste bag while lifting.
304
• Waste should be stored in a neat fashion within a designated collection area

of each ward or department, which should be secured against unauthorized
access and must be removed from clinical areas daily or more frequently if
necessary. The area should be cleaned when necessary and kept dry.
• Bulk waste transport vehicles are the responsibility of the transport man-
ager. Loaded vehicles leaving the health care facility or hospital site must be
properly secured. Spillage should be dealt with safely. Vehicles should have
a regular cleaning and disinfection schedule.
• Central collection or storage points should be secured from unauthorized
access, the elements, pests or rodents.
• All employees who are required to handle and move clinical waste should be
adequately trained in safe procedures and in dealing with spillages or other
incidents in their area of work. A record of training should be kept.
• Staff who regularly have to handle, transfer, transport or incinerate clinical
waste containers must be provided with appropriate protective equipment,
i.e. heavy-duty gloves, appropriate footwear, and industrial apron or leg
shields, waterproof clothing, face visors or respiratory equipment as
required.
• Spillages of waste should be treated according to the local policy.
• All accidents and incidents involving clinical waste, particularly those
resulting in injury to or contamination of handlers, must be reported with-
out delay to the line manager.
Methods for safe use, handling and disposal of sharps

The safe handling and disposal of needles and other sharp instruments form part of
an overall strategy of clinical waste disposal to protect staff, patients and visitors from
exposure to blood-borne pathogens.
Sharps are any medical items or devices, which are contaminated with blood, tissues
and high risk body fluids that can cause laceration or puncture wounds. Examples
include discarded hypodermic needles, instruments used in invasive procedures (e.g.
blood sampling, surgery and dentistry, acupuncture, ear-piercing and tattooing).
In clinical settings, sharps injuries are predominantly caused by needle devices and
associated with venepuncture, administration of medication via intravascular lines
and recapping of needles.
Contaminated sharps represent the major cause of accidents involving potential
exposure to blood-borne diseases, and must be handled with care at all times. Health
care facilities should provide documented operating procedures for safe handling of
sharps, and ensure that health care workers are fully trained in the recommended
handling techniques.
305
General principles for handling and use of sharps are:
• Avoid sharps usage wherever possible.

• Handling should be kept to a minimum. Needles should not be bent or
broken by hand, removed from disposable syringes or otherwise manipu-
lated by hand. Sharps must not be passed directly from hand-to-hand.
• Never leave sharps lying around; dispose of them carefully.
• Do not keep syringes, needles or any other sharps object in pockets. Many
needlestick injuries happen during re-sheathing, therefore used needles
must not be re-sheathed unless there is a safe means available for doing so.
Syringes/cartridges and needles should be disposed of intact. However in
certain situations, where re-sheathing of needles is necessary, it is essential
that a safe method is used i.e. one-handed scoop technique (see Fig. 17.1).
A mechanical device for holding or disposing of needles should be con-
sidered. Alternatively, the needle can be destroyed at the point of use using
a mechanical device.
• Do not use needles or any sharps if there is any suspicion of a broken seal
or other indication that it may have been used previously.
Sharps disposal: It is the personal responsibility of the individual using a sharp to dis-
pose of safely as soon as possible after use. Where the specific clinical procedure pre-
vents the user from doing this, the user still retains overall responsibility for ensuring
the safe disposal of used sharps.
If a sharp has been accidentally dropped, it must be recovered and disposed of prop-
erly. If the search is unsuccessful, the individual should ensure that other people using
the area are informed so that they can take care. It is particularly important to notify
cleaning staff of the possible danger. The person in charge of the area should be
notified and a record kept until the sharp has been found and properly disposed of.
Figure 17.1 Never recap needle by hand. However, recapping of needle is

required in certain situations. To recap needle safely, place the needle horizontally,
on a flat surface. Using one hand, insert the needle into the cap, as shown. Then,
use your other hand to pick up the cap and tighten it to the needle hub.
306
Where possible, needles and syringes should be discarded as a single unit into a des-
ignated sharp box. Glass slides, glass drug ampoules, razors, disposable scissors and
IV cannulae must be discarded into a sharps box.
When syringes containing arterial blood are to be sent to the laboratory, needles
should be removed and the nozzles of the syringes sealed by means of a luer rubber
cap or a blunt hub on the syringe nozzle.
Used needles and syringes must not be disposed of in domestic waste. Health care
staffs who treat patients at home should place any sharps and syringes that they gen-
erate in appropriate containers for disposal through their employer’s clinical waste
disposal system or via collection as appropriate.
When an injury occurs with a contaminated sharp, bleeding should be encouraged

and the site should be washed under running water. The injury must be reported to
the line manager without delay and should be dealt with according to the written
protocols.
Use of sharps boxes: All sharps boxes must be correctly assembled and used accord-
ing to the manufacturer’s instructions. They must be puncture resistant and should
comply with appropriate standards (e.g. British Standard BS 3720, UN 3291). They
should be kept in a location that excludes injury to patients, visitors and staff. To avoid
damage by heat, sharps boxes should not be placed near radiators or in direct sunlight.
They should be readily available wherever blood samples are taken. The person in
charge of the ward or department is responsible for ensuring safe handling and dis-
posal of sharps within their own area.
Sharps containers should be closed securely when three-quarters full and placed at a
designated secure collection point. The sharps container must never be overfilled
since used sharps protruding from overloaded containers constitute a very signifi-
cant hazard to those who have to handle them. The lid of the sharps box must not be
used as a means of ensuring that the needle and syringe ‘fit’ inside the box.
Used sharps boxes must be suitably marked for identification from wards or depart-
ments of the hospital or the health care facility. This enables the exact location and
responsibility for any offending container to be determined.
Do not use sharps boxes for any other purpose e.g. storage of ward items, etc.
In the ward, sharps boxes must be securely stored whilst awaiting collection. The staff
responsible for the transport of the boxes must take special care and should wear
heavy-duty gloves when collecting sharps containers.
Particular attention should be paid for the needs for the provision of sufficient
sharps boxes in a number of areas where use of sharps is high e.g. operating theatres,
accident and emergency and out-patients departments.
307
Management and disposal of clinical waste

Of all the categories comprising clinical medical waste, microbiological waste and
sharps pose the greatest risk for injuries and infections. On-site incineration should
be considered for microbiological, pathological and anatomical waste, provided the
incinerator is engineered to completely burn these wastes and stay within local emis-
sions standards. Improper incineration of waste with high moisture and low energy
content (e.g. pathology waste), can lead to emission problems. Contaminated sharps
and related waste should be disposed of by incineration.
Some clinical waste may be considered for disinfection and subsequent transfer to
landfill. Waste known or likely to contain Hazard Group 3 and 4 pathogens (see table
17.3) should be made safe either by autoclaving within the laboratory or in the case
of an autoclave malfunction, should be packaged in accordance with the approved
requirements for carriage, and transferred to an incinerator as soon as possible.
Laboratory waste should not be allowed to accumulate for more than 24 h.
The contents of disposable items in group E wastes, such as excreta, may be dis-
charged to the sewer via the sluice, WC or purpose-built disposal unit. These items
do not normally fall within the definition of infectious waste for transport purposes
and therefore do not have to be packaged in UN type approved containers.
Household waste is disposed of by landfill and may be compacted. Clinical waste

must not be compacted prior to disposal. Pathological waste (e.g. human tissue,
limbs, placentae) must be disposed of by incineration.
Treatment methods
Clinical waste is treated or decontaminated to reduce the microbial load and to
render the by-products safe for further handling and disposal by landfill. Historically,
treatment methods involved steam-sterilization (autoclaving), incineration, or
interment (for anatomical wastes). Alternative treatment methods developed in recent
years include, (but are not limited to) chemical disinfection, grinding/shredding/
disinfection methods, energy-based technologies (e.g. microwave or radiowave
treatments) and disinfection/encapsulation methods.
308
Table 17.3 Categorization of biological agents according to hazard and categorizes of containment.*
Group 1 Group 2 Group 3 Group 4
European One that is unlikely One that can cause human One that can cause severe One that causes severe human
Community to cause human disease and might be a human disease and presents disease and is a serious hazard
(EC) disease. hazard to workers; it is a serious hazard to workers; to workers; it may present a high
unlikely to spread in the it may present a risk of risk of spreading to the community;
community; effective spreading to the community no effective prophylaxis or
prophylaxis or treatment but effective prophylaxis or treatment is usually available.
usually available. treatment is usually available.
UK A biological agent A biological agent that can A biological agent that can A biological agent that causes
(Advisory unlikely to cause cause human disease and cause severe human disease severe human disease and is a
Committee on human disease. may be a hazard to employees; and presents a serious hazard to serious hazard to employees; it is
Dangerous it is unlikely to spread to the employees; it may present a risk likely to spread to the community
Pathogens community and there is to the community, but there and there is usually no effective
[ACDP]) usually effective prophylaxis is usually effective prophylaxis prophylaxis or treatment available.
or effective treatment available. or treatment available.
USA** Agents that offer no Agents of ordinary potential Agents that offer special Agents that are extremely hazardous
or minimal hazard hazard, including those that may hazards to laboratory to laboratory workers or cause more
under ordinary produce disease of varying workers. serious epidemic disease.
conditions of degrees of severity as a result
handling. of accidental laboratory infections.
World Health An organism unlikely Moderate individual risk, High individual risk, low High individual and community
Organisation to cause human low community risk: a community risk: a pathogen risk: a pathogen that usually causes
(WHO) disease. pathogen that can cause that usually causes serious human or animal disease
human or animal disease serious human or animal and which may be readily transmitted
but is unlikely to be a serious disease but does not from one individual to another,
hazard to laboratory workers, ordinarily spread from directly or indirectly. Effective
the community, livestock or one infected individual to treatment and preventive measures
the environment. Laboratory another. Effective treatment are not usually available.
exposures may cause serious and preventive measures
infection, but effective treatment are available.
and preventive measures are
available and the risk of spread
of infection is limited.
*All the systems differ in their wording but agree in general principles.
**The USA uses ‘Classes’ while others use ‘Groups’. USA subsumed its classes into biosafety levels.
309
Reference and further reading

Association of Operating Room Nurses. Regulated medical waste definition and treat-
ment: a collaborative document. AORN Journal 1993; 58: 110–114.
Ayliffe GAJ. Clinical waste: how dangerous is it? Current Opinion in Infectious Diseases
1994; 7: 499–502.
British Medical Association. The Safe Use and Disposal of Sharps. London: BMA, 1993.
Blenkharn JI. The disposal of clinical wastes. Journal of Hospital Infection 1995; 30
(Suppl.): 514–520.
Collins CH, Kennedy DA. The Treatment and Disposal of Clinical Waste. Leeds: H and H
Scientific Consultants Ltd, 1993.

Collins AH and Kennedy DA. Laboratory–acquired infections: History, incidence, causes

and prevention. 4th edn. Oxford; Butterworth Heinemann, 1999.
Daschner F. The hospital and pollution: role of the hospital epidemiologist in protecting
the environment. In: Wenzel RP (ed). Prevention and Control of Nosocomial Infections,
3rd edn. Baltimore: Williams & Wilkins; 1997, 595–605.
Daschner F. Unnecessary and ecological cost of hospital infection. Journal of Hospital

Infection 1991; 18 (Suppl. A): 73–78.
Department of the Environment, Scottish and Welsh Office. Waste management: The
duty of care, a code of practice. London: HMSO, 1992.
Gwyther J. Sharps disposal containers and their use. Journal of Hospital Infection 1990; 15:
287–294.
Gordon JG and Denys GA. Infectious Waste: efficient and effective management. In:
Block SS (ed). Disinfection, Sterilization and Preservation. 5th edn. Baltimore: Lippincott
Williams & Wilkins; 2001, 1139–1157.
Gordon JD, Reinhardr PA, Denys GA, Alvarado CJ. Medical waste management. In:
Mayhall CG (ed). Hospital Epidemiology and Infection Control, 2nd edn. Philadelphia:
Lippincott Williams & Wilkins; 1999, 1387–1397.
London Waste Regulation Authority (LWRA). Guidelines for the segregation, handling,
transport and disposal of clinical waste. 2nd edn. London: LWRA, 1994.
NHS Executive. Health Guidance Note. Safe disposal of clinical waste whole hospital pol-
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41: 1–6.
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Pruess A, Townend WK. Teacher’s Guide: Management of Wastes from Health-care

Activities. Geneva, World Health Organization, 1998. WHO/EOS/98.6.
Rutala WA, Mayhall CG. SHEA position paper: Medical Waste. Infection Control and
Taylor LJ. Segregation, collection and disposal of hospital laundry and waste. Journal of
Hospital Infection 1998; 11 (Suppl. A): 57–83.
UK Department of the Environment. Waste management: The duty of care, a code of prac-
tice. London: HMSO, 1992.
UK Department of Health. Expert Advisory group on AIDS and the Advisory group on
Hepatitis. Guidance for clinical health care workers: Protection against infection with blood
borne viruses. London: DoH, 1998.
UK Health and Safety Commission. Safe disposal of clinical waste. Norwich: HMSO, 1999.
UK Advisory Committee on Dangerous Pathogens (ACDP). Categorisation of biological

agents according to hazard and categorises of containment. 4th edn. Sudbury: HSE, 1995.
311
PEST CONTROL
Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges and mice
are among the typical arthropod and vertebrate pest populations found in health
care facilities. Insects can serve as agents for the mechanical transmission of micro-
organisms, or as active participants in the disease transmission process by serving as
vectors. Arthropods recovered from health care facilities have been shown to carry a
wide variety of pathogenic microorganisms.
Apart from the possibility of disease transmission, food may be tainted and spoiled, fab-
ric and building structure damaged. Pharaoh’s ants have been responsible for the pene-
tration of sterile packs and the invasion of patient’s dressings, including those in use on
a wound. Cockroaches can carry Gram-negative bacilli and spoil food. Cockroaches, in
particular, have been known to feed on fixed sputum smears in laboratories. Insects
need to be kept out of all areas of the health care facility, but this is especially important
for the operating rooms and any area where immunosuppressed patients are located.
Hospital kitchens, boiler rooms, ducts and drains provide warmth, water, food and
shelters for cockroaches, pharaoh’s ants and other pest. In addition, insects also feed
on food scraps from kitchens/cafeterias, foods in vending machines, discharges on
dressings either in use or discarded, medical wastes, human wastes, and routine solid
waste. Both cockroaches and ants are frequently found in the laundry, central sterile
supply departments, or anywhere in the facility where water or moisture is present
(e.g. sink traps, drains, cleaning staff closets).
Every effort must be made to achieve a reasonable level of control or the eradication
of pests. Hospital management is responsible for ensuring that the premises are free
from pests. Each health care facility should have a pest control programme. This may
be contracted to an approved pest control contractor.
From a public health and hygiene perspective, it is reasonable to control and eradicate
arthropod and vertebrate pests from all indoor environments, including health care
facilities. Modern approaches to institutional pest management usually focus on:
1. Eliminating food sources, indoor habitats, and other conditions that attract
pests.
2. Excluding pests from the indoor environments.
3. Applying pesticides as needed.
Sealing windows in modern health care facilities helps to minimize insect intrusion. It
is essential that older buildings should be of sound structure and well maintained.
Cracks in plaster and woodwork, unsealed areas around pipe work, damaged tiles, badly
fitted equipment and kitchen units are all likely to provide excellent points of entry or
refuge for pests. The drains should be covered, and any leaking pipe work repaired.
312
Close-fitted windows and doors, fly screens and bird netting will help to exclude
pests from hospitals and other health care facilities. When windows need to be
opened for ventilation, ensuring that screens are in good repair and closing doors to
the outside can help with pest control.
Pests require food, warmth, moisture, refuge, and a means of entry; hospital staff
should be encouraged to keep food covered, to remove spillage and waste, and to
avoid accumulations of static water.

Barker LF. Pests in hospitals. Journal of Hospital Infection 1981; 2: 5–9.
UK Department of Health. Pest Control Management for the Health Services. UK

Department of Health; London: HMSO, 1992. [HSG(92)35].
313
18
Infection Control
Informat ion Resources
INTERNET RESOURCES
Journals Websites
American Journal of Infection http://www.mosby.com/ajic

Control
Canada Communicable Disease http://www.hc-sc.gc.ca/main/lcdc/web/
Report
Communicable Disease Review http://www.phls.co.uk/publications/CDR
(CDR)
Emerging Infectious Diseases http://www.cdc.gov/ncidod/EID/index.htm
Eurosurveillance http://www.eurosurv.org
Infection Control and Hospital http://www.slackinc.com/general/iche
Epidemiology
Journal of Hospital Infection http://www.elsevierhealth.com/journals/jhin
Morbidity and Mortality Weekly http://www.cdc.gov/mmwr/
Report (MMWR)
WHO weekly Epidemiology Record http://www.who.int/wer/
Organizations and regulatory bodies Websites
Association for Professionals in Infection http://www.apic.org

Control and Epidemiology (APIC), USA
Association of Preoperative Nurse www.aorn.org
(AORN), USA
Center for Disease Control and Prevention http://www.cdc.gov
(CDC), USA
Communicable Disease Surveillance and http://www.who.int/emc
Response (WHO)
Community and Hospital Infection Control http://www.chica.org
Association (CHICA), Canada
315
Organizations and regulatory bodies Websites
European Operating Room Nurses www.eorna.org

Association (EORNA)
Department of Health, England, UK http://www.doh.gov.uk/dhhome.htm
Food and Drug Administration (FDA), http://www.fda.gov
USA
Health Canada Disease Prevention and www.hc-sc.gc.ca/
Control Guidelines
Hospital Infection Society, UK http://www.his.org.uk
Hospital in Europe Link for Infection http://helics.univ-lyon1.fr
Control through Surveillance (HELICS)
Infection Control Nurses Association http://www.icna.co.uk
(ICNA), UK
Infectious Diseases Societies Worldwide http://www.idlinks.com/
Infectious Diseases Society of America http://www.idsociety.org/index.htm
International Federation Infection of http://www.ific.narod.ru
Infection Control (IFIC)
International Health Care Worker Safety www.med.virginia.edu/~epinet/
Centre, USA
International Society of Infectious www.isid.org
Diseases
John Hopkins University-Infectious http://www.hopkins-id.edu/
Diseases, USA index_id_linls.html
Medical Devices Agency (MDA), UK http://www.medical-devices.gov.uk
National Disease Surveillance Centre, http://www.ndsc.ie
Republic of Ireland
National Foundation for Infectious www.nfid.org/
Diseases, (USA)
National Institute for Public Health http://www.rnsp-sante.fr/
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Public Health Laboratory Services http://www.phls.co.uk
(PHLS), UK
Robert Koch-Institut, Germany http://www.rki.de/index.htm
Scottish Centre for Infection and http://www.show.scot.nhs.uk/scieh/
Environmental Health (SCEIH)
Société Francaise d’Hygiène Hospitalière, http://sfhh.univ-lyon1.fr/
France (SFHH)
Society for Healthcare Epidemiology of http://www.shea-online.org
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World Health Organization (WHO) http://www.who.int/
316
Infection Control Information Resources
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COMPUTER SOFTWARE
CD-ROM
• Bloodborne Viruses and Infection Control: a Guide to Health Care
Professionals. London: BMA Board of Science & Education, 1998.
• Hospital Infection Control: Principles and Practice. EA Partnership and the
Infection Control Nurses Association, 2000.
• Infection Control Training and Policies for Hospital. Howard JP, Casewell M,
Desi N. London: WB Saunders Company, 1998.
Epi Info
Epi Info is a software programme developed by the Centers for Disease Control
and Prevention to manage and analyse data collected during an epidemiologic inves-
tigation. Epi Info also calculates statistical test use in an outbreak situation. The Epi
Info can be downloaded from the CDC web site, www.cdc.gov free of charge.
EPINet
The Exposure Prevention Information Network (EPINet) system collect data about
precutaneous injuries among health care workers. Run by the International Health
Care Workers Safety Centre at the University of Virginia Health Sciences Centre,
EPINet also standardizes reporting of information pertaining to such injuries as well
as contact with patient’s blood and body fluids. Hospitals can use the EPINet system
to share and compare information and to identify successful injury-prevention
measures. EPINet can be reached at its web site www.med.virginia.edu/~epinet/
WHOCARE
WHOCARE was developed by the WHO. It comes in two versions: the Basic version,
published 1989 which was designed for surveillance of surgical sites infections, and
comprehensive version which treats other kind of nosocomial infection. It is avail-
able from the WHOCARE distribution centre in Copenhagen, Denmark (Fax: 45 32
68 38 77).
epinet InCONTROL
The package is designed by Public Health Laboratory Services in Wales to assist infec-
tion control nurses in the routine management and surveillance of hospital acquired
infections. It helps monitor alert organisms and conditions within their hospital. It
is available free to Infection Control Practitioners working in the UK National Health
Service. Web site address: www.hospitalacquiredinfection.net The programme can be
downloaded from www.phls.wales.nhs
321
Index
A quaternary ammonia compounds, 62,

64
Absolute risk, 43 triclosan, 62, 65
Acid alcohol-fast bacillus (AAFB), 112 Aprons and gowns, 100, 141–142
Acinetobacter spp., 283 Arm splint, 81
Acquired immunodeficiency syndrome Ascariasis, 104
(AIDS), 104 Aspergillosis, 24, 104
See also HIV infection Attack rate, 43
Actinomycosis, 104 Auroscope tips, 81
Air borne precautions, 96–97 Auto-infection, 2
Air borne transmission, 5 Autoclave, 56–57
Air conditioning, 23
Air fluidized beds, 301 B
Airways and endotracheal tube, 81
Alcohol, 59, 62, 63 Baby feeding bottles and teats, 81
Alcohololic hand rub, 99 Bacillus cereus, 156
Aldehydes Barrier precautions, 7, 8
formaldehyde, 66 Bath water, 81
glutaraldehyde, 66 Baths, 81
Amoebiasis, 104 BCG (Bacilli Calmette-Guérin) vaccine,
Ampoule, 81 144–145
Anesthetic tubing Bed-frames, 82
See ventilatory tubing Bedpans and urinals, 82, 101
Anthrax, 104 Bedpan washers, 101
Antibiotic Beds, 20
lock therapy, 269 See also Linen
prophylaxis surgical, 250–251 Bias
Antibiotic associated diarrhoea information bias, 45
See Clostridium difficile infection selection bias, 44
Antiseptics, 56 Bilharziasis, 111
alcohols, 59, 62 Biological agents
antimicrobial activity (Table), 62 categorisation of, 178
chlorhexidine, 62, 64 Birthing pool, 82
hexachlorophane, 62, 65 Bladder irrigation, 280
iodine compounds Bleach
iodophores, 62, 64 See Chlorine-based disinfectant
323
Blinds, 19 Chain of infection

Blood-borne (viral) infections causative agent, 1
infection control precaution, 191 mode of transmission, 5
procedure after death, 199 portal of entry, 6
protection to newborn, 198 portal of exit, 4
responsibility of health care, 193 reservoir of infection, 3
risk of acquiring, 206–207 susceptible host, 6
risk to HCWs from patients, 192 Chlorine-based disinfectants, 59–60, 63
risk to patients from HCWs, 192 Cheatle forceps, 83
routes of transmission, 190 Chemical disinfectants
surgical procedures, 194–198 See Disinfectants
Blood and body fluids Chickenpox, 165
precautions, 78 See also Varicella/herpes zoster
Blood spills Chi-square test, 49
management of, 77 Chlamydia trachomatis, 104
Bloodstream infection, 28 Chlorhexidine, 62, 64, 125
Bone marrow transplant patients, 21 Chlorine-based disinfectants, 59–60, 63
Botulism, 104, 156 Cholera, 104
Bowls, 82 Ciprofloxacin, 161
Breast pump, 82 Cleaning, 55
Brucellosis, 104 See also Environmental cleaning
Building work, 24 Clinical waste
categorization, 304
definition, 303
C disposal of sharps, 305
handling of clinical waste, 304–305
Campylobacter gastroenteritis, 104, 158 safe handling of sharps, 305
Candidiasis, 104 sharps boxes, 307
Carpets, 19, 83 treatment methods, 308
Case-control studies, 40–41 Clostridium botulinum, 115, 156
Catering services Clostridium difficile infection, 105, 157
cook-chill food production systems, 292 clinical features, 147
causes of food poisoning, 295 control of antibiotic usage, 148
food handlers, 294 infection control measures, 148–149
food trolleys, 293 management, 147
general rules of food hygiene, 293 patients discharge, 149
HACCP, 291 risk factors, 147
hospital kitchen, 294 Clostridium perfringes, 105, 156
ice machines, 284, 295–296 Cohort studies, 39–40
inspection, 294 Commodes, 83
refrigerators, 294 Confidence intervals, 51–52
staff health/hygiene, 292 Confounders, 45
texture modified products, 293 Conjunctivitis, 105
ward kitchens, 295 Construction and renovation, 24
Cardiac monitor, 83 Contact isolation, 96
Cefotaxime, 161 Contact precautions, 97, 102
Ceftriaxone, 162 Contact transmission, 5
Ceilings, 18 Cooling towers, 23–24
Central venous catheter Coxiella burnetti (Q fever), 111
See Intravenous catheters Creutzfeldt-Jakob Disease, 105, 169–172
324
Index
childbirth, 173 enteral feeding lines, 84

clinical manifestations, 169 fixtures and fittings, 84
diagnosis, 170 floors, 84
distribution of tissue infectivity in the furniture and ledges, 85
body, 171 haemodialysis machines, 85
infection control precautions, 170 hoist, 85
methods of decontamination, 171–172 humidifiers, 85
mode of transmission, 169 hydrotherapy pools, 85
occupational exposure, 173 infants incubators, 85
post-mortem, 172 laryngoscope blade, 86
surgical procedures, 170 lockers top, 86
Critical items, 57 mattresses and pillows, 86
Cross-infection, 3 methods prior to inspection, service
Cross sectional studies, 41–42 and repair, 70
Crockery and cutlery, 83, 100 mops, 86
Cryptococcus, 105 nail brushes, 86
Cryptosporidiosis, 105 neurological test pin, 86
Curtains & blinds, 19 nebulizers, 86
Cytomegalovirus, 105, 212, 218, 219 oxygen tents, 86
pillows, 86
proctoscope, 86
D razors, 87
rhino/laryngoscope, 87
Decontamination procedure scissors, 87
airways and endotracheal tube, 81 shaving brushes, 87
ampoules, 81 sheepskins, 87
arm splint, 81 sigmoidoscope, 84
arthroscope, 84 splints and walking frames, 87
auroscope tip, 81 speculae, 87
babies feeding bottles and teats, 81 stethoscope, 87
bath water, 81 suction equipment, 80, 88
baths, 81 thermometers, 88
bed frames, 82 toilet seats, 88
bedpans and urinals, 82 tooth mugs, 88
beds and cots, 82 toys, 88
birthing pool, 82 trolleys, 89
bowls, 82 tubing, anaesthetic/ventilator,
breast pumps, 82 89
cardiac monitors, 83 ultrasound, 89
carpets, 83 urinals, 89
cheatle forceps, 83 ventilators, 89
cleaning equipment, 83 wash hand basins/sink, 89
commodes, 83 wheel chairs, 89
crockery and cutlery, 83 X-ray equipment, 89
drains, 84 Diarrhoea, 105
drip stands, 84 See also Gastrointestinal infection
duvets, 84 Diphtheria, 105, 220, 224
enuresis monitors, 81 Disinfection, 55
endoscopes, 84 Disinfection procedure, 81
See also Endoscopes See also Decontamination procedure
325
Disinfectants (chemical) Endoscopic Unit, 70

alcohols, 59, 62–63 Endogenous infection, 2
aldehydes, 66 Enteric (typhoid) fever,
antimicrobial activity, 63 paratyphoid, 106
chlorine-based, 59–60, 63 typhoid, 106
formaldehyde, 66 Enteric pathogens
glutataldehyde, 63, 67 See Gastrointestinal infections
hydrogen peroxide, 67–68 Enterobacter spp., 261
ortho-phthaladehyde, 67–69 Epidemiology
peracetic acid, 63, 66–68 case-control study, 40
peroxygen compounds, 63 epidemic curve, 33–34
phenolic, 60–64 experimental study, 39
properties and use, 58–59 cohort study, 39–40
Drains nosocomial infection, 42
surgical, 130, 247, 249, 255 risk ratio & odds ratio, 43–44
Drip stands, 84 surveillance, 39
Droplets precautions, 97, 102 Environment cleaning, 73–76, 78,
Droplets transmission, 5 101
Duvets, 84 cleaning equipment, 83, 86
Dysentery terminal cleaning of room, 75
amoebic, 106 Epidemic curve, 34
bacillary, 106 Epiglottis, 106
Epi info, 45–46, 321
Equipment
E cleaning and disinfect in, 78–79
decontamination prior to service and
Ebola virus, 106 repair, 79
See also Viral haemorrhagic fevers Error
Echinococcosis, 106 type I (alpha) error, 49
Ectoparasites type II (beta) error, 49
fleas, 181 Escherichia coli 0157, 157
lice, 180–181 Ethylene oxide, 69
scabies, 181–182 Exogenous infection, 2–3
Encephalitis & encephalomyelitis, Exposure prone procedures, 193–194
106 Exogenous infection, 2, 3
Endogenous infection, 2 Experimental studies, 39
Endoscopes, 69 Eye wear, 240
arthroscope, 69, 84
automatic washer/reprocessor system,
72–73 F
cleaning and disinfection, 71–72
cystoscopes, 69 Face mask
endoscopic unit, 70 See Mask
laparoscope, 69 Fibreoptic endoscopes
microbiological quality of water, 73 See Endoscopes
problems due to inadequate Fisher exact test, 49–50
decontaminations, 72 Fixtures and fittings, 19, 84
proctoscope, 84 Fleas, 181
renewal of disinfectant, 73 Floors, 18–19, 84
sigmoidoscope, 84 Food handlers, 294
326
Index
Food and catering service parts frequently missed, 231

See Catering services routine handwashing, 228
Food poisoning, 155–159 surgical (scrub) and disinfection, 231,
Formaldehyde, 66 254–255
Furniture, 19 technique, 229
wash hand basin, 20, 231
Health Care Workers
G health status, 205
immunization against hepatitis, 72,
Gas gangrene, 106 107
Gastrointestinal infections, 155–159 measures to protect, 204
incubation periods, 155 occupational risks, 206
infection control precautions, 155 post-exposure counselling, 213
notification, 155 post exposure prophylaxis, 213
risk groups, 155 diphtheria, 223
German measles, 106 hepatitis A virus, 222
Glandular fever, 108 hepatitis B virus, 210, 212
Gloves, 100, 237–239 hepatitis C virus, 213
donning technique, 236 human immunodeficiency virus,
glove materials, 237 210–211
glove removal technique, 236 meningococcal infection, 162, 223
latex allergy, 237 pertussis, 223
types of gloves, 240 varicella zoster, 222
Glutaraldehyde, 63, 66–67 pre-employment assessment, 204
Gonococcal infections, 107 pregnant staff,
Gowns cytomegalovirus, 216
See Aprons and gowns hepatitis B, 216
Gram-negative bacilli, multi-resistant parvovirus B18, 218
risk factors for colonisation, 134 rubella, 215
infection control measures, 134–135 varicella-zoster, chickenpox, 217
Glycopeptide resistant enterococci protection against tuberculosis, 213
See Vancomycin resistant enterococci responsibility of HCW, 193
Gut decontamination restrictions of work, 219–222
See Selective gut decontamination screening for tuberculosis, 214
Heat sterilization, 56
Hepatitis B immunoglobulin (HBIG),
H 198
Hepatitis viral
Haemophilus influenzae, 109, 115 hepatitis A, 107
Hand hygiene hepatitis B, 107, 185–187
areas most frequently missed, 26 hepatitis C, 107, 186–188
compliance, 234 hepatitis D, 187–188
facilities, 20 hepatitis E, 107
hand care products, 234 hepatitis G, 188
hand cleaning preparations, 232 incubation periods, 114
hand drying, 231 infection control precautions, 191
hygienic hand disinfection, 230 interpretation of serological makers,
hygienic hand rub, 230–231 187
methods of hand decontamination, 228 protection of newborn, 198
nail brushes, 233 risk to health care worker from, 192
327
Hepatitis viral (continued) Infection Control Doctor, 9

risk to patients from health care worker, Infection Control Link Nurse, 12
192–193 Infection Control Manual, 13
routes of transmission, 190 Infection Control Nurse, 10
Herpes simplex, 107 Infection Control Team, 11
Herpes zoster (shingles), 107 Infectious mononucleosis, 108
Hexachlorophane, 62, 65, 125 Infestation
Hoist, 85 with ectoparasites, 180–182
Hookworm, 108 Influenza, 108
Hospital waste virus, 97, 116
See Clinical Waste Internet resources, 315–316
Host defense mechanisms, 6–7 Intravenous catheter
Human immunodeficiency virus (HIV) anticoagulant flush solutions, 269
infection antimicrobial prophylaxis, 269
clinical features, 188–189 aseptic techniques, 265
consent & pre-test discussion, 189–190 catheter dressing regimens, 268
infected health-care worker, 192–193 dressing, 268
infection control precautions, 107, 191 education and training, 263
laboratory diagnosis guidewire exchange, 270
CD4 count, 190 in-line filters, 268
HIV serology, 190 monitoring and surveillance, 263
HIV viral load, 190 pathogenisis, 262
post exposure prophylaxis, 210 parenteral solutions, 264
routes of transmission, 190 points of access for microbial
window period, 190 contamination, 262
Humidifiers, 85, 287, 298 procedure for insertion of central
Hydrogen peroxide, 67, 68 venous catheter, 267
Hydrotherapy pool, 85 procedure for insertion of peripheral
Hypochlorite line, 266
See Chlorine-based disinfectant replacement of catheters, 269
Hypothesis selection of catheter type, 264
error of hypothesis testing, 49 selection of insertion site, 265
testing, 49 sources of infection, 261–262
sources of microbial contamination,
263
I surveillance, 263
Iodine & Iodophors, 62, 64
Ice machines, 295–296 Isolation
Impetigo, 108 categories of, 95–96, 102
Incidence rates, 42 precautions
Incubation periods, 114–118 airborne isolation, 96–97, 102
Incubators, infants, 85 droplets, 97, 102
Immunocompromized patients, protective isolation, 87, 95
96–97 source isolation, 95
Infection control standard isolation, 96
link nurses, 12 rooms, 20
risk assessment, 18 protective isolation room, 21
risk management, 14 source isolation room, 20–21
strategies to control, 7 Isopropyl alcohol (isopropanol), 59
Infection Control Committee, 11 See also Alcohol
328
Index
K Link Nurse, 12
Listeriosis, 108
Kitchen, Food and Catering Service Locker top, 86
See Catering Service Look back investigations, 35
Klebsiella spp., 228 Lyme disease, 108
L M
Laboratory specimens, 102–103 Malaria, 108

Laryngoscope blades, 86 Marburg disease, 108
Lassa fever, 108 See also Viral Haemorrhagic Fever
See also Viral Haemorrhagic Fever (VHF)
Latex allergy, 237 Mask, 100, 241
Laundry Services Mattresses and pillows, 86
See Linen and Laundry Service Measles, 108
Legionnaires’ disease Measures of association, 43–44
case definition, 152 Measures of central tendency, 46
clinical features, 151 Measures of disease frequency, 42
cooling towers, 23–24 Measures of dispersion, 48
diagnosis, 152 Meningitis, 109
incubation period, 151 coliforms, 109
investigation, 153 Haemoplilus influenzae type b,
prevention, 152–154 109
risk factors, 151 Listeria monocytogenes, 109
source of infection, 151 meningococcal (Neisseria meningitides),
surveillance and notification, 154 109
Leprosy, 108 pneumococcal, 109
Leptospirosis, 108 tuberculous, 109
Lice (Pediculosis) viral, 109
body louse, 180 Meningococcal disease, 109, 160–164
control measures, 180–181 chemoprophylaxis, 161
head louse, 180 clinical symptoms, 160
pubic or crab louse, 180 diagnosis, 161
Linen and laundry service emergency action by medical
air-fluidized beds, 301 practitioner, 160
dry cleaning, 300 health care worker, 162
general principles to prevent infection, household contact, 162
298 immunization of contacts, 163
high temperature wash, 299 incubation period, 160
infectious linen, 298 management in hospital, 161
laundry bags, 299 management of contacts, 162–163
laundry contract, 299 notification, 161
laundry process, 299 transmission, 160
laundry staff, 298 Methicillin resistant Staph. aureus
low temperature wash, 300 (MRSA), 109, 121
mattresses and pillows, 301 ambulance transportation, 126
microbiological sampling, 300 clearance of carriage, 126
staff uniforms, 300–301 decolonization therapy, 125
transport of linen, 299 health care worker, 127
329
Methicillin resistant Staph. aureus (MRSA) Odds Ratio, 44

(continued) Operating Theatres
infection control measures, 109, 122–124 conventional ventilated theatre, 22
microbiological clearance, 126 environmental cleaning, 257
mode of transmission, 122 microbiological monitoring, 256
screening, 126 staff movement, 255
source of infection, 121–122 theatre wear, 253
transfer of patients, 124, 126 ultra clean theatre, 22–23
treatment of carriage, 125 Operation, surgical
visit to other department, 124 pre-operative shaving, 251
Mops, 86 skin disinfection, 254
MRSA surgical technique, 255
See Methicillin resistant Staph. aureus Operative patient care, 248
Multi-resistant Gram-negative bacilli antibiotic prophylaxis, 250
See Gram-negative bacilli patient’s risk factor, 249
Mumps, 109 pre-operative hospitalization, 251
Mupirocin (Bactroban), 125 pre-operative showers, 248
Mycobacterium spp., 73 pre-operative shaving, 251
atypical, 73 Orf, 110
M. chelonei, 91 Ortho-phthaladehyde, 67, 69–70
M. tuberculosis, 61, 78 Outbreak control
Mycoplasma, 110 communication, 34
definition, 30
N management, 30, 32
outbreak control plan, 34
recognition, 32
NaDCC (Sodium dichloroisocyanurate), 59
summary of outbreak investigation, 33
Nail brushes, 233
Overshoes, 240
Nebulizers, 86, 288–289
Oxygen tents, 86
Needlestick injury
See Sharps injuries
Neurological test pins, 86 P
Nocardia, 110
Non-critical items, 58
P value, 50
Nosocomial pneumonia
Parovirus B19, 219
See Pneumonia, nosocomial
Pathology specimens, transport of, 103
Nosocomial infections
Patient isolation
bloodstream infections, 28
See Isolation of patients
incidence of (various), 27
Pediculosis (Lice infestation), 180–181
respiratory tract infections, 27
Peracetic acid, 63, 66, 67–68
surgical site infections, 28
Peroxygen compounds, 63
surveillance, 28–29
Personal protective equipment
urinary tract infection, 27
aprons & gowns, 100, 102, 196,
239–240
O face protection, 102, 196, 239
footwear, 196
Observational studies, 39 gloves, 100, 237–239
Occupational Health Department masks, 196, 241
pre-employment screening, 204 overshoes, 240
role and responsibility, 203 theatre wear, 253
330
Index
Pertussis (Whooping cough), 110 Protective isolation, 96

Pest control, 312 Pseudomembranous colitis, 147
Pharaoh’s ants, 312 Pseudomonas aeruginosa, 61, 73
Phenolics, 60–62, 64 Psittacosis (Q fever), 111
Pillows, 86 Pulmonary tuberculosis
Pinworm infection, 110 See Tuberculosis
Plague, 110
Plastic overshoes, 240
Pneumonia, nosocomial Q
factors influencing colonization,
285 Q fever, 111
humidification with heat and moisture Quaternary ammonium compounds, 62,
exchangers, 286 64–65
pathogenesis, 285–286
postural changes, 286
respiratory filter, 286 R
risk factors, 286
strategy for prevention, 285–287 Rabies, 111, 179
suction catheters, 286 Razors, 87
Pneumonias, 110 Relative risk, 43
Pneumocystis carinii, 116 Resident organisms, 227
Poliomyelitis, 110 Resistant organisms, 109, 119
Pontaic fever, 151 Rhino/laryngscope, 87
Post exposure prophylaxis (PEP) Rifampicin, 106, 109
diphtheria, 223 Ringworm, 111
hepatitis A virus, 222 Risk management, 14
hepatitis B virus, 210, 212 Risk ratio, 43
hepatitis C virus, 213 Rubella, 106, 111
human immunodeficiency virus,
210–211
meningococcal infection, 223 S
pertussis, 223
varicella zoster, 222 Salmonellosis, 111, 158
Povidone iodine Scabies, 111, 181–182
See Iodine and Iodophores Schistosomiasis, 111
Predictive value, 52 Scissors, 87
Pre-employment screening, 204 Selective decontamination therapy, 289
Pregnant health care workers Semi-critical items, 57
cytomegalovirus, 216 Sensitivity and specificity, 52
hepatitis B, 216 Sharps
parvovirus, 218 injury and management, 205–209
rubella, 216 boxes, 307
varicella-zoster virus (chickenpox and safe handling and disposal, 307
shingles), 217 Shaving brushes, 87
Pre-operative skin disinfection, 254 Sheepskins, 87
Prevalence rate, 42 Shiglellosis, 111, 158
Prevalence survey, 41–42 Shingles
Prion diseases See herpes zoster
See Creutzfelt-Jakob disease Sigmoidoscope, 84
Proctoscope, 84 Soap, 234
331
Sodium dichlorocyanurate T
(NaDCC), 59
Source isolation, 95 Tacky mats, 256
Sources of infection, 4 Terminal cleaning of room, 75
Spillages Tetanus, 112
management of blood spills, 77 Theatre
management of infectious spills, 78 See operating theatre
Staff health Theatre wear, 253
See Health Care Workers Thermometers, 88
Standard precautions, 96 Threadworms, 112
Staphylococcal infection Toilet seats, 88
food poisoning, 111, 156 Toxocara, 112
See also MRSA Toxoplasmosis, 112
Sterilizer, 56–57 Toys, 88
Sterilization Tooth mugs, 88
dry heat, 56 Transplant patients
moist heat, 56 infection in, 98, 114
Stethoscope, 87 Transient microorganisms, 229–230
Streptococcal (! haemolytic) infection, Transmission
111 mode of
Suction catheter, 80, 286 airborne transmission, 5, 96
Suction equipment, 80 contact transmission, 5, 97
Surgical hand scrub, 252–253 droplet transmission, 5, 97
Surgical prophylaxis, 250 Trichomoniasis, 112
Surgical site infection Trichuriasis, 112
definitions, 246–247 Triclosan, 62, 65, 125
incidence, 28 Trolleys, 89
microbiology, 248 Tuberculosis, 112
operative factors atypical mycobacteria, isolation, 141
draping, 255–256 clinical manifestations, 137
duration of operation, 255 contact tracing, 144–145
skin disinfection, 254 duration of isolation, 140
staff movement, 255 incubation period, 139
surgical hand scrub, 252, 253 infection control precautions,
surgical technique, 255 140–142
theatre wear, 254–255 mode of transmission, 138
wound drains, 255 multi-drug resistant tuberculosis, 143
pre-operative factors negative pressue isolation room, 21
risk factors, 248 pre-employment screening, 213–215
postoperative factors risk factors, 139
antibiotic prophylaxis, 251 treatment, 139
pre-operative shaving, 251 Tubing, anaesthetic/ventilator, 89
pre-operative showers, 248 Two-by-two contingency table, 44
wound dressing, 256 Typhoid and paratyphoid fever, 112
surveillance of SSI, 245
wound classification, 249
Surveillance U
advantages and disadvantages, 31
methods, 29, 31 Ultrasound equipment, 89
Syphilis, 111 Urinals, 89
332
Index
Urinary catheterization Viral haemorrhagic fevers, 175

antibiotic, prophylactic and treatment, clinical manifestations, 175
279 diagnosis, 175
bladder irrigation, 278 incubation period, 176
catheter material, 274 infection control precautions, 177
catheter size, 274 laboratory investigation, 177
drainage bag, 274 management, 177
emptying the drainage bag, 276 mode of transmission, 177
incidence of, 27 notification, 175–176
meatal care, 274 risk categories, 176
policy and staff training, 279 source of infection, 176
prevention of bacterial colonization, Viral hepatitis
277 See Hepatitis
procedure for urinary catheterization,
275
removal of catheter, 278 W
specimen collection, 278
use of antimicrobial agents, 278–279 Walls and ceilings, 18
Ward kitchen, 295
Wash basin/sink, 89
V Waste disposal
See Clinical waste
Vancomycin resistant enterococci (VRE) Wheel chairs, 89
infection control measures, 130–131 Whipworm, 112
mode of transmission, 130 Whooping cough, 112
risk factors, 130 Wound infection
screening of patients, 132 See surgical site infection
source of infection, 130
Varicella\herpes zoster
clinical features, 165 X
infection control measures, 166
neonates, 167 X-ray equipment, 89
period of infectivity, 165
pregnant women, 167
pregnant staff, 217–218 Y
susceptible patients, 166–167
transmission, 165 Yellow fever, 112, 118
Varicella zoster immunoglobulin (VZIG), Yersinia enterocolitica, 115
166–167
Ventilation and air conditioning, 23
Ventilators, 89, 289 Z
Vibrio cholerae, 157
Vibrio parahaemolyticus, 157 Z score, 49
Vincent’s angina, 112 Ziehl-Nielsen Stain, 139
333

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MANUAL OF INFECTION CONTROL

Treasurer, International Federation of Infection Control

LONDON ! SAN FRANCISCO

Cambridge University Press

© Greenwich Medical Media Limited 2003

This publication is in copyright. Subject to statutory exception and to the provision of

ISBN-13 978-0-511-19481-8 eBook (EBL)

ISBN-13 978-1-841-10107-1 paperback

H ospital-acquired (nosocomial) infection is a major problem in the hospitals of

A fundamental activity in health care establishments is to continually improve the

…by forseeing in a distance, which is only done by men of talents, the

• Dr. Christopher Armstrong, MRCPath, Consultant Microbiologist and

Foreword to the Second Edition ...................................................... vii

1. Principles of Infection Control ............................................................ 1

2. Administrative Arrangements .............................................................. 9

3. Design and Maintenance of Health Care Facilities .............................. 17

Cooling Towers and Water System .............................................. 23

Vancomycin Resistant Enterococci (VRE) .................................... 130

14. Prevention of Infection Associated with Intravenous Therapy ...... 261

Linen and Laundry Service ............................................................ 298

AAFB Acid and Alcohol Fast GRE Glycopeptide resistant

ICU Intensive Care Unit RIBA Recombinant immunoblot

ANTISEPSIS The destruction or inhibition of microorganisms

ANTISEPTIC A chemical agent used in antisepsis.

CARRIER A person (host) who harbours a microorganism

CASE A person with symptoms.

CHEMOPROPHYLAXIS The administration of antimicrobial agents to

COHORT A group of patients infected or colonized with same

COLONIZATION The presence of microorganisms at a body site(s)

COMMENSAL A microorganism resident in or on a body site with-

COMMUNICABLE PERIOD The time in the natural history of an infection during

CONTACT An exposed individual who might have been

CONTAMINATION The presence of microorganisms on a surface or in a

DISINFECTANT A chemical agent which under defined conditions is

ENDEMIC The usual level or presence of an agent or disease in

ENDOGENOUS Microorganisms originating from the patient’s own

EPIDEMIC An unusual, higher than expected level of infection

EPIDEMIOLOGY The study of the occurrence and cause of disease in

EXOGENOUS Microorganisms originating from a source or

FLORA Microorganisms resident in an environmental or

HOSPITAL-ACQUIRED Infection acquired during hospitalization; not

IMMUNITY The resistance of a host to a specific infectious

IMMUNOCOMPROMISED A state of reduced resistance to infection that results

INCIDENCE The number of new cases of a disease (or event)

INCIDENCE RATE The ratio of the number of new infections or disease

INCUBATION PERIOD The time interval between initial exposure to the

INDEX CASE The first case to be recognized in a series of trans-

INFECTION The damaging of body tissue by microorganisms or

ISOLATION The physical separation of an infected or colonized

MICROBIOLOGICAL The reduction of the number of pathogenic

MICROORGANISM A microscopic entity capable of replication. It

OUTBREAK An outbreak may be defined as the occurrence of

PATHOGEN A microorganism capable of producing disease.

PATHOGENICITY The ability of an infectious agent to cause disease in

PREVALENCE RATE The ratio of the total number of individuals who

RESERVOIR Any animate or inanimate focus in the environment

SEROCONVERSION The development of antibodies not previously

SOURCE Place where microorganisms are growing or have