PRINCIPLES OF INFECTION PREVENTION AND CONTROL

Patients are at risk for developing infections during their hospital stay. A recent study estimated that 4%
of hospitalized patients in the United States develop a health care–associated infection (HAI). To help
better understand preventive measures, infections can be categorized by where they originate. Those
that develop outside the hospital are called community onset. Those that develop in the hospital are
called hospital-onset or nosocomial infections. However, in the current era, patients can receive care in
many different settings—the home, the hospital, a skilled nursing facility, or an outpatient treatment
center. Patients who are at home but getting care in a nonhospital setting can develop community-onset
infections that are related to health care and are not community acquired.

The term health care–associated infection refers to infections that develop in a patient during the
course of medical treatment. There are certain factors that predispose patients to HAIs, including
illnesses and treatment regimens which may reduce the immune response to infection; in addition, the
use of artificial airways and catheters, which bypass normal barriers to microbes, may play a role. HAIs
can also be related to certain pathogens that are more likely to be resistant to one or more classes of
antimicrobial agents. For example, Pseudomonas aeruginosa is a common cause of hospital acquired
pneumonia; however, it is not routinely seen as a cause of community-acquired disease.

Forts to decrease hospital-acquired infection and HAIs are commonly organized and coordinated by a
hospital’s Infection Prevention (IP) program.

SPREAD OF INFECTION
 Three elements must be present for transmission of infection within a health care setting:
o (1) a source (or reservoir) of pathogens
o (2) a route of transmission for the pathogen
o (3) a susceptible host

SOURCES OF INFECTIOUS AGENTS

Humans(patients, personnel, or visitors) are the primary source of infectious agents in the health care
setting, but inanimate objects (e.g., contaminated medical equipment, linen, medications) have also
been implicated in transmission. Patients quickly contaminate their local hospital environment,
particularly high-touch surfaces such as call lights, bed rails, tray tables, and bathrooms. People may also
serve as their own sources of infection via endogenous flora.

SUSCEPTIBLE HOSTS
Susceptibility and resistance to infection vary greatly. Host factors in the acute setting that predispose to
HAI can be considered modifiable or nonmodifiable.
MODES OF TRANSMISSION
 The three major routes for transmission of human pathogens in the health care environment
are:
o Contact (direct and indirect)
o Droplet
o Airborne

•CONTACT TRANSMISSION
Contact transmission is the most common route of transmission and is divided into two subgroups:
direct and indirect.
 Direct contact transmission occurs when a pathogen is transferred directly from one person to
another. It occurs less frequently than indirect contact in the health care environment but is
more efficient.
 Indirect contact transmission is the most frequent mode of transmission in the health care
environment and involves transfer of a pathogen through a contaminated intermediate object
or person.

Inanimate objects that may serve to transfer pathogens from one person to another are called fomites.

•DROPLET TRANSMISSION
Droplet transmission is a form transmission via respiratory droplets. Organisms transmitted by
respiratory droplets include Influenza viruses and Neisseria meningitidis.

•AIRBORNE TRANSMISSION
Airborne transmission occurs via the spread of airborne droplet nuclei. These are small particles (≤5 µm
in diameter) of evaporated droplets containing infectious microorganisms that can remain suspended in
air for long periods and can travel further distances than droplets.

•MISCELLANEOUS TYPES OF AEROSOL TRANSMISSION

The separation of organisms that are transmitted by aerosols into the categories of droplet and airborne
is based on the usual manner in which disease is transmitted. In-depth investigations of outbreaks have
demonstrated that the line between these two categories of transmission is sometimes blurry.
 Based on the examples, aerosol transmission of droplet nuclei can be further refined as follows:
o Obligate transmission: Under natural conditions, disease occurs after transmission of a
microorganism only through airborne(droplet nuclei) aerosols. An example of
microorganism spread by obligate transmission is Mycobacterium tuberculosis.
o Preferential transmission: Natural infection results from transmission through multiple
routes, but airborne transmission predominates. Measles is an example of a disease
transmitted by preferential transmission.
o Opportunistic transmission: Microorganisms that cause disease through other routes—
droplet or contact—but only under certain environmental conditions may be
transmitted via airborne transmission.
OTHER SOURCES OF INFECTION NOT INVOLVING
PERSON-TO-PERSON TRANSMISSION
Common vehicle transmission occurs via exposure to pathogens in contaminated food, water, or
medications (e.g., heparin solution). Vector-borne transmission of infectious diseases from insects and
rats and other vermin occurs but is of less significance in US health care facilities.

 STRATEGIES FOR THE PREVENTION OF INFECTION:

1. Creating a Safe Culture
2. Maintaining a Healthy Workforce
3. Eliminating the Source of Pathogens
4. Interrupting Transmission
5. Standard Precautions
6. Hand Hygiene
7. Gloves
8. Mouth, Nose, Eye, and Face Protection
9. Respiratory Protection
10. Gowns, Aprons, and Protective Apparel
11. Cough Etiquette
12. Transmission-Based Precautions
13. Transport of Infected Patients
14. Protective Environment
15. Medical Devices and Bundles

1. CREATING A SAFE CULTURE

From an organizational perspective, a crucial first step to decrease the risk for HAIs is the creation by
leadership, at all levels, of a culture of safety in which there is a shared commitment to the safety of
patients and health care workers.

2. MAINTAINING A HEALTHY WORKFORCE

The day-to-day care of hospitalized patients relies on people. A sick health care worker not only has
difficulty executing assignments but could also serve as a source of infection for vulnerable patients.
There are multiple different components to maintaining a healthy workforce. The standard and
transmission-based

Precautions described later not only prevent transmission of pathogens from patient to patient but also
protect health care workers. Other efforts employed to protect health care workers are employee
immunization and chemoprophylaxis.

•THE OCCUPATIONAL SAFETY

And Health Administration (OSHA) requires that employers offer hepatitis B vaccination.
 3. ELIMINATING THE SOURCE OF PATHOGENS
It is impossible to eliminate all pathogens from any working environment. Nonetheless, standard IP
procedures always include efforts to eliminate pathogens; therefore recommended practices for
cleaning and disinfecting noncritical surfaces in patient care areas should be followed.
 Procedures designed to remove environmental pathogens fall into two major categories:
general sanitation measures and specialized equipment processing.

4. INTERRUPTING TRANSMISSION
General sanitation measures and equipment processing have limits. To prevent the spread of infections
between patients and to keep themselves healthy, health care personnel must take measures to stop
infection. Best practices to limit the transmission of pathogens in the hospital have been put forth by the
Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease
Control and Prevention (CDC). These recommendations include standard precautions and transmission-
based precautions.

5. STANDARD PRECAUTIONS
The term standard precautions refers to the simplest level of infection control based on the recognition
that all blood, body fluids, secretions, and excretions (with the exception of sweat) may contain
transmissible infectious agents. Standard precautions are intended to be applied to the care of all
patients in all health care settings all the time. This is the primary strategy for the prevention of health
care–associated transmission of infections among patients and health care personnel.

6. HAND HYGIENE
The importance of hand hygiene to reduce the transmission of infectious agents cannot be
overemphasized and is an essential element of standard precautions. Hand hygiene includes hand
washing with either plain or antiseptic-containing soap and water for at least 15 seconds or the use of
alcohol-based products (gels, rinses, and foams).

7. GLOVES
Gloves protect both patients and health care workers. They protect patients from exposure to
pathogens that may be carried on the hands of health care workers. Gloves protect caregivers from
contamination when they are contacting blood, body fluids, secretions, excretions, mucous membranes,
and nonintact skin of patients and when they are handling or touching visibly or potentially
contaminated patient care equipment and environmental surfaces.

8. MOUTH, NOSE, EYE, AND FACE PROTECTION

Face protection is an important component of standard precautions because the mucous membranes of
the eyes, nose, and mouth are particularly vulnerable to some types of pathogens. Masks protect
mucosal surfaces against splashes or sprays.
 9. RESPIRATORY PROTECTION
Respiratory protection (use of NIOSH-approved N-95 or higher level respirator) is intended for diseases
(e.g., M. tuberculosis) that could be transmitted by the airborne route. Health care workers should be fit
tested to ensure that they are wearing the appropriate respirator and can feel confident in their safety
while caring for patients.

10. GOWNS, APRONS, AND PROTECTIVE APPAREL

Isolation gowns and other apparel (aprons, leg coverings, boots, or shoe covers) also provide barrier
protection and can prevent the contamination of clothing and exposed body areas from blood and body
fluid contact and transmissible pathogens (e.g., respiratory syncytial virus and C. difficile).

11. COUGH ETIQUETTE

The emergence of novel respiratory viruses such as SARS and Middle East Respiratory Syndrome
(MERS) along with pandemic H1N1 influenza have reinforced the need for a strategy for preventing
transmission of respiratory infections at the first point of contact within a health care setting (e.g.,
physician’s office), termed respiratory hygiene/cough etiquette. This concept is a component of
standard precautions.

12. TRANSMISSION-BASED PRECAUTIONS

Transmission-based precautions are for patients who are known or suspected to be infected with
pathogens that require additional control measures to prevent transmission.
 There are three categories of transmission-based precautions based on the primary route by
which the pathogen is transmitted:
o Contact precautions
o Droplet precautions
o AII (see earlier section titled “Modes of Transmission”)

 CONTACT PRECAUTIONS are intended to reduce the risk for transmission by direct or indirect
contact with the patient or the patient’s environment.

 DROPLET PRECAUTIONS are employed for patients with presumed or confirmed infection with
organisms known to be transmitted by respiratory droplets such as influenza.

•AIRBORNE INFECTION ISOLATION

refers to isolation techniques intended to reduce the risk for selected infectious agents transmitted by
small droplets of aerosol particles.

•CYSTIC FIBROSIS PATIENTS

A patient population of particular interest to RTs are those with Cystic Fibrosis (CF). Patients with CF are
at risk for recurrent respiratory infection, developing bronchiectasis, and acquiring resistant pathogens.
Respiratory infection can trigger declines in lung function that require hospitalization.
 13. TRANSPORT OF INFECTED PATIENTS
By limiting the transport of patients with contagious diseases, the risk for cross infection can be reduced.
However, infected patients sometimes do need to be transported.

14. PROTECTIVE ENVIRONMENT

A specialized engineering approach to protect highly immunocompromised patients is a protective
environment. Such an environment is used for patients with allogeneic hematologic stem cell
transplants to minimize the number of fungal spores in the air.

15. MEDICAL DEVICES AND BUNDLES

A large percentage of HAIs are device-related infections, including ventilator-associated pneumonia
(VAP), catheter-related bloodstream infection, and catheter-associated urinary tract infection (CAUTI).

•DISINFECTION AND STERILIZATION

Medical instruments are used in tens of millions of procedures in the United States every year. When
properly performed, cleaning, disinfection, and sterilization processes can reduce the risk for infection
associated with the use of invasive and noninvasive medical instruments.

THE SPAULDING APPROACH TO DISINFECTION AND

STERILIZATION OF PATIENT CARE EQUIPMENT
In 1968, Earle H. Spaulding published his approach to disinfection and sterilization, which was based on
the degree of risk for infection involved in the use of the item in patient care. The three categories he
described were:
o Critical
o Semicritical
o Noncritical

 Critical items are those that enter normally sterile tissue or the vascular system.
 Semicritical items come into contact with mucous membranes or nonintact skin; this category
includes most respiratory equipment.
 Noncritical items come into contact with intact skin (an effective barrier to most microbes) only.
These items may include noncritical patient care items and noncritical environmental surfaces.
Most noncritical reusable items.

 Under Spaulding Approach to Disinfection and

Sterilization of Patient Care Equipment are the following:
1. Cleaning
2. Disinfection
3. Sterilization
 1. CLEANING
Medical equipment must be cleaned and maintained according to the manufacturer’s instructions.
Cleaning is the first step in all reprocessing of equipment, including that undergoing low- or high-level
disinfection and sterilization. Cleaning involves removing all dirt and organic material from equipment,
usually by washing.

2. DISINFECTION
Disinfection describes a process that destroys the vegetative form of many or all pathogenic organisms
except spores on medical equipment or other inanimate objects.

•CHEMICAL DISINFECTION
Chemical disinfection involves the application of chemical solutions to contaminated surfaces or
equipment. Numerous disinfectants are used alone or in combination in the health care setting.

3. STERILIZATION
Sterilization destroys all microorganisms on the surface of an article or in a fluid, which prevents
transmission of pathogens associated with the use of that item. Both physical and chemical means can
achieve sterilization.
 Physical methods include various forms of heat (via steam) and ionizing radiation.
 Chemical Methods of sterilization include low-temperature sterilization technologies such as
ethylene oxide (ETO) gas.

•STEAM STERILIZATION
Moist heat in the form of steam under pressure is the most common, most efficient, most reliable, and
easiest sterilization method.

•IMMEDIATE-USE STERILIZATION
Immediate-use (previously referred to as flash sterilization) steam
sterilization (IUSS) is a modification of conventional steam sterilization in which the item is placed in an
open tray or a specially designed container to allow for the rapid penetration of steam.

•LOW-TEMPERATURE STERILIZATION TECHNOLOGIES

Low-temperature (<60°C) sterilants are needed for sterilizing temperature- and moisture-sensitive
medical devices and equipment. Low-temperature sterilant technology includes ETO, hydrogen peroxide
gas plasma, ozone, vaporized hydrogen peroxide, and peracetic acid.

•EQUIPMENT-HANDLING PROCEDURES
Equipment-handling procedures that help prevent the spread of pathogens include maintenance of in-
use equipment, proper reprocessing of reusable equipment, and application of single patient-use
disposables instruments.
•MAINTENANCE OF IN-USE EQUIPMENT
In-use respiratory care equipment that can spread pathogens includes nebulizers, ventilator circuits,
bag-valve-mask devices (manual resuscitators), and suction equipment. Oxygen therapy and pulmonary
function equipment is also implicated as potential sources of HAIs.

•NEBULIZERS
Because they produce aerosols capable of spreading pathogenic microbes, large volume (Jet) nebulizers
remain among the most common types of respiratory equipment linked to HAIs.19 Small volume
medication nebulizers (SVNs) can also produce bacterial aerosols.

•VENTILATORS AND VENTILATOR CIRCUITS

The internal workings of ventilators are uncommon sources for infection; this is partly a result of the
widespread use of high-efficiency particulate air/aerosol (HEPA) filters, which have an efficiency rate of
99.97%, and the use of sheathed suction catheters, which help to reduce endotracheal tube
contamination.

•BAG-MASK DEVICES
Bag-mask devices are a source for colonizing both the airways of intubated patients and the hands of
medical personnel. Nondisposable bag-mask devices should be sterilized or high level disinfected
between patients.

•SUCTION SYSTEMS
Tracheal suctioning increases the risk for infection. Proper hand hygiene and gloving help to minimize
this risk. Although much has been made of the IP advantages of sheathed suction systems over open
ones, evidence is mixed as to whether sheathed systems are clearly superior.

•OXYGEN THERAPY APPARATUS

O2 therapy devices pose much less risk than other in-use equipment but still pose a potential infection
hazard. In-use nondisposable O2 humidifiers have a contamination rate of 33%. Conversely, prefilled
sterile disposable humidifiers present negligible infection risk.

•PULMONARY FUNCTION EQUIPMENT

The inner parts of equipment for pulmonary function testing are not a major source for spread of
infection. However, contamination of external tubing, connectors, rebreathing valves, and mouthpieces
can occur during testing.

•OTHER RESPIRATORY CARE DEVICES

Use of other respiratory care equipment—including O2 analyzers, the handheld bedside spirometer, and
circuit probes—has been linked to hospital outbreaks of gram-negative bacterial infections.

•REPROCESSING REUSABLE EQUIPMENT

Improperly reprocessed reusable equipment is another potential source of pathogens. General
principles for cleaning, disinfection, and sterilization were provided previously.
•RESPIRATORY CARE EQUIPMENT
Several factors must be considered in selecting a reprocessing method for reusable respiratory care
equipment. The most critical is compliance with the equipment manufacturer’s instructions for use,
which at a minimum should agree with the device’s infection risk (critical, semicritical, or noncritical).

 BRONCHOSCOPE REPROCESSING -- Bronchoscopes routinely become contaminated with high

levels of organisms because of the body cavities in which they are used. The benefits of these
medical devices are numerous; however, proper reprocessing is crucial.

•DISPOSABLE EQUIPMENT
An important alternative to reprocessing equipment continually is employing single-patient-use
disposable devices. In the past, only O2 therapy devices (i.e., masks, cannulas), suction apparatus
(i.e., catheters, tubing), and some supplies were disposable. Today, manufacturers provide a range of
disposable devices, including humidifiers, nebulizers, incentive spirometers, ventilator circuits, bag-
valve-masks, and monitoring transducers.

 Three major issues are involved in using disposable devices:

o cost
o quality
o reuse

•FLUID AND MEDICATION PRECAUTIONS

Unit dosing has decreased but not eliminated the infection hazard associated with medications.

•HANDLING CONTAMINATED ARTICLES AND EQUIPMENT

Reusable contaminated items should be enclosed in a biohazard labeled impervious bag or rigid
container before removal from a patient’s room. This practice helps prevent accidental exposure of both
personnel and the environment to contaminated articles.

•HANDLING LABORATORY SPECIMENS

When laboratory specimens (e.g., sputum) are being gathered, extreme care must be taken to prevent
contamination of the external surface of the container. If the outside of the container is contaminated,
the caregiver must either disinfect it or place it in an impervious bag.

SURVEILLANCE FOR HOSPITALACQUIRED INFECTIONS

•SURVEILLANCE
Is an ongoing process of monitoring patients and health care personnel for the acquisition of infection,
colonization of pathogens, or both.

•Surveillance is one of the five key recommended components of an IP program; the others are:
investigation, prevention, control, and reporting.

•Surveillance is a systematic process designed to review and analyze HAI data on patients.