Infection Control

1. Infection Control DR. MAZIN BARRY, MD, FRCPC, FACP, DTM&H Infectious Disease Consultant Assistant Professor of Medicine

2. Outline • Hospital Acquired Infections (HAI) • Hand Hygiene (HH) • Isolation Precautions • Injection Practices and vaccinations

3. HAI • At any time, over 1.4 million people worldwide are suffering from infections acquired in hospital • Between 5% and d10% of patients admitted to hospitals acquire one or more infections • Causes more serious illness • Prolong hospital stay • Long-term disability • High additional financial burden • High personal burden on patients and their families • Deaths

4. Most frequent sites of infectionand their risk factors URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency LACK OF HAND HYGIENE Most common sites of health care-associated infection and the risk factors underlying the occurrence of infections SURGICAL SITE INFECTIONS Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision BLOOD INFECTIONS Vascular catheter Neonatal age Critical careSevere underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision 17% 14%

5. Prevention of HAI • Validated and standardized prevention strategies have been shown to reduce HAI • At least 50% HAI could be prevented • Most solutions are simple and not resource-demanding and can be implemented

6. Colonization Versus Infection • People who carry bacteria without evidence of infection (fever, increased WBC) are colonized • If an infection develops, it is usually from bacteria that colonize patients • Bacteria that colonize patients can be transmitted form one patient to another by hands of healthcare workers Bacteria can be transmitted even if the patient is not infected.

7. Infected Colonized The Iceberg Effect

8. The inanimate environment can facilitate transmission

9. Hand transmission • Hands are the most common vehicle to transmit healthcare associated pathogens • Transmission of healthcare associated pathogens from one patient to another via healthcare worker’s hands

10. Why should you clean your hands • Any HCW involved in health care needs to be concerned about hand hygiene • Their hand hygiene concerns you ! • You must perform hand hygiene to : - protect the patient against harmful microbes in your hands or present on your skin - protect yourself and the healthcare environment from harmful microbes

11. Five moments of hand hygiene

12. 5 Moments of Hand hygiene

13. How to clean your hands • Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if hands are not visibly soiled • Handwashing with soap and water – essential when hands are visibly dirty or visibly soiled (following exposure to body fluids)

15. Hand hygiene and glove use • The use of gloves does not replace the need to clean the hands • Remove gloves to perform ahnd hygiene, when an indication occurs while wearing gloves • Wear gloves only when indicated, otherwise they become a major risk for germ transmission

16. Compliance with Hand hygiene • Compliance with hand hygiene differs across facilities and countries • Main reasons for non-compliance reported by HCWs - Too busy - Skin irritation - Glove use - Don’t think about it

17. Hand hygiene improvement strategy • System change - Access to safe, continuous supply of water, soap, towels, alcohol based hand rub at the point of care • Training / Education - Regular training to all HCW • Evaluation and feedback - Monitoring hand hygiene practices, perceptions and knowledge, while providing results feedback to HCWs • Reminders in the workplace - Reminding HCWs • Safety culture - Creating an environment that facilitates awareness, raising about patient safety issues

18. Isolation Precautions

19. Mode of transmission • A microorganism may be spread by a single or multiple routes. • Contact, direct or indirect • Droplet • Airborne • Vector-borne (usually arthropod) and • Common environmental sources or vehicles - includes food-borne and waterborne, medications e.g., contaminated IV fluids

20. Types of Isolation Precautions • Standard precautions • Transmission-based precautions • Contact precautions • Airborne precautions • Droplet precautions

21. Definition of standard precautions • Apply to all patients receiving care in hospitals regardless of their diagnosis or presumed infection status. • Apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain blood; (3) nonintact skin; and (4) mucous membranes.

22. Standard Precaution - Hand hygiene Handwashing with either plain or antiseptic containing soap and water, and use of alcohol-based products (gels, rinses, foams) that do not requre the use of water Perform hand hygiene: • Before and after patient contact • After removing gloves or any other PPE item • After touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn

23. Standard precautions Personal protective equipment (PPE) • The selection of PPE based on • The nature of patient interaction and/or • The likely mode(s) of transmission • Designated containers for used disposable or reusable PPE should be placed in a convenient to the site of removal • Hand hygiene is always the final step after removing and disposing of PPE

24. Standard precautions – Gloves (PPE) • Exposure to blood, body fluids, secretions, excretions, mucous membranes and non-intact skin, and contaminated items • Perform hand hygiene immediately after glove removal • Change gloves when heavily contaminated 4. Disposable glove should not be reused

25. Standard precautions – Gown (PPE) 1. When splashes or sprays of blood and body fluids, secretions and excretions to skin and working clothes are likely 2.When working clothes has substantial contact with patient, environmental surfaces or patient items 3. Select an appropriate gown for the procedure

26. Standard precautions – Mask and eye protection (PPE) Surgical masks and eye protection: • When splashes or sprays of blood and body fluid, secretions and excretions are likely • Sterile technique • Respiratory etiquette Change PPE promptly if heavily contaminated during the procedure

27. Standard precautions - prevent hcws exposure to bloodborne pathogens • Prevent needles and other sharps instrument injuries • Prevent mucous membrane exposures • Safe work practices and PPE to protect mucous membranes and non-intact skin

28. Standard precautions: Environmental measures • Clean and disinfect non-critical surfaces in patient-care areas are part of SP. • Clean and disinfect all frequently touched surfaces in patient-care areas • FDA-registered disinfectants or detergents

29. Respiratory hygiene and cough etiquette • Three elements include: • Educate healthcare workers, patients, and visitors • Post signs in appropriate language(s) • Source control measures: • Cover the nose/mouth when coughing or sneezing • Use tissue paper respiratory secretions and dispose in the waste receptacle • Perform hand hygiene after contact with respiratory secretions and contaminated objects • Place a surgical mask on the coughing person when tolerated and appropriate • Spatial separation, ideally >3 feet

30. TRANSMISSION-BASED PRECAUTIONS - Management of visitors • Visitors as sources of healthcare associated infections – e.g., pertussis, influenza, tuberculosis • Cough etiquette • Use of barrier precautions by visitors • Educate patients and family members • Follow signs for isolation precautions

31. TRANSMISSION-BASED PRECAUTIONS - Contact Precautions • Infections spread by direct or indirect contact with patients or patient-care environment –C. difficle, MRSA, VRE, ESBL and MDR GNR • Limit patient movement • Private/SINGLE room or cohort with patients with same infection • Wear disposable gown and gloves when entering the patient room • Remove and discard used disposable gown and gloves inside the patient room • Wash hands immediately after leaving the patient room • Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces) • Use dedicated equipment if possible (e.g., stethoscope)

32. Contact precautions signs

33. Droplet Precautions • Reduce the risk of transmission by large particle droplets (larger than 5 m in size). • Requires close contact between the source person and the recipient • Droplets usually travel 3 feet or less • E.g., influenza including H1N1, other respiratory viruses, rubella, parvovirus B19, mumps, H. influenzae, and N. meningitidis

34. Droplet Precautions cont. • A private/single room or • Cohort with patient with active infection with same microorganism • Use a mask when entering the room and definitely if within 3 feet of patient • Limit movement and transport of the patient. Use a mask on the patient if they need to be moved and follow respiratory hygiene/cough etiquette • Keep at least 3 feet between infected patient and visitors

35. Droplet precautions signs

36. Airborne Precautions • Tuberculosis, measles, varicella, MERS-CoV • Place the patient in an airborne infection isolation room (AIIR) • Pressure should be monitored with visible indicator • Use of respiratory protection (e.g., fit tested N95 respirator) or powered air-purifying respirator (PAPR) when entering the room • Limit movement and transport of the patient. Use a mask on the patient if they need to be moved • Keep patient room door closed.

37. Airborne precautions signs

38. Safe injection practices • Large outbreaks of HBV and HCV among patients in the United States • The primary breaches • Reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline bag) • Use of a single needle/syringe to administer intravenous medication to multiple patients.

39. Vaccination • Annual Influenza vaccine • HBSAB • VZV