Hospital Infection Control Manual

   


           

                 




                          

        

         

                  

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1

CHAPTER

1.

INTRODUCTION…………………………………………

2

CHAPTER

2.

HOSPITAL INFECTION CONTROL COMMITTEE ……

4

CHAPTER

3

HOSPITAL HYGIENE…………………………………….

7

CHAPTER

4

OUTBREAK MANAGEMENT & ISOLATION………….

20

CHAPTER

5

ANTIBIOTIC POLICY…………………………………….

25

2 CHAPTER 1

INTRODUCTION A hospital is a place where sick people congregate to avail of the services of doctors in different specialties. The 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. It is thus the primary responsibility of every hospital administrator to ensure that adequate resources are allocated for hospital infection control. Employers also have a responsibility to provide a safe working environment for the Health care Workers and the employees are duty bound to comply with safety standards and procedures set by the institution. The administration should include an infection control committee that monitors the infections acquired within the hospital and goes about implementing measures to combat this. Infection control specialists and the representatives from the various departments should form a committee, designated the Hospital Infection Control Committee (HICC) to develop the manual keeping the needs of all specialties in mind and to monitor the implementation and effectiveness of the control programme. In general, infections that occur more than 48-72 hrs after admission and within 10 days after discharge are considered as nosocomial. Hospitalized patients are generally more vulnerable to infection than any other healthy individual, since the host is immunosuppressed, the environment is conducive to the growth of resistant bacteria and the transmission of these bacteria is very much facilitated by the activities of the Health Care Workers (HCW) and other patients. The epidemiological triad of host, environment and agent work together with strong links of transmission. Sometimes there is a large increase in the commonly occurring types of infection, or appearance of a new kind of infection e.g. Salmonella infection in newborns. This is called an outbreak of nosocomial infection. Such an infection is usually due to a single type of bacteria and the source can be traced e.g. a solution contaminated with Pseudomonas causing wound infection in one ward. The importance of hospital infection can be considered both in terms of morbidity and of prolonged occupancy of the hospital bed. Approximately 10% of hospitalized patients

3 develop infections every year .In developing countries, this may go up to 25%. One-third of these are preventable. Diagnosing and treating these infections puts intense pressure on the health services and health budget. A Hospital Infection Control Manual is an essential part of any infection control programme. It should establish standards in all aspects of infection control. In a large referral hospital, doctors and nursing staff work in different specialties and super specialties. Each specialty has evolved its own style of working and they have varied procedures which can be performed only by skilled personnel. The procedures of infection control should thus be adapted to suit the needs of all specialties and still maintain the basic principles needed for effective control of infection. Over time all precautions tend to get diluted and recruitment of new staff members without knowledge of infection control procedures followed will lead to an increase in the hazard of spread of infection within the hospital. This can be overcome by a standard manual which is updated yearly and is available to all staff for easy reference over the hospital computer network system or in the wards/reading rooms. The manual should include policy and procedures on: 1. Standard Precautions for HCWs 2. Isolation policies 3. Cleaning and decontamination of surfaces and equipment and management of spills 4. Antibiotic policy 5. Outbreak management. 6. Waste management and disposal of sharps. (Damani) The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections, Dept. of Health, UK “The term “Health Care Associated Infections” (HCAI) encompasses any infection by any infectious agent acquired as a consequence of a person’s treatment by the hospital or which is acquired by health care workers in the course of their duties. Effective prevention and control of HCAI has to be embedded into everyday practice and applied consistently by everyone. It is particularly important to have a high awareness of the possibility of HCAI in both patient and health care workers to ensure early and rapid diagnosis. This should result in effective treatment and containment of the infection. Effective action relies on an accumulating body of evidence that takes account of current clinical practices. This evidence base should be used to review and inform practice. All staff should demonstrate good infection control and hygiene practice. However, it is not possible to prevent all infections.”

4 CHAPTER 2

HOSPITAL INFECTION CONTROL COMMITTEE The Hospital Infection Control Committee (HICC) is an essential part of good infection control practices and must function effectively. The Head of the Institution may be nominated as the Chairperson. The Secretary should be a Senior Clinical Microbiologist, Infectious disease specialist or Epidemiologist. Other members should include: 1. Heads of all clinical and paraclinical departments. 2. Administrator or his representative e.g. Medical Superintendent or Resident Medical Officer (RMO). 3. Chief of Nursing staff e.g. Nursing Superintendent or Assistant 4. Engineer from the Public Works Dept. e.g. Asst. Engineer 5. Engineer from the Water supply Dept. e.g. AE, PHED 6. Head of Pharmacy services 7. Infection Control Team(ICT) including Infection Control Doctor(ICD) and Nurse(ICN) 8. Chief technician of infection control lab or chief technician responsible for processing of all outbreak and surveillance samples. 9. Chief Security Officer 10. Chief Biomedical Engineer(BM Engineer) responsible for the working of all the Medical equipment in the hospital. The committee should meet every 6 months. The ICT is responsible for the day-to- day activities in infection control and monitoring their implementation and effectiveness. AIMS OF THE HICC: 1. Recommend appropriate policies for the prevention of Hospital Acquired Infection and ensure that they are implemented. 2. Maintain records on surveillance, outbreaks and needle stick injury incidents. These are compiled by the Infection Control Team and come up for discussion during the meetings.

5 3. Formulate an antibiotic policy based on the needs of the different specialties and prevalent susceptibility patterns. 4. Implement policies for the safety of health care workers. 5. Regulate and give recommendations on purchase of equipment needed for infection control e.g. autoclaves in CSSD, steam sterilizers etc. 6. Regulate and give recommendations on any construction or renovation work in the hospital. The plan should be approved by the committee. 7. Discuss and find solutions to problems related to infection control encountered by different doctors in their specialties.(Damani) INFECTION CONTROL TEAM (ICT) Infection Control Team (ICT) – Consists of: -

a) Infection Control Doctor (ICD). b) Infection Control Nurse (ICN) a) ICD – Microbiologist / Infectious Disease Specialist / Epidemiologist Should be a Registered Medical Practitioner. One for every 1000 beds Experience in: -

1. 2. 3. 4.

Sterilization / Disinfection Microbiology Hospital Infection Epidemiology Surveillance Functions: 1. Draws up annual plans for prevention of hospital infection. 2. Implementation of agreed policies 3. Sets quality standards and coordinates surveillance activities. 4. Coordinates with administrator, PWD, PHED and BM engineer for proper maintenance, or upgradation of existing facilities. Should be involved in the design ,construction and commissioning of any new building. 5. Help the ICN to conduct continuing education programmes in infection control practices for the staff members. b) ICN – Senior Registered Nurse(BSc or MSc) Training in Infection Control is preferred. Full-time job. One for 250 beds.

6 This includes: 1. Assists ICD and ICC in drawing up annual plans for prevention of hospital infection 2. Monitor all infection control procedures, e.g. sterilization procedures in the CSSD, use of disinfectants and adherence to universal precautions by all members of staff. 3. Surveillance of infection to prevent outbreaks. She will identify, investigate and follow-up on infections acquired from the hospital which will help in prevention of outbreaks. 4. Conduct continuing education programmes on infection control practices to all grades of staff. In a large hospital there will be a team of ICDs and ICNs, who make up the ICT. The ICT is responsible for the day-to-day activities of the infection control programme. The ICT conducts monthly meetings presided over by the seniormost ICD.(Damani) Infection Control Lab It is recommended that for surveillance and outbreak investigation activities, an infection control lab may be set up under the Microbiology Department. This may be supervised by the senior most ICD who is also a Microbiologist. The processing of specimens in the lab is done by: 1. Senior lab technician/Scientist - Preferably BSc MLT /MSc. Microbiology and preference given to person with PhD in any subject related to infection control. Experience in typing of organisms will be an added advantage. 2. Junior Lab technician – BSc MLT or DMLT 3. Junior Lab assistant(JLA) – Passed Higher secondary with experience in lab work 4. Cleaner/Attender . Functions of the Lab: 1. Participate in Surveillance activities and outbreak investigation as instructed by the ICD. 2. Maintain in stock all the pathogens identified in outbreaks. 3. Typing of nosocomial pathogens – phage typing, biocin typing, molecular methods. All the other bacteriology labs should send the multi-drug resistant nosocomial strains identified in pus, blood samples etc. to this lab for full identification and typing.

7 CHAPTER 3

HOSPITAL HYGIENE In the chain of infection, the mode of transmission is the easiest link to break and is the key to control of cross-infection in hospitals.

Based on the above, the 5 pillars of infection control are: 1. Hand washing 2. Isolation of infected patients 3. Barrier nursing of immuno suppressed. 4. Prudent use of antibiotics 5. Decontamination and proper disinfection / sterilization of items and equipments used in invasive procedures (Damani) These guidelines are divided into two parts: 1. General policies to be followed uniformly all over the hospital. 2. Specific policies for special areas. GENERAL POLICIES: I STANDARD PRECAUTIONS : (CDC GUIDELINES 1987) A set of precautions to protect health care worker from occupational exposure to bloodborne infections. 1. BARRIER PROTECTION 2. HAND WASHING 3. SAFE TECHNIQUE 4. SAFE HANDLING OF SHARP 5. SAFE HANDLING OF SPECIMEN 6. SAFE HANDLING OF SPILLS 7. USE OF DISPOSABLES 8. IMMUNISATION WITH HEP-B VACCINE

8 1. BARRIER PROTECTION: Materials that protect the HCW from infection. Gloves

Mask

Apron

Eye wear

Foot wear Gloves All skin defects must be covered with water proof dressing Use well fitting, disposable / autoclaved Change if visibly contaminated / breached Remove before handling telephones, performing office work, leaving workplace Mask & Goggles Facial protection – When splashing or spraying of blood / blood fluids expected Apron Gowns/Special uniforms – in high risk areas Foot wear

· Feet should be well covered on all sides, especially while working in areas where spillage of infectious material is common, like operation theatres, labour room, laboratories. Soft shoes are preferred to sandals. 2. HAND WASHING: Protects both HCW and patients .The single measure that is universally acknowledged and proved to reduce HCAI. The main forms are: a) Social handwashing – Done for simple cleaning of hands with soap and water. Reduces the transient flora. A modification is careful handwashing which is done immediately after touching a patient or after contamination. All areas of the hand upto the wrist are cleaned by rubbing for at least 2 minutes. Fig 1 below shows the areas commonly missed while washing, in red. b) Hygienic hand disinfection – After social hand washing, to get a more sustained effect, especially while caring for infected patients in special care units like ICUs and neonatal units. 70% ethyl alcohol hand disinfectants may be rubbed thoroughly over the hands. This effectively kills all transient flora, the action is fast and short-lived, hence has to be repeated after touching each patient.

9 c) Surgical hand disinfection – Preoperative washing hands by surgeon. Done with antibacterial soap e.g containing chlorhexidine or an iodophore, followed by 70%alcohol rub. Hands are scrubbed thoroughly for 5-10 minutes upto the elbows, taking care to scrub nails and interdigital areas. (Hospital Hygiene and infection control, WHO 1999)

Fig.1 Areas missed (in red) Running water is an essential pre-requisite for proper handwashing. In its absence, Fig 2 shows how hands can be washed using a container with a tap fitted (Model Injection Practices Manual, IndiaClen Programme evaluation Network 2006)

Fig 2. Washing hands when running water is not available 3. SAFE TECHNIQUE & SAFE HANDLING OF SHARPS : These are techniques to be followed while using sharp instruments like scalpel, scissors and needles. a) Dispose your own sharps yourself. b) Never pass used sharps to another person. e.g. give used scalpel to assistant in a kidney tray, not directly c) During exposure-prone procedures, minimize the risk of injury by ensuring that the operator has the best possible visibility. E.g. by positioning the patient, adjusting good light source and controlling bleeding. (CDC guidelines 1987) d) Protect fingers from injury by using forceps instead of fingers for guiding suturing.

10 e) To collect blood a vacuum system is ideal f) Never recap, bend or break disposable needles. g) Place used needles and syringes in a rigid puncture resistant container or destroy using needle destroyer. Every institute should have a Sharps Policy to provide a safe working environment, the basis of which should be: A. Reduce use and Select the right devices. B. Care in use -

Handle used items with care for reuse or disposal.

C. Disposal

Dispose infected waste safely.

-

4. SAFE HANDLING OF SPECIMEN: These are to be followed while sending blood or other body fluids to a laboratory for tests. a) Wear gloves while collecting any specimen from a patient. b) Keep all containers labeled and ready before collection c) Use aseptic techniques d) Keep all disinfectant containers ready before collection e) Collect into a screw capped unbreakable container , screw it tight and dispatch safely f) If it has to be sent to a distant lab follow packing instructions as for infectious material and put a biohazard label on the package. 5. SAFE HANDLING OF SPILLS: Spilling of blood and body fluids is a common hazard in the laboratory, theatres and wards. A uniform policy is necessary to protect both HCWs and patients from spread of blood-borne infections by this route. Chemical Disinfectants effective in inactivating all blood-borne pathogens: Disinfectant

Concentration

Period of contact

1. Hypochlorite

1%

30min

2. Formalin

4%

30min

3. Gluteraldehyde(Cidex)

2%

30min

4. Hydrogen peroxide

6%

30min

11 The following steps should be followed if there is a spill: Spill on floor/ work surface should be covered with paper towel / blotting paper / newspaper / absorbent cotton. 1% (10,000 ppm) Hypochlorite solution should be poured on the spill and covered with paper for 30 minutes. All the paper / cotton should be removed with gloved hands. 0.1% or 0.5% Hypochlorite is used for general disinfection. 6. USE OF DISPOSABLES It is impossible to avoid all contact with infected tissue or potentially contaminated body fluids. Even when they are not touched with the bare hands, they come into contact with instruments, containers, linen etc. All objects that come into contact with patients should be considered as potentially contaminated. If an object that comes into such contact is disposable it should be discarded as waste. If it is reusable transmission of infectious agents should be prevented by cleaning, disinfection or sterilization. 7. IMMUNISATION WITH HEP-B VACCINE Every Hospital should have facilities for immunization of all the HCWs against Hepatitis B.

II. CLEANING AND DECONTAMINATION “The ‘environment’ means the totality of a patient’s surroundings which includes the fabric of the building and related fixtures, fittings and services such as air and water supplies. It is the duty of the administration to see to it that all parts of the premises in which it provides health care are suitable for the purpose, are kept clean and are maintained in good physical repair and condition.” The Health Act 2006 Code of Practice for the Prevention and Control of Health Care Associated Infections, Dept. of Health, UK. The cleaning arrangements should 1. Detail the standards of cleanliness required in each part of the premises 2. Make available a schedule of cleaning frequencies 3. Include adequate provision of suitable hand wash facilities and antibacterial hand rubs. 4. Include effective arrangements for the appropriate decontamination of instruments and other equipment.

12 A. SURFACES:

These are meant to be clean and not sterile. Cleanliness can be

ensured only if cleaning is repeated as often as contamination occurs. The physical action of scrubbing with detergents and rinsing with water during environmental cleaning effectively removes 90% of micro-organisms. Non-sporulating bacteria are unlikely to survive on clean surfaces. It is essential that methods of cleaning do not produce aerosols or dispersion of dust in patient care areas. Brooms should not be used in intensive care facilities. Fresh cleaning solution should be made before each cleaning procedure and discarded after use. There should be an area for cleaning and drying of used mops. 1. Floors: Vacuum clean or dry mop twice daily. Wet mop with detergent and phenol (1%) solution. Use 2% if there is obvious contamination. 2. Furniture and ledges: Wet mopping daily with warm water and detergent. 3. Washbasin and sink: Clean with detergent. If contaminated use 0.5%Hypochlorite. 4. Mattresses and pillows: These should be enclosed in a waterproof cover. This should be cleaned with a detergent after a patient is discharged and disinfected with 0.5% hypochlorite, if contaminated. 5. Medicine trays: Keep all trays, with medicines and dressings inside a drawer or closed cupboard. If kept exposed in a tray, keep covered and away from open windows. 6. Toilet seats: Wash daily with detergent and dry. Use 0.5% hypochlorite if soiling with blood is likely as in Urology and Gynaecology units. 7. Beds, bed-frames: For normal cleaning use detergent and hot water. Perform cleaning after discharge of patient and weekly in case of long stay patients. Use 0.5% hypochlorite to disinfect if there is any contamination with blood or body fluids. 8. Cleaning of a room after source isolation of an infected patient: Fumigation of the room or swabbing to monitor effectiveness of the cleaning procedure is NOT needed. a. Cleaner should wear apron and thick household gloves b. Dust the high ledges window frames etc. c. Wet mop all ledges, fixtures and fittings including taps and door handles d. Vacuum clean the floor.

13 e. Wash floor with detergent and 1% phenol solution. f. Wipe mattresses with freshly prepared 0.5% hypochlorite solution. B. EQUIPMENT: Disposables to be discarded after contamination and autoclavable items to be autoclaved after use on one patient. 1. Fibre-optic endoscopes (and other heat sensitive instruments): Manufacturers instructions for sterilization, if present should be followed. i. All accessories should be disconnected as far as possible and immersed in a detergent solution ii. All channels should be flushed and brushed ,if accessible ,to remove all organic materials iii. External surfaces and accessories should be cleaned with a sponge or soft cloth. Accessories that are reusable should be autoclaved iv. Immerse the instrument in 2% Gluteraldehyde, so that all channels are perfused, for 30 minutes. Discard the detergent after use. v. If tuberculosis is suspected, the period of contact may be extended to 1 hr. vi. After disinfection, endoscopes should be rinsed with with sterile water, followed by a rinse with 70% alcohol. 2. Suction equipment: Following use the reservoir should be emptied (according to hospital waste disposal policy) washed with hot water and detergent, rinsed and stored dry. 3. Anaesthetic or ventilator tubings: Wash and sterilize in CSSD. Never use Gluteraldehyde to disinfect respiratory equipment. For patients with tuberculosis or AIDS, use disposable tubing. For ventilator, follow manufacturer’s instructions. Use disposable filters or autoclave between patients. 4. Humidifiers/Nebulizers: Clean and sterilize device between patients. Fill with sterile distilled water which has to be changed every 24hrs, if not used up. 5. Infant incubators: Wash all removable parts, clean with detergent and dry. If contaminated, wipe with 70% ethyl alcohol or isopropyl alcohol (if metallic) and with 0.5%hypochlorite (if plastic).

14

Taken from the Guidelines for prevention of Nosocomial Pneumonia, CDC, Atlanta C. INSTRUMENTS : 1. Speculums and rigid endoscopes: Clean and wash thoroughly. Rinse and dry. Send to CSSD for autoclaving. An alternative is immersion in 2%Gluteraldehyde for 10 minutes after disassembling any accessories. Rinse with sterile distilled water after disinfection. 2. Thermometers: Individual thermometers are recommended for each patient (at least in ICUs). For multi-use, after each use wipe with 70%alcohol and store dry. Wash with detergent at least twice daily. Alternatively, for individual thermometers, wash with detergent and immerse in 70% alcohol for 10 minutes after the patient is discharged. Store dry. 3. Scissors: Surface disinfect with a 70% alcohol wipe. 4. Urinals and bedpans: Wash with detergent between each use. Store dry. Heat disinfect at 80oC between patients, clean and reuse.

15 5. Cheatle forceps: Do not use. If necessary to use, autoclave daily and store dry in a closed container. 6. Oxygen face mask: Wash with detergent and dry if contaminated. Before each use, wipe with 70% ethyl or isopropyl alcohol. SPECIFIC POLICIES I.

WARDS 1. Beds (centre) should be at least 3.6m away from each other. 2. There should be good ventilation. 3. Toilets and baths should be easy to clean and conveniently located. 4. Wash basins to be located within easy walking distance. One wash basin per 6 beds is recommended. 5. Walls and ceilings should be kept in good repair, because micro organisms tend to colonise only walls that are moist or sticky. 6. Pipe penetrations and plumbing fixtures should be smooth, and tightly sealed.. 7. Overcrowding of wards should be avoided. Visiting hours should be fixed for 2 hours daily and only one bystander allowed per patient. 8. It is recommended that food for the patient is provided by the hospital dietary department based on recommendations by the attending doctor /dietician. This will reduce the traffic in the wards during the day. 9. Cleaning schedule should be decided and followed. Brooms which raise dust are NOT recommended. Instead, vacuum cleaning or dry mopping followed by wet mopping may be done at least twice daily and after any contamination. 10. Detergent and 1% phenolic disinfectants may be used for floors. For non-metallic surfaces 0.5% hypochlorite may also be used. 11. 70% ethyl or isopropyl alcohol may be used to wipe medicine trolleys and shelves where instruments or medicines are kept, after thorough wet mopping. Cleaning: Wet mopping with 1% phenol and detergent at least twice daily. 0.5% hypochlorite if there is visible contamination 1% hypochlorite for blood spills. Clean ledges and window frames daily

16 II. INTENSIVE TREATMENT UNITS 1. No bystanders allowed. 2. Restrict entry of visitors to 2hrs per day. 3. Floors and shelves to be cleaned as for wards. 4. Staff should wear masks and aprons while working in the unit. 5. Staff from the unit should not be sent outside for any purpose. 6. Staff from outside should not enter the unit. 7. Ventilators, nebulisers and humidifiers to be cleaned, sterilized/disinfected as recommended above. 8. Environmental samples to be taken and Fumigation to be done only after any renovation work and during outbreak investigation. Routine fumigation or swabbing is not required. III.

OPERATION THEATRES

A. Environment: 1. Positive pressure ventilation, High Efficiency Particulate Air filtration (HEPA) filtered air with at least 20 air exchanges per hour. 2. Temperature – 18-25oC, Humidity – 40 – 60%, Bacterial count of air(using slit samplers) - < 30cfu/m3 3. Air-conditioning – Monitoring and servicing by accredited technicians. 4. Number of staff and movement inside the operating theater – to be minimum. 5. Proper cleaning of the floor, walls and the lights above the operating table is essential B. STAFF & INSTRUMENTS 1. The surgeon, anesthetist and assisting nurse should scrub thoroughly before the procedure. 2. All articles used for surgical procedures must be STERILE. 3. Staff working in the theatre should on no account be sent outside for any errand during working hours. 4. All staff should change to theatre dress before entering. No other staff working in other parts of the hospital should be allowed inside.

17 C. PATIENT 1. Pre-existing skin lesion diabetes and other immunosuppressive condition - to be corrected. 2. Pre-operative stay in hospital – to be kept to a minimum. 3. Pre-operative shaving using razors & brushes – to be avoided. Clip the hair or use depilatory creams. 4. Antibiotic prophylaxis – not to exceed 24 hrs. 5. Operative site - to be disinfected properly. Use 0.5% Chlorhexidine / 10% Povidone Iodine followed by 70% Ethyl alcohol/Iso propanol. First incision to be put only after the alcohol has dried. IV.

NEONATAL UNITS

A. ENVIRONMENT: 1. Floors: Cleaning should be performed in the following order – patient areas, accessory areas and then adjacent halls. Brooms are NOT recommended inside the unit. In the cleaning procedure, dust should not be dispersed into the air. Wet mopping with detergent and 1% phenol/0.5% Hypochlorite should be performed twice daily and at the time of any contamination. Mop heads should be machine laundered and thoroughly dried daily. 2. Surfaces: All ledges and fixtures should be cleaned by wet mopping with detergent once daily. In addition, wipe surfaces where medicines and equipment are kept with 70% ethyl alcohol. Cabinet counters, work surfaces, and similar horizontal areas should be cleaned once a day and between patient use with a disinfectant/detergent and clean cloths, as they may be subject to heavy contamination during routine use. Friction cleaning is important to ensure physical removal of dirt and contaminating microorganisms. 3. Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed periodically with a disinfectant/detergent solution as part of the general housekeeping program. Keep all medicines, vials and other minor equipment in closed shelves if not in use. 4. Sinks should be scrubbed clean at least daily with a detergent. 5. Always keep the doors closed with a self-closing device. 6. There should be a separate isolation room for babies with suspected sepsis, where source isolation precautions are to be followed.

18 B. EQUIPMENT: 1. Cradles / incubators/baby warmers: Surface clean once daily with detergent and 70% ethyl alcohol. The mattresses may be cleaned between babies with detergent and wiped with 70%alcohol. Change sheets daily and use laundered linen from the hospital supply. When the incubators / open care units are being cleaned and disinfected after the baby is discharged, all detachable parts should be removed and scrubbed meticulously. If the incubator has a fan, it should be cleaned and disinfected; the manufacturer’s instructions should be followed to avoid equipment damage. The air filter should be maintained as recommended by the manufacturer. Mattresses should be replaced when the surface covering is broken, because such a break precludes effective disinfection or sterilization. Incubators not in use should be thoroughly dried by running the incubator hot without water in the reservoir for 24 hours after disinfection. Infants who remain in the nursery for an extended period should be transferred periodically to a different, disinfected unit so that the originally occupied unit can be cleaned. 2. Suction catheters: Catheter tips should be sterile, disposable. Keep the bottles and rubber tubes clean and dry when not in use. Wash the bottles with detergent and dry, daily and between patients. Flush catheter with sterile distilled water after each use. C. BABY CARE: 1. Hand washing:

Medical and hospital personnel must follow careful hand-washing

techniques to minimize transmission of disease. The following steps are recommended by the CDC, Atlanta: I. Personnel should remove rings, watches, and bracelets before washing their hands and entering the neonatal nursery. Fingernails should be trimmed short and no nail polish should be permitted. II. Before handling neonates for the first time, personnel should scrub their hands and arms to a point above the elbow thoroughly with an antiseptic soap. After vigorous washing, the hands should be rinsed thoroughly and dried. Antiseptic preparations (e.g. Chlorhexidine 4 % or 70% alcohol ) should be used for scrubbing before entering the nursery, before providing care for neonates, before performing invasive procedures, and after providing care for neonates.

19 III. A 10-second wash without a brush, but with soap and vigorous rubbing followed by thorough rinsing under a stream of water, is required before and after handling each neonate and after touching objects or surfaces likely to be contaminated with virulent microorganisms or hospital pathogens. Hand washing is necessary even when gloves have been worn in direct contact with the infant. Hand washing should immediately follow removal of gloves, before touching another infant. Alcohol-containing foams kill bacteria satisfactorily when applied to clean hands and with sufficient contact. They can be used in areas where no sinks are available or during emergency. But they are not sufficient in cleaning physically soiled hands, because transient organisms are not removed. 2. Feeding of babies Mother' s milk is the best food for both normal and low birth weight babies. The borderline term and growth retarded low birth weight babies can suckle fairly well at the breast and should be given expressed breast milk in preference to formula feeds by appropriate techniques such as clean cup and spoon or cleaned and sterilized ‘gokarnam’. Milk should not be kept for long periods in open containers. The child should be put directly to the breast as soon as possible. (IAP recommendation). The mother may be given appropriate instructions regarding personal hygiene, which should include hand washing techniques: a) Always wash your hands before expressing or handling your milk. b) Be sure to use only clean containers to store expressed milk. Try to use screwcap bottles or hard plastic cups with tight caps. Do not use ordinary plastic bags or formulabottle bags. Do not store milk for more than 1 hr at room temperature. Use chilled milk (kept at 0-4oC) within 24 hours. 3. Invasive procedures: For all invasive procedures, including lumbar puncture, introducing a cannula or withdrawing blood for any investigation, ALL aseptic precautions have to be taken. This includes STERILE gloves and wipe with povidone iodine and 70% alcohol, over the area.

20 CHAPTER 4

ISOLATION POLICY AND OUTBREAK MANAGEMENT 1.ISOLATION STRATEGIES In order to prevent the spread of infectious diseases the patients with communicable diseases were often segregated. However as the knowledge about the different modes of transmission increased the strategies involved have become more evidence based and targeted. Though the Centres for Disease Control (CDC), Atlanta, USA, has published guidelines regarding isolation practices in hospitals, each health care facility should devise its own strategies based on the local needs. Though appropriate door signs may be necessary, care must be taken to ensure no breach of confidentiality and not to stigmatise the patient. Isolation procedures can be divided into two main categories: Protective isolation — This is to prevent infection in immunocompromised patients who are at increased risk of infection both from other patients and from the environment. Isolation measures are usually maximal for those undergoing transplantation. A specialized room with positive pressure ventilation and HEPA filtration is required. Source isolation – A two- tier approach is recommended by the CDC. The Standard precautions are for all patients admitted in the health care facility regardless of their disease status. It reduces the risk of transmission of microbes from both known and unknown sources of infection. These include: hand washing, gloves for body substances, gown if soiling is likely, and mask if splash is likely. The additional precautions are dependent on the different modes of transmission. Under this there are six categories of isolation or precaution: 1.

Strict isolation - Spread is by contact or airborne. Single room with door shut. Gloves, mask and gown for all those who enter. Diseases for which this is needed are – Viral haemorrhagic fevers, pneumonic plague, pharyngeal diphtheria, primary Varicella and disseminated zoster.

21 2.

Contact isolation – Spread is by contact. Single room. May cohort with patients with same infection. Gloves and gown if there is likelihood of contact. Diseases include: Scabies, infection of wounds or burns with multiply resistant organisms(e.g. MRSA), rabies and rubella.

3.

Droplet precautions – Spread is by large droplets. Requires close contact with the person and occurs when the particles come into contact with eyes or mucous membranes of a susceptible person. Single room. May cohort with similar patients, but at least 1 m separation between patients. Gloves and gown if soiling is likely. Masks only for those in close contact. Diseases are: Meningococcal meningitis, measles, mumps, pertussis, H.influenzae epiglottitis.

4.

Airborne precautions – Spread is by small droplets, e.g. pulmonary tuberculosis, where patient is sputum positive. Small droplets remain suspended for longer periods and travel farther. Single room with a negative pressure .At least six changes of air / hour .The air has to be exhausted well away from any air intakes. Masks used should be particulate respirator type with filter. The patient is kept here till at least three consecutive sputum samples become negative for AFB. One month for severely ill patients and those with multi-drug resistant tuberculosis. This is also recommended for HIV infected patients with undiagnosed respiratory infection. Not needed for atypical mycobacterial infection.

5.

Enteric precautions – Diseases spread by faeco oral route. No need of separate room. Toilet facilities may be shared if patient is hygienic. 2. SURVEILLANCE & OUTBREAK MANAGEMENT Surveillance of nosocomial infection is the foundation for organizing and maintaining

an infection control programme. This information obtained should reach those who may influence practice, implement change or provide financial resources necessary to improve outcome. The data also provides a baseline to compare after certain new infection control measures are implemented. When there is an ongoing surveillance programme, any sudden change in the infection rates i.e. outbreak situation, can be noted and infection control action implemented, before the actual outbreak occurs. The process of surveillance incorporates four key stages: Data collection, analysis, interpretation and dissemination.

22 Collection: Methods 1. Continuing Surveillance (CS) of all patients: All records, i.e. clinical, laboratory, nursing etc. are continuously surveyed. This is time-consuming and some specialties may not have any infection. This requires staff, IT resources, and a well organized reporting system. 2. Ward liaison (WL): Twice weekly visits to wards and review records. 3. Laboratory based: Laboratory records only. Depends wholly on the kind of investigation done 4. Laboratory based Ward Surveillance (LBWS): Follow up lab records in the ward. This is more accurate. 5. LBWS + WL: Time consuming but more accurate. 6. Targeted surveillance: Only high risk areas, e.g. ICUs, newborn units etc. A minimum data set for surveillance includes: Name/Hospital no. Date of birth Sex Ward/Unit Name of consultant Date of admission

Organism isolated/suspected Antibiotic sensitivity Treatment given Other risk factors Outcome Date of discharge/death

Date of onset of infection Site of infection

Surveillance methods should be flexible enough to accommodate technological changes, shortening lengths of stay and to include procedures carried out after discharge in the community. Analysis: A simple comparison of actual number of cases with the expected number is routinely carried out Validity of data - Incidence increases when there is awareness of a problem,

23 improved diagnostic methods, ongoing screening programmes and higher reporting propensity. Interpretation The data generated should be appropriately risk adjusted, for meaningful infection rates. Clearly defined surveillance objectives can overcome problems of data interpretation. Dissemination  Active participation by all those who are engaged in filling forms and updating data is ensured only when the final information from the various parts of the hospital is analyzed and sent back to them as useful information that helps in their day-to-day clinical work. The main objectives of surveillance should be: 1. Establishing endemic infection rates 2. Comparing infection rates between health care establishments 3. Evaluating control measures 4. Identifying outbreaks 5. General reduction of nosocomial infection rate. Lab personnel or clinicians cannot be expected to conduct a surveillance programme. This can be assigned to the Infection Control Lab and the ICD with the help of the ICN can coordinate the data collection. Analysis and interpretation can be done by an Epidemiologist who is part of the ICT. An outbreak situation is detected and can be immediately brought under control if their activities are well coordinated by the ICD. In the absence of an outbreak, the data may be used by the administrators to convince the media and general public about the effective infection control precautions taken by the administration. The ICD and ICN use the data to monitor infection rates in wards and ICUs and post-operative infection rates. This helps in targeting continuing education programmes and evaluating any gaps in implementation of the hygiene policies of the hospital. OUTBREAKS AND THEIR MANAGEMENT Outbreaks within hospitals can involve the whole hospital, one theatre, one ward ,one unit or one wing of the hospital The exact measures taken depends on the kind of infection

24 and its mode of spread. The ICT with the help of the hospital management has to plan the steps to be taken and implement it on a day-day basis. The basic steps of outbreak control alone are discussed here: 1. Surveillance data indicate an outbreak situation. 2. Confirm the existence of an outbreak by comparison with previous data. An outbreak is the occurrence of an infection at a rate greater than that expected within a defined area (unit or ICU or theatre or ward) over a defined period of time e.g. one month or one week. 3. Create a case definition, i.e. the cases that come under the label ‘outbreak case’, should be similar clinically / laboratory wise or both. 4. Identify the index case and construct an epidemic curve in time. This will help in narrowing down the source and mode of transmission. 5. Screen the staff (for carrier state) and environment, if necessary. 6. Take immediate control measures e.g. close down the ICU or source ward/theatre, any major defects like a break in the chain of waste disposal or sudden shortage of cleaning staff in that ward will have to be addressed on an urgent basis. 7. Summarise the investigation and report on steps taken and disseminate the information to the appropriate authorities. Communicate this information to the personnel involved, in the hospital. 8. Implement long-term measures so that such an outbreak does not occur in the future.

25 CHAPER 5

ANTIBIOTIC POLICY An antibiotic policy is not a restriction on the independence to prescribe antibiotics, but a sensible guide to the practicing doctor on how to manage infections in the most effective manner. The policy will help the doctor solve the most important problems of rapidity of action, cost and availability, best route of administration, the most effective dose and duration of therapy. Generally the microbiologist insists that the antibiotic should be given according to the pattern of sensitivity obtained after the organism is grown and identified. This takes a minimum of 24- 48 hrs. Many of the infections can be diagnosed clinically, e.g. meningitis, lobar pneumonia, infective endocarditis, enteric fever etc. and need early treatment. The antibiotic policy will help in the following ways: 1. Giving the correct advice to the clinician regarding the antibiotic to be started, after appropriate cultures have been taken. The sensitivity report will then confirm whether the same antibiotics may be continued. If the policy is good, there will be almost no change in the antibiotics started. 2. Another important bonus to the administration is that the number of multi drug resistant strains that typically cause nosocomial outbreaks will also dramatically decrease. 3. The pharmacy can order the needed antibiotics in greater quantities rather than spreading out the resources over drugs that are rarely needed. The ICT cannot make this policy on its own. The HICC has a big role here. Since all the specialists are members, the policy may be made by the Microbiologist or Infectious disease specialist, after receiving suggestions from all of them. The policy can be reviewed by the committee every year and updated. It should be available for easy reference in tabular form in all the wards, ICUs and casualty services. If the hospital has a computer networking system, this will help in easy dissemination to all the medical officers.

26 The following policy is based on one followed by the National Health Services (NHS), UK. These guidelines were developed by a multi-disciplinary working group to ensure balanced input. It has considered the antimicrobial choice for specific conditions, and the existing policies for specific agents. By following the guidelines it will be possible to maintain a high standard of patient care, delivered in a consistent way, by all the doctors in the hospital. It may be modified appropriately based on cost and availability. INDICATIONS FOR ANTIMICROBIAL THERAPY The use of antimicrobials has adverse consequences which compromise the efficacy of therapy for individual patients and the hospital as a whole. These include: 1. Adverse drug-related effects for patients 2. Alteration of normal flora leading to superinfection with organisms such as Pseudomonas aeruginosa, Candida spp. and Clostridium difficile. 3. Selection of drug-resistant strains 4. Increased rates of cross infection 5. Unnecessary cost The decision to use antimicrobial agents must take these effects into account and is always a balance of risk against benefit. Directed Therapy Antimicrobial treatment should normally be directed by the results of microbiological investigations confirming the presence of a true infection which is amenable to antimicrobial therapy. Empiric Therapy Where delay in initiating therapy to await microbiological results would be life threatening or risk serious morbidity antimicrobial therapy based on a clinically defined infection is justified.

Where empiric therapy is used the accuracy of diagnosis should be reviewed

regularly and treatment altered/stopped when microbiological results become available. Microbiological samples must always be sent prior to initiating antimicrobial therapy. Rapid tests, such as Gram films, can help determine therapeutic choices when empiric therapy is required.

27 CHOICE OF ANTIMICROBIAL The sections in this policy indicate the suggested approach to treating the most common forms of infection encountered in a hospital setting. The use of a restricted range of antimicrobial agents provides greater familiarity with their efficacy and potential side effects. It also allows the Microbiology services to provide appropriate sensitivity data to guide therapy. However this general guidance is not applicable to all patients. The choice of antimicrobial may need to be modified in the following situations: 1. Hypersensitivity to first choice antimicrobial (see guidance on hypersensitivity) 2. Recent antimicrobial therapy or preceding cultures indicating presence of resistant organisms 3. In pregnant or lactating patients 4. In renal or hepatic failure MONITORING TREATMENT The continued need for antimicrobial therapy should be reviewed at least daily. For most types of infection treatment should continue until the clinical signs and symptoms of infection have resolved – exceptions to this are indicated in the relevant sections. Parenteral therapy is normally used in seriously ill patients and those with gastrointestinal upset. Oral therapy can often be substituted as the patient improves. Where treatment is apparently failing, advice from a clinical microbiologist should normally be sought rather than blindly changing to an alternative choice of antimicrobial agent.

ANTIBIOTIC POLICY 1. SPECIFIC GASTROINTESTINAL INFECTIONS

As most cases of gastroenteritis are self-limiting, antimicrobials are not indicated and management should focus on fluid and electrolyte replacement. Furthermore, many cases have a viral aetiology and current antimicrobials are ineffective. Moreover, in some situations, antimicrobial therapy may be associated with an adverse clinical outcome.

28 Shigellosis and Salmonellosis: First choice: Ciprofloxacin 500mg po bd for 5 days. Although this can be commenced empirically, it should be noted that resistance to ciprofloxacin is increasing and therapy may have to be modified according to in-vitro susceptibility testing. Second choice: III gen. Cephalosporins, especially for children. Giardiasis and amoebiasis: First choice: Metronidazole 2g daily for 3 days (if tolerated) or 400mg tds for 5 days. Second choice: single dose Tinidazole 2g 2. COMMUNITY ACQUIRED PNEUMONIA

Pneumonia is defined as ' community acquired'if it presents within the first three days of hospital admission. Mild - moderate infection Amoxicillin 500mg TDS PO Penicillin allergy - Erythromycin 500mg QDS PO/Azithromycin Severe infection Crystalline penicillin IV Penicillin allergy - Cefuroxime 1.5g TDS IV Continue IV therapy for at least 24 hours. Severe CAP - 10 to 14 days treatment Staphylococcus suspected (eg post influenza during epidemics and cavitation seen on CXR) add Cloxacillin 1g 6th hrly IV. 3.

COMMUNITY ACQUIRED MENINGITIS

If meningitis is suspected, take blood samples and then give antibiotics before LP or CT scan. LP may be done within one hour of starting antibiotics. If confident that patient has typical meningococcal rash and no allergy - Benzyl penicillin 2.4g IV every 4 hours. If adult without a typical meningococcal rash - Cefotaxime IV 2g QDS. If patient > 50 years, or immuno-compromised, or pregnant, and no typical meningococcal rash - consider adding Amoxicillin 2g IV every 4 hours (to cover listeriosis) For suspected meningococcal contacts(Prophylaxis): Adults - Rifampicin 600mg PO every 12 hours for 2 days Children over 1 year - Rifampicin 10mg/kg PO every 12 hours for 2 days Children under 1 year - Rifampicin 5mg/kg PO every 12 hours for 2 days Pregnant females - Ceftriaxone 250mg IM stat

29 4. UNCOMPLICATED URINARY TRACT INFECTION (UTI) Clinical signs: Dysuria, frequency, nocturia Lower abdominal pain or discomfort Asymptomatic bacteriuria is common in elderly patients, suggest treating bacteriuria in elderly patients if symptomatic NB Mild symptoms may not require antibiotic treatment. Mild clinical signs – Consider non drug treatment until MSU available - > 2L oral fluids per day Trimethoprim 200mg BD for 3 days Or Nitrofurantoin 50mg QDS for 7 days If there is no response, send urine for culture and treat accordingly. Pregnancy – III gen. Cephalosporin,oral/IV(asymptomatic bacteriuria is common and should be treated. Clinical signs:

5. PYELONEPHRITIS

Pyrexia, rigors, loin pain +/- urinary tract symptoms and renal colic Initial antimicrobial therapy is almost always given intravenously. Cefuroxime IV 750mg TDS for at least 5 days. > 2L oral fluids per day. Culture negative MSU with pyuria and/or persistent symptoms - consider urethritis including Chlamydia or TB. Refer to Urologist after first time in males and second UTI in females. 5. PELVIC INFLAMMATORY DISEASE (PID) Empirical treatment of PID should be initiated in sexually active young women and others at risk of sexually transmitted diseases if all the following minimum criteria are present, and no other cause for illness can be identified: Lower abdominal tenderness Adnexal tenderness Cervical motion tenderness (' cervical excitation' ) All patients should have a negative pregnancy test and ectopic pregnancy, appendicitis and ovarian cysts excluded before a diagnosis of PID is made.

30 Delay in diagnosis and effective treatment for PID can increase the risk of tubal damage. Therefore, treatment should start immediately, without waiting for the results of the swabs. The patient' s sexual partner must have antibiotic therapy to prevent possible reinfection. She should be advised to abstain from sexual intercourse until both she and her partner have completed the antibiotics. Outpatient Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days Or Ceftriaxone 250mg IM stat Inpatient Cefuroxime 750mg IV TDS and Metronidazole 500mg IV TDS Or Metronidazole 1g PR TDS and Doxycycline 100mg PO BD IV therapy should continue for a minimum of 24 - 48 hours, then: Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days 6. OTITIS MEDIA

Inflammation of the middle ear which may be followed by profuse purulent discharge as the ear-drum perforates. Discharge usually settles after a few days. Continuing discharge may indicate mastoiditis. It may be associated with an obstruction of the eustachian tube. Non antibiotic treatment: Drain pus through acute perforation, clean debris Analgesics such as paracetamol, NSAIDS and dihydrocodeine Decongestants may be of some benefit. Amoxicillin PO 500mg TDS for 5 days Treatment failure Cefaclor PO 500mg TDS for 5 days 7.TONSILLO PHARYNGITIS

Inflammation of the part of the throat behind the soft palate and/or tonsils due to bacterial or viral infection causing a sore throat, fever and dysphagia. There is little evidence that antibiotics are beneficial unless quinsy or necrosis are suspected. Non antibiotic treatment: Warm saline throat irrigations Throat lozenges containing local anaesthetics Analgesics such as paracetamol, NSAIDS and dihydrocodeine. Penicillin V PO 500mg QDS for 10 days

31 Treatment failure / Penicillin allergic Erythromycin PO 250mg QDS for 10 days Severe infection Parenteral treatment may be required Benzylpenicillin IV 1.2g QDS Treatment failure / Penicillin allergic Clarithromycin IV 500mg BD 8.CELLULITIS / ERYSIPELAS

Intravenous antibiotics are required if patient meets one of the following criteria: Systemically unwell Rapidly spreading or extensive disease Immuno-compromised Cloxacillin IV 1 - 2g QID and Benzylpenicillin IV 1.2 - 2.4g every 4 to 6 hours If confident of diagnosis of erysipelas, omit Cloxacillin IV Add Metronidazole 500mg TDS in diabetic patients After 48 - 72 hours if appropriate oral therapy can replace Parenteral : Cloxacillin 1g QID and Amoxicillin 1g TDS 9. ENTERIC FEVER Oral antibiotics are best to tackle the infection in the Peyer’s patches. Though oral route is recommended for uncomplicated cases, parenteral Ciprofloxacin is recommended in the presence of complications, with switch over to oral route after the symptoms have resolved. Ciprofloxacin resistance is coming up due to the continued misuse of quinolones in wound infections and common respiratory infections. In such cases, parenteral third gen. cephalosporin followed by oral Cefixime is recommended. Ciprofloxacin 250mg TDS IV or 750mg BD orally for 10 – 14 days is the drug of choice. These are only the common infections. A comprehensive list can be made after discussion with specialists. The basic principle is that simpler antibiotics are used first to preserve the efficiency of higher ones. If this is followed by all the doctors in a hospital and then the peripheral hospitals and dispensaries are also made aware, spread of multi drug resistant strains in the hospitals can be reduced, In addition the total cost of treatment of infections is reduced significantly.