This presentation is the gist of hospital infection control. Has touched all important policies and parameters involved in infection control in a healthcare settings in brief.

1. PRINCIPLES AND PRACTICES
IN HOSPITAL INFECTION
CONTROL
Maj (Dr) Shilpi Gupta
Gd Spl (Microbiology)

2. 1. Introduction
2. Definitions and types of Healthcare associated infections (HCAI)
3. Organisation of Hospital Infection Control Committee (HICC)
4. Various parameters under Hospital Infection Control (HIC)
(a) Surveillance
(b) Standard precautions
(c) Infection control in ICU and OT
(d) Antimicrobial Stewardship Program
5. Conclusion

3. She was progressing in the neonatal intensive
care unit until she developed a bloodstream
infection related to her umbilical catheter.
A baby was born prematurely.

4. The surgery goes well but he later dies in a
nursing home of a MRSA wound infection that
developed after surgery.
An adult has open heart surgery.

5. She has lived with this unbearable
infection through 6 months of relapses.
A lady contracts Clostridium difficile
after giving birth.

6. A lady is being treated for cancer
• And now has to fight two diseases because she got
Hepatitis C from an unsafe injection

8. Florence Nightingale, Notes on Hospitals, 1863
It may seem a strange principle
to enunciate as the very first
requirement
of a hospital is
that it do the sick no harm

9. INTRODUCTION
• In 1972 – Centers for Disease Control and Prevention (CDC)
initiated the hospital infection branch.
• Infection control
– prevention and management of infection
– application of research based knowledge to practices.

10. IMPORTANCE
HCAI Developed
countries
Developing
countries
Hospitalized
patients
3.5%-12% 5.7%-19.1%
ICU settings Upto 51% Upto 88.9%
http://www.who.int/csr/bioriskreduction/infection_control/en/index.html

11. Occurrence
of HCAI
Added
burden
to the
hospital
Increase
length of
stay
Increase
cost
Increase
morbidity
&
mortality

12. HEALTH ECONOMICS RELATED TO HCAI
PARAMETER NON - INFECTED HCAI INFECTED
Mean mortality 2.5 % 8.75 %
Mean LOS ICU 2.27 days 8 days
Mean LOS Hospital 10.3 days 33.5 days
Costs (Bed charges,
pharmacy, bedside
procedures, consumables,
investigations, consultation)
$ 2268 $ 7186

13. DEFINITION
• Earlier Nosocomial infection
• Healthcare associated infection (HCAI)
• Infection neither present nor incubating at the time of admission
and becomes apparent after 48 hrs of hospital admission

14. TYPES OF HOSPITAL ACQURIED INFECTION
HCAI
Surgical site
infection
Urinary tract
infection
Respiratory infection
(VAP/HAP)
Blood stream
infections (CLABSI)

15. CAUSATIVE MICROORGANISMS
• Two-third of total infections are 6 ESKAPE organisms

16. CAUSATIVE MICROORGANISMS contd...
• Other Bacterial organism
• Burkholderia cepacia
• Stenotrophomonas maltophilia
• Clostridium difficile
• Candida spp.
• Virus
• HBV, HCV, HIV
• Respiratory viruses

17. RISK FACTORS
• Hands of HCWs
• Invasive procedures
Iatrogenic
• Contaminated air conditioning
system
• Contaminated water
• Contaminated instruments
Organisational
• Severity of illness
• Immuno-compromised state
• Length of stay
Patient related

18. ORGANISATION OF HICC
Chairperson: MS/ Dean
Member Secretary: Senior
Microbiologist
Members: HODs/ MOI/c Dept and
wards,Addl MS, Nursing suptd
Support services: OI/C CSSD, BMW,
Med Store
Infection Control Team (ICT)

19. INFECTION CONTROL TEAM (ICT)
Comprises of
• Infection Control Officer (ICO) - Microbiologist
• Infection Control Nurse (ICN)

20. Schematic Representation of Working of ICT
HODs / In-charge
of clinical
dept./wards
Daily ward
rounds
Obsn on IC
procedures &
practices
Training
program
Surveillance of
HCAI
ICN
ICO
Chairperson
Coordinate
lab findings
with cases
Formulate
A/B policy
Data
compilation
Secretary

21. PARAMETERS UNDER
HIC

22. SURVEILLANCE
• Recording and counting of infections arising in the hospital
• Important means of monitoring HCAI
• Determined in term of rates

23. OBJECTIVE OF SURVEILLANCE
• Establish endemic baseline rate.
• To establish priorities for infection control activities.
• To identify trends manifested over a finite period.
• Evaluating and monitoring infection control measures.

24. TYPES OF SURVEILLANCE
Passive
Lab based
Alert organisms
- Multidrug resistant
organism (MDRO)
- MDR GNB, MRSA,
VRE
Ward based
Alert conditions
- Chicken pox
- Post surgical sepsis
Active
High risk area
– Operation Theatres
– ICU, NICU, PICU
- Burns, Dialysis
units, Labour room
- CSSD
-

25. STANDARD PRECAUTIONS

26. HISTORY OF INFECTION CONTROL PRECAUTION
• UNIVERSAL PRECAUTIONS
• HIV & other blood borne infections
1985
• BODY SUBSTANCE ISOLATION
• Blood & body fluids
1987
• STANDARD PRECAUTION
• TRANSMISSION BASED PRECAUTION
(hospitalized)
1996
• ISOLATION PRECAUTIONS
• SARS-CoV-1, H1N1
2007

27. 1.HAND HYGIENE
3. ISOLATION PRECAUTIONs
2.PPE
4. STERILIZATION AND
DISINFECTION
5. ENVIRONMENTAL
INFECTION PREVENTION AND
CONTROL
KEY ELEMENTS OF STANDARD
PRECAUTION

28. Improved Patient Outcomes Associated
With Proper Hand Hygiene
Ignaz Philipp Semmelweis
(1818-1865)
Chlorinated lime hand antisepsis

29. Impact of Hand Hygiene on Hospital Infections
YEAR AUTHOR SETTING DURATION IMPACT ON INFECTION RATE
1977 Casewell et al Adult ICU 2 years Klebsiella spp. decreased
1989 Konly JM Hospital 6 years HCAI decreased (33% to 12%)
1994 Webster NICU 9 mon MRSA eliminated
2003 McDonald Orthopaedic 10 mon HCAI decreased (36%)
SSI rates (8.2% to 5.3%)
2007 Archibald et al Neurosurgery 2 years SSI rates decreased (54%)
2007 Pessoa S et al Neonatal unit 27 mon Decrease in HCAI in VLBW
neonates
(15.5 to 8.8/ 1000 patient-days)
2008 Ngyun et al Urology 6 mon HCAI rates (13.1 – 2.1%)
2011 Chen Y Hosp wide 4 years MRSA and MDR Acinetobacter
decreased
2017 Ahmad Hosp wide 6 mon HCAI decreased

30. HAND HYGIENE
• When to observe?
• How to observe?

31. HAND HYGIENE
When to observe ?
• The “My 5 Moments for Hand Hygiene”approach

32. HAND HYGIENE
How to observe ?
• Hand wash
• Availability of soap, scrubs
• Hand rubs (alcohol based)
- Availability of gels, solutions
Note: Hands should always be washed whenever soiled

33. Areas Most Frequently Missed
HAHS © 1999

35. PERSONAL PROTECTIVE EQUIPMENT (PPE)

36. TRANSMISSION BASED PRECAUTIONS
Types
Mode of
transmission
Examples
Contact
HCW,
environment
&/or eqpt
MRSA, MDR
GNB, C. difficile
Gloves
Gowns
Airborne
Air currents
Tuberculosis,
measles, Chicken
pox
N 95 mask
Droplet
Droplets
Mumps,
influenza, N.
meningitidis
Mask
PPE

37. ISOLATION ROOM
Ref: Shweta K, Gupta SK, Chandrashekhar R, Kant S. Planning and Designing an Isolation Facility in Hospitals: Need of the Hour. Int J Res
Foundation Hosp Healthc Adm 2015;3(1):48-56.
Positive Pressure
Room
Negative Pressure
Room

38. FUNCTIONAL CLASSIFICATION ISOLATION ROOMS
Features S Standard N Negative P Positive
Basic facilities
(separate area,
dedicated eqpt)
Present Present Present
Key ventilation
criteria
No air pressure
difference
Air pressure in room
lesser than in
adjacent area
Air pressure in room
is greater than in
adjacent corridor
Transmission
based
precautions
Contact or droplet Airborne Prevention of infection
immunosuppressed
Examples • MRSA
• MDR GNB
• Gastroenteritis
• COVID 19
• Chicken pox
• Tuberculosis
• Aspergillosis in bone-
marrow transplant
recipients

39. STERILIZATION & DISINFECTION
• Sterilization is defined as a process where all microbes are
removed from a defined object, inclusive of bacterial spores
• Disinfection is a process where most microbes are removed from
defined object or surface, except spores
• Antisepsis is a process of removal of germs from the living tissue
or skin.

40. SPAULDING CLASSIFICATION
CLASSIFICA
TION
DEFINITION EXAMPLES PROCESSING
Critical Enters sterile tissue
including the vascular
system
• Surgical instruments
• Biopsy instruments
Sterilization
Semicritical Contacts non-intact
skin or mucous
membranes but do not
penetrate them
• Anaesthesia equipment
• Endoscopes
High level
disinfection
(sterilization preferred
if heat tolerable)
Noncritical Touches only intact
skin and not mucous
membranes
• ECG leads
• BP cuffs
• Bedpans
• Stethoscope
Low level
disinfection

41. METHODS OF STERILIZATION
HEAT
STERILIZATION
CHEMICAL
STERILIZATION
RADIATION
STERILIZATION
Steam (autoclave) Ethylene oxide Non ionizing
radiation
- UV irradiation
Hot air oven Glutaraldehyde based
formulations
Hydrogen peroxide
Peracetic acid
Ionizing radiation
- X-ray
- Gamma

42. CLASSIFICATION OF DISINFECTANTS
HIGH LEVEL INTERMEDIATE
LEVEL
LOW LEVEL
Ethylene oxide Ethyl or Isopropyl
alcohol (70%)
Quaternary
ammonium
compounds
(chlorhexidine)
2% Glutaraldehyde Hydrogen peroxide
1% Sodium
hypochlorite
Phenolic solutions

43. POINTS TO NOTE
Cleaning before sterilization
Concentration
Duration or contact time

44. Monitoring of autoclave
TYPE FREQUENCY QUALITY INDICATOR
Mechanical With each cycle Temperature
Pressure
Time
Chemical With each load Chemical indicator tape
Biological Weekly Spores of Bacillus
stearothermophilus

45. Monitoring
Chemical indicator tape Biological indicator Test strips

46. ENVIRONMENTAL INFECTION PREVENTION AND
CONTROL

47. GENERAL PRINCIPLES FOR CLEANING AND
DISINFECTING ENVIRONMENTAL SURFACES
Division of area
• High touch
• Low touch
Frequency
• More in high risk areas
Cleaning procedures
• Wet mopping recommended
• Proceed from cleaner to dirtier area
Use of disinfectant
• Type
• Appropriate dilution
Source: Manual Guide for Environmental Cleaning and Disinfection, Ministry Of Health Infection Control
Directorate 2016

48. INFECTION CONTROL IN ICU
• Objective: To reduce occurrence of Device associated
hospital acquired infections (DA-HAI)
• Infection in a patient with a device (i.e., central line, ventilator, or indwelling
urinary catheter) that was in use within the 48-hour period before onset of
infection.
• Central line associated blood stream infections (CLABSI)
• Ventilator associated pneumonia (VAP)
• Catheter associated urinary tract infections (CAUTI)

49. INDIAN STUDIES
Study
period
Place of
study
HAI
incidence
VAP CAUTI CLABSI Reference
2004-2005 New Delhi 34.1% 31.4 11.2 3.4 Habibi et al
2006-2007 Puducherry NA 30.6 NA NA Joseph et al
2010-2011 Chandigarh 29.1% 6.0 9.08 13.8 Datta P et al
2009-2010 Pune 17.6% 32 9 16 Singh et al
2010-2011 Vellore NA 40.1 NA NA Mathai et al
2011-2013 Puducherry 50.2% 72.5 12.4 3.9 Bammi et al
2015-2016 New Delhi NA 16.7 7.3 10.3 Bineeta et al

50. WARNING
Nosocomial Infections in ICU are Waiting

51. CARE BUNDLES
• A care bundle is a collection of preventive
interventions that are evidence based such that
the application of all the interventions is
consistent for all the patients at all times to
prevent DA-HAI.

52. VAP BUNDLE
• Hand hygiene
• Elevation of head end of bed (30˚– 45˚)
• Oral care with 2% chlorhexidine 4-6 hourly
• Avoid use stress ulcer prophylaxis who are not at risk
• Daily assessment of readiness to wean and use of weaning protocols
• Review necessity of ventilator daily

53. CAUTI BUNDLE
• Hand hygiene
• Urinary Flow
• Meatal Care
• Catheter change interval – unless infected
• Irrigation with antimicrobials – not advised
• Review necessity of catheter daily

54. CLABSI BUNDLE
• Hand hygiene
• Avoid femoral vein for central venous access
• Insertion with maximal sterile barrier (MSB) precautions
• Skin antisepsis with 2% chlorhexidine
• Review necessity of CVC daily

56. INFECTION CONTROL IN OT
• Objective: To reduce surgical site infections (SSI)

57. RISK FACTORS FOR SSI
Pre-operative
• Pre-op bathing
• Surgical
antimicrobial
prophylaxis
(SAP)
• Hair removal
• Site preparation
• Surgical hand
hygiene
Intra-operative
• Perioperative
oxygen
• Maintaining
normothermia
• Blood glucose
control
• Appropriate &
adequate use of
PPE
• HVAC system
Post-operative
• Surgical wound
dressing
• Blood glucose
control
Source: Global guidelines for the prevention of surgical site infection, WHO, 2018

58. PARAMETERS OF HEATING VENTILATION AIR
CONDITIONING (HVAC)SYSTEM
HVAC
system
Temper-
ature
Humidity
Pressure
Air flow
Air
quality

59. RECOMMENDATIONS FOR HVAC SYSTEM FOR OT
Parameter Requirement Remarks
Temperature 21 °C +/- 3 °C For Ortho for Joints replacement as 18° C +/-
2° C)
Humidity 20 to 60% Ideal RH is considered to be 55%
Pressure 2.5 Pascal Positive pressure maintained between OT
and adjoining areas at all times
Air changes per
hour (ACH)
4 - 20 ACH Minimum 4 fresh air changes out of total
minimum 20 air changes.
Air velocity 25-35 FPM (feet per
minute)
Airflow needs to be unidirectional and
downwards on the OT table.
Air Quality HEPA (High-efficiency
particulate arrestance)
filters
Filtration area should extend one feet on
each side of the OT table
Source: REVISED GUIDELINES FOR AIR CONDITIONING IN OPERATION THEATRES.
NABH-Air Conditioning 2018

60. AIR FLOW AND FILTERS

61. VALIDATION OF HVAC SYSTEM
Temperature and
Humidity check
Air Change Rate
Calculation
Validation of HEPA Filters by
appropriate tests like DOP
(Dispersed Oil Particulate)
Pressure Differential
levels of the OT with
adjoining areas
Air velocity at outlet of
terminal filtration unit

62. ANTIMICROBIAL STEWARDSHIP

64. ANTIMICROBIAL PRESCRIBING FACT: THE 30% RULE
30%
Hospitalized
patient receive
A/B
Antibiotics
prescribed
inappropriately in
community
Surgical
prophylaxis is
inappropriate
Antimicrobial cost
can be saved by
AMSP

65. WHAT IS ANTIMICROBIAL STEWARDSHIP?
• DEFINITION: Coordinated interventions designed to measure
and improve the appropriate use of antimicrobial agents by
promoting optimal antimicrobial drug regimen.
Drug selection
Dosing
Route of administration and
Duration of therapy
Source: Antimicrobial Stewardship program Guideline (2018), Indian Council of Medical Research (ICMR)

66. AMSP TEAM
Ideal
Stewardship
team
ID
Physician
Pharmac
-ists
Clinical
Microbio-
logist
HICC
Source: Antimicrobial Stewardship program Guideline (2018), Indian Council of Medical Research (ICMR)

67. COMPONENTS OF AMSP
AMSP
Antibiotic
policy
Prescription
Audit
Formulary
restriction/
Preauthori-
zation
Streamlining
/ de-
escalation
Infection
control
Education
Source: Antimicrobial Stewardship program Guideline
(2018), ICMR

68. ANTIBIOTIC POLICY
• Antibiotic policy is to be prepared by the antimicrobial
stewardship team.
• Objectives:
• To achieve best clinical outcomes
• Limiting the selective pressure
• Reduce excessive costs
• The policy is reviewed and updated annually

69. NATIONAL GUIDELINES FOR ANTIBIOTIC POLICY
• Treatment Guidelines for Antimicrobial Use in Common
Syndromes. Indian Council of Medical Research (ICMR)
Department of Health Research New Delhi, India 2019.
• NCDC(MOHFW) has launched National Treatment Guidelines
for Antimicrobial Use in Infectious Diseases (Version 1.0
(2016).
• Antibiotic policy, Dept of Medicine with multidisciplinary
collaboration, AIIMS New Delhi.

70. Key Prevention Strategies
 Prevent infection
 Diagnose and treat infection
effectively
 Use antimicrobials wisely
 Prevent transmission

71. CONCLUSION
• HIC is a multidisciplinary team approach
• Standard Precautions – Minimum preventive measure
followed at all times, for all patients and in all situation
• Bundle care in critical settings is the need of hour
• Using antibiotics rationally with an implementable antibiotic
policy

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