This document discusses hospital acquired infections and infection control in a healthcare setting. It begins by outlining the goals of infection control training, which are to ensure healthcare workers understand how pathogens can be transmitted, apply accepted infection control principles, and minimize transmission. It then provides a brief history of hygiene and discusses definitions such as hospital acquired infections. It outlines the public health importance of hospital infections, including increased mortality, morbidity, and costs. It discusses sources, routes of transmission, and factors influencing hospital acquired infections. It also describes common infection sites and criteria. The document concludes by outlining various infection control strategies including standard precautions, isolation precautions, prevention of specific infections like urinary tract and surgical site infections, and the importance of

1. HOSPITAL AQUIRED INFECTIONS
&
INFECTION CONTROL IN A HEALTH
CARE SETUP
Dr. SUMI NANDWANI

3. Goals of Infection Control
Training
• Ensure that health professionals understand how
pathogens can be transmitted in the work environment
(patient to healthcare worker, healthcare worker to
patient and patient to patient )
• Apply current scientifically accepted infection control
principles
• Minimize opportunity for transmission of pathogens to
patients and healthcare workers

4. Points to be discussed …………
 History of Hygiene
 Overview : Hospital Aquired infections (HAI)
 Other definitions
 Public Health Importance, Consequences
 Sources, Routes of Transmission & Factors influencing HAI
 Sites and Criteria for HAI
 Control of HAI
 Take Home Message

5. History of Hygiene
Greek Era : Aristotle
recommended Boiling water
to armies. Advised the
Alexander
Semmelweis: Practiced & emphasizes
the importance of washing hands with
chlorinated water in Obstetrics to
reduce maternal mortality

6. Historical Aspects Changed
the History
1867 –Dr. Joseph Lister first
identifies airborne bacteria and
uses Carbolic acid spray in surgical
areas
1880 – Johnson and Johnson
introduce antiseptic surgical
dressings.
Reduction of Hospital associated
infections
Mortality reduced
Morbidity reduced

7. What are Hospital Acquired Infections ?
(Nosocomial Infections, Health Care Associated
Infections)
Any infection that is not present
or incubating at the time the
patient is admitted to the hospital
This includes infections acquired
in the hospital but appearing
after discharge, and also
occupational infections among
staff of the facility

8. Other definitions
Community Acquired Infection
An infection Present or Incubating at the time of admission to
a health care facility without any association to previous
hospitalization at the same facility
Colonization
The presence of microorganism in or on a host, with growth
and multiplication but without tissue invasion or damage
Contamination
The presence of microorganism on inanimate objects
(Clothing, surgical instruments, water, food, milk ) or in
substances

9. Public Health Importance
Major public health problem
Incidence- 2% to 12% in the developed countries
The overall incidence in various hospitals in India varies
between 10-20% (inadequately reported/ under reported)
The incidence depends on type of hospital, type of patients and
the type of surgeries performed.

10. Consequences of Hospital Infections
Prolongs hospital stay. An estimated 1 to 4 extra days for a urinary tract
infection, 7 – 8 days for a surgical site infection, 7 – 21 days for a blood
stream infection, and 7 – 30 days for pneumonia.
Extra expenses US$5 billion are added to US health costs every year as a
result of NI
The patient suffers bodily mentally and economically.
Increase in mortality rate
Law suits
Technical competence of experienced doctors turned into disaster
Quality of care suffers and it leads to bad public image
Infected patients are twice as likely to die, twice as likely to spend time in
ICU and five times more likely to be readmitted after discharge

11. Source of HAI
 Endogenous : normal flora of the patient- About 50% of N.I.
 Exogenous :
1. Other patients and environment
2. Hospital personnel (surgical team/staff)
3. Inanimate objects-Tools, instruments, and materials used
4. Seeding from distant focus of infection (prosthetic
device, implants)
 Good infrastructures do not mean a safe environment

12. Routes of Transmission
Transmission
Contact Transmission
Direct
Indirect
Droplet Transmission
Airborne Transmission
Common Vehicle Transmission(uncommon)
Vector-borne Transmission (uncommon)

13. Factors Influencing H.A.I.
The microbial agent
Patient susceptibility
Environmental factors

14.  Urinary tract infection: most common type of N I (30-
40% of reported cases), associated with an indwelling
urinary catheter or instrumentation.
 Lower respiratory and surgical wound infections are
the next ( each about 15%).
 Less frequent include bacteraemia (5%), intravenous
site infection, gastrointestinal tract and skin infections.
Nosocomial Infection Sites

15. Criteria of Nosocomial Infections
Surgical site infection Any purulent discharge, abscess or
spreading cellulitis at the surgical
site during the month after operation
Urinary infection Positive urine culture (1 or 2
species) with at least 100000
bacteria/ml, with or without clinical
symptoms
Respiratory infection Respiratory symptoms with at least
2 signs: cough; purulent sputum;
new infiltrate on chest, appearing
during hospitalization
Vascular catheter
infection
Inflammation, lymphangitis or
purulent discharge at the insertion
site
Septicaemia Fever or rigours and at least one
positive blood culture

16. The chain of infection.
Source of
infection
Method of
spreading
Person at risk Point of entry
Breaking this chain by removing any part of it will control or stop
the spread of infection

17. Control of Hospital Infections
Infection control is an essential component of care and one which has
too often been undervalued
Prevention of HAI require a multifaceted approach
Three main principles :
Remove source of infection
Block route of transfer
Increase in resistance of host
To
prevent
infection,
one must
break the
chain of
infection.

18. Thus the Control may be through:
General measures
Special Control measures
Infection Control Organisation in Hospitals
Surveillance and control programmes
Prevention of infections like HIV, Hepatitis B,C in Health Care
setting and Health care workers
Proper management of waste in hospital

19. General Measures
Personal hygiene
Standard Precautions
Environmental sanitation
Efficient house keeping services
Provision of ancillary facilities (Good and efficient CSSD, Mechanised
laundry, waste disposal , Minimum handling of food , Isolation and reverse isolation
facilities, Procedure manuals, Regular health check-up of the workers, Check on visitors)

20. Personal hygiene
The most important person in this organisation is
YOU.
You get it right and both you and the organisation will
meet all the legal requirements.
You get it wrong and someone could become ill: That
someone could be YOU.

21. Isolation Precautions (CDC Recommendations)
Four types of precautions, evidence-based
recommendations based on the mode of
transmission of the organism known or suspected
to be present.
1.Standard Precautions
Transmission Based Precautions:
2.Contact Precautions
3. Airborne Precautions
4. Droplet Precautions

22. Standard - Apply for Blood, All body fluids, Non-intact skin, Mucous
membranes
Transmission-Based Precautions-
Contact Precautions- Apply for Gastrointestinal, respiratory, skin, or wound
infections, Skin infections that are highly contagious
Airborne Precautions- Apply to Tuberculosis ,Measles, Varicella (including
disseminated zoster) ,
Droplet Precautions- Apply to Haemophilus influenzae type b, Neisseria
meningitidis, Diphtheria (pharyngeal), Mycoplasma pneumonia,
Pertussis, Pneumonic plague, Streptococcal,, pharyngitis, pneumonia, or
scarlet fever, Serious viral infections eg. Adenovirus , Influenza, Mumps,
Parvovirus B19, Rubella
These guidelines were developed for hospitalized inpatients, and the
principles can be applied in outpatient settings

23. Standard Precautions
Standard Precautions are to be used with all patients, regardless of diagnosis.
formerly known as Universal Precautions
#1: Handwashing
#2: Gloves
#3: Mask, Eye Protection, Face Shield
#4: Gown
# 5: Patient-care Equipment
#6: Environmental Control
#7: Linen
#8: Sharps
#9: Ventilation Devices
#10: Patient Placement
All our patients should be treated as though they have potential blood born infections

24. #1: Handwashing
Hand hygiene is still the single most
important procedure for preventing the
spread of infection!
(Wash hands with plain soap or waterless
antiseptic agent, alcohol-based product)

26. Words of Wisdom on Hand
Washing
Soap, water and
Common sense are still
the Best Antiseptics
William Osler

27. 2,3,4- Personnel safety devices
The use of protective gears should be made mandatory for all
the personnel if chances of contact with Blood or Body fluid
is anticipated/inevitable

28. # 5: Patient-care Equipment
Clean or reprocess reusable equipment before using it
for the care of another patient.
Ensure that single- use items are discarded properly.
# 6: Environmental Control
Routine care, cleaning, and disinfection of
environmental surfaces, beds, bedrails, bedside
equipment, and other frequently touched surfaces.
#7: Linen
Handle, transport, and process used linen soiled with
blood or body fluids

29. #8: Sharps
All used needles and sharps should be
deposited in puncture resistant containers.
Bending, Reshaping, should be prohibited.
Do not recap the needles .
All used Disposable syringes and needles
should be discarded into Bleach solution at
the work station before final disposal.

30. DISPOSAL OF USED NEEDLES AND SYRINGESOF
SHARPSDestroy
needle
Cut syringe
tip
Decontaminate in twin
bucket having 1% bleach
SHARPS including
catheter guide wires

31. Dealing with Needle stick
Injuries
Consider all Needle stick injuries as a serious health hazard in
the era of AIDS
All events of Needle stick injuries to be reported to the
supervisory staff.
Wash the injured areas with soap and water.
Encourage bleeding if any.
Prophylaxis for prevention of HIV/HBV is top priority.

32. Risk of Transmission – Blood borne viruses
Human immunodeficiency virus (HIV)
Percutaneous exposure 0.33%
Mucocutaneous 0.09%
Hepatitis B virus (HBV)
Percutaneous exposure
sAg 1 – 6%
eAg 22 – 31%
Hepatitis C virus (HCV)
Percutaneous exposure 1.9%

33. #9: Ventilation Devices
Use mouthpieces, resuscitation bags, or other
ventilation devices as an alternative to mouth-to-
mouth resuscitation methods.
#10: Patient Placement
Place a patient who contaminates the
environment in a private room.

34. Special Measures
Proper planning of OTs and monitoring of its functioning
Monitoring Functioning of Nurseries and ICUs
Isolation facilities, daily washing, asepsis
Infection Oriented training to hospital staff to assess the
standards of asepsis, personal hygiene and cleanliness

35. ORGANIZATION
Hospital administrator/head
should establish
ICC (provides resources for ICP)
ICT
IC Officer IC Nurse Microbiologist

36. Hospital Surveillance and Control Programme
Weekly
Report
OPD Reports Bacteriological
Reports
Discharge
Reports
Personal
Clinics
Ward Visits Autopsies
Training
Programme
Regular
Reports
Infection Committee
Investigations
CONTROL

37. Handling , Operating on HIV/High risk
groups
It is a concern - all should be cared equally.
Law may not change for equality but motivated
health workers should bring in change of attitude.
Adherence of Universal Health precautions bring in
safety to all HCW.
Follow the precautions even in Non HIV patients as
some of our patients are in window period and more
dangerous than truly positive with Sero testing.
We handle so many patients in emergency situation
with out any details.

38. Post Exposure Management
Managing the site
Counseling
Vaccine and prophylaxis

39. Post Exposure Management HBV
In susceptible HCWs who have never been immunized, the
HBV vaccine series and one dose of HBIG at 0.06 ml/kg should
be immediately administered.
Exposures to nonresponders and hyporesponders to the HBV
vaccine require HBIG at the time of exposure
Routine follow up should include anti-HBs, anti-HBc, HBsAg,
and liver functions tests with repeat at 1 and 6 months.
The HCW should be instructed to be aware of the signs and
symptoms of acute hepatitis

40. Importance of Vaccination in Hepatitis B
Infection.
We have > 400 Million carriers with Hepatitis B infections.
Every HCW is at risk of infection.
Vaccination is safe - great hope for prevention
All HCW’s must take at least three doses of Vaccine, At 0 – 1 – 6
months
High risk HCW’s should undergo estimation of anti HB s (
antibodies ) to know whether they were well protected.
Never forget to take Hepatitis B
Vaccine if You are a HCW

41. Post Exposure Management of HIV
HIV PEP Evaluation
Exposure
Status of Source
HIV+ and
Asymptomatic
HIV+ and
Clinically symptomatic
HIV status unknown
Mild Consider 2-drug PEP Start 2- drug PEP Usually no PEP or consider
2-drug PEP
Moderate Start 2-drug PEP Start 3- drug PEP Usually no PEP or consider
2-drug PEP
Severe Start 3-drug PEP Start 3- drug PEP Usually no PEP or consider
2-drug PEP

42. Handling of Spills & Surface Disinfection
• Notify people in the area
• Don appropriate PPE
• Place absorbent material on spill
• Apply appropriate disinfectant 1% hypochlorite– min contact
time (30 min)
• Pick up material; dispose
• Reapply disinfectant and wipe
• For large/high hazard spills use 5 % hypochlorite

43. CATEGORIES OF BIO-MEDICAL WASTE
Cate
gory
Waste type Colour coding Treatment & Disposal
1. Human
anatomical
Yellow Incineration / deep burial
2. Animal waste Yellow Incineration / deep burial
3 Microbiology &
Biotechnology
Waste
Yellow/ Red Autoclaving/microwaving/ Incineration
4 Waste Sharps White / blue /
Translucent
puncture proof
containers
Disinfection by chemical
treatment/autoclaving/ Microwaving &
mutilation/shredding
5 Discarded
medicines and
Cytotoxic drugs
Black Destruction/ neutralization & disposal in
secured landfills

44. Categor
y
Waste type Colour coding Treatment & Disposal
6 Soiled
waste
Yellow/red Incineration / autoclaving/ microwaving
7 Solid (
plastic)
Blue/ White/ Red Disinfection by chemical
treatment/autoclaving/ Microwaving &
mutilation/shredding
8 Liquid
waste
------- Disinfection by chemical treatment and
discharge into drains
9 Incineration
Ash
Black Disposal in municipal landfill
10 Chemical Black Chemical treatment and discharge into drains
for liquids and secured landfill for solids

45. Prevention of Urinary tract Infection
CDC: Guideline for prevention of catheter-associated urinary tract infections 2009
Avoid catheterization
Use intermittent catheterization
Decrease duration of catheterization
Insert catheters aseptically
Maintain a close sterile drainage system
Use condom catheter in cooperative patients
Maintain gravity drainage
Apply topical meatal antimicrobials in women
Separate infected and non-infected patients

46. Prevention of Surgical site infections
 Pre-operative
 Intra-operative
 Post-operative

47. Preoperative preventive measures
Preparation of the patient
Hand/ forearm antisepsis for surgical team
Antimicrobial prophylaxis

48. Intra-operative preventive measures
Ventilation
Cleaning & disinfection of surfaces
Sterilization of surgical instruments
Surgical attire & drapes
Asepsis & surgical technique
Normothermia and glucose control

49. Post-operative incision care
Protect with a sterile dressing for 24-48 hrs
Wash hands before & after dressing changes & any contact
with the surgical site
Use aseptic technique when an incision dressing must be
changed

50. Prevention of ventilator associated
pneumonia
• Standard Precautions (Hand hygiene, Gloving)
• Aseptic technique for performing or changing tracheostomy tube
• Sterile fluid to remove secretion
• Sterile single use catheter if open system suction
• Elevation of the head end of bed 30°-45°
• Care of oral cavity
• Sedation vacation
• Spontaneous breathing trial
• Oral access to trachea and stomach
• EVAC tube for drainage of subglottic secretion

51. Prevention of Blood Stream Infections
CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections,
2011
Hand hygiene
Maximal barrier precautions
Chlorhexidine skin antisepsis
Optimal catheter site selection, with Subclavian vein as the
preferred site for non-tunneled catheters in adults
Daily review of line necessity with prompt removal of
unnecessary lines
Line secure and dressing clean and intact

52. Staff health promotion and education:
1. HCW are at risk of acquiring infection, they can also
transmit infection to patients and other employee.
2. Employee health history must be reviewed,
immunizations recommendations to be considered.
3. Release from work if sick, occupation injury
must be notified.
4. Continuous education to improve practice, better
performance of new techniques.

53. Infection Control
is
Responsibility
Of

54. Everyone

55. Take Home Message
ALL Hospitals should implement
Infection Control Program

56. ReferencesPrinciples, And Practices of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe.
www.cdc.gov/cdc.htm
www.cdc.gov/ncidod/dhqp/gl_isolation.html.
www.his.org.uk
www.ific.narod.ru
WHO : Prevention of Hospital aquired infections. A practical guide. 2nd ed. 2002.
Computational Fluid Dynamics Applications in Hospital Ventilation Design. The Australian Hospital Engineer 2003; 26(1):35-40.
Nosocomial Infections, Burke JP. N Engl J Med. 2003;348:651-656.
The direct medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009, R. Douglas Scott
II, CDC.
CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
CDC: Guideline for prevention of catheter-associated urinary tract infections 2009
CDC: Guideline for prevention of Surgical Site Infections, 1999
Dr. SUMI NANDWANI
Associate Professor, Microbiology,
E.S.I.C-P.G.I.M.S.R and
Hospital, Basaidarapur, New Delhi
E Mail suminandwani@gmail.com