Infection control
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Infection Control. by Simran S Ghatore. The pre-scientific era. Epidemics and plagues throughout history (black plague..) Physicians fear of contagious disease Hippocrates and others suspected an unseen invisible cause Climate and environment blamed - not the ill, dying or dead.

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Infection Control

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Infection Control

by Simran S Ghatore


The pre-scientific era

  • Epidemics and plagues throughout history (black plague..)

  • Physicians fear of contagious disease

  • Hippocrates and others suspected an unseen invisible cause

  • Climate and environment blamed - not the ill, dying or dead


Microbiology - scientific era

Anton van Leeuwenhoek (1632-1722)

  • Dutch linen draper

  • Amateur scientist

  • Grinding lenses, magnifying glasses, hobby

  • First to see bacteria “little beasties”

  • No link between bacteria and disease


Scientific era continued . . . . .

Ignaz Semmelweiss (1818-1865)

  • Obstetrician, practised in Vienna

  • Studied puerperal (childbed) fever

  • Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems

  • Reduced maternal mortality by 90%

  • Ignored and ridiculed by colleagues


Scientific era continued . . . . .

Louis Pasteur (1822-1895)

  • French professor of chemistry

  • Studied how yeasts (fungi) ferment wine and beer

  • Proved that heat destroys bacteria and fungi

  • Proved that bacteria can cause infection - the “germ theory” of disease


Scientific era continued . . . . .

Joseph Lister (1827-1912)

  • Scottish surgeon

  • Recognised importance of Pasteur’s work

  • Concerned about infection of compound fractures and post-operative wounds

  • Developed carbolic acid spray to disinfect instruments, patient’s skin, surgeon’s skin

  • Largely ignored by medical colleagues


Scientific era continued

Robert Kock (1843-1910)

  • German general practitioner

  • Grew bacteria in culture medium

  • Showed which bacteria caused particular diseases

  • Classified most bacteria by 1900


Contemporary issues

  • Antibiotic resistance

  • Prevalence of hospital acquired infection

  • Prion diseases - BSE ‘mad cow disease’ - new variant Creutzfeldt-Jakob disease (nvCJD) (thought to be the humanequivalent) - Gerstmann-Straussler-Scheinker disease – kuru and fatal insomnia.

    -Prions are mutated proteins

    -majority of prion related diseases involve neurological damage.

    -not all scientists accept they are the cause of disease.

    (see later)

    (more info)


Antibiotic resistance

  • Not a new problem - Penicillin in 1944 (A.Flemming) – 1st antibiotic – most resistance?

  • Hospital “superbugs”

  • Methycillin Resistant Staphylococcus Aureus [MRSA]

  • Vancomycin Intermediate Staphylococcus Aureus [VISA]

  • Tuberculosis - antibiotic resistant form

    • 400 deaths per year in UK

    • Up to £100,000 per patient to treat

    • Annual NHS cost - £5 million!!


MRSA

  • Discovered in 1981

  • Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers

  • Widespread in hospitals and community

  • Resistant to most antibiotics

  • When fatal - often due to septicaemia


Hospital acquired infection

  • Incidence of 10%

  • 5,000 deaths per year - direct result of HAI

  • 15,000 deaths per year linked to HAI

  • Delayed discharge from hospital

  • Expensive to treat [£3,500 extra]

  • Cost to NHS - £1 billion per year

  • Effective hand washing is the most effective preventative measure

  • Dirty wards and re-use of disposable equipment also blamed


Prion diseases

  • Prions [“pree-ons”] - proteinaceous infectious particles

  • Corrupted form of a normally harmless protein found in mammals and birds

  • Causes fatal neurodegenerative diseases of animals and humans

  • Animals: scrapie - sheep, bovine spongiform encephalopathy [BSE or Mad Cow Disease]

  • Humans: Creutzfeldt-Jakob disease [CJD]

  • Prions found in blood, tonsil and appendix tissue


Prions and surgery

  • Prions cannot be destroyed by sterilisation

  • Theoretical risk of cross infection from contaminated instruments and blood transfusion


Comparisons of mortality

Deaths per year in the UK


The nature of infection

  • Micro-organisms - bacteria, fungi, viruses, protozoa and worms

  • Most are harmless [non-pathogenic]

  • Pathogenic organisms can cause infection

  • Infection exists when pathogenic organisms enter the body, reproduce and cause disease


Hospital acquired infection

  • Infection which was neither present nor incubating at the time of admission

  • Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation (Rcn, 1995)

  • Also called nosocomial infection


Modes of spread

Two sources of infection:

  • Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli

  • Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998)


Spread - entry and exit routes

  • Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum

  • Artificial orifices - such as tracheostomy, ileostomy, colostomy

  • Mucous membranes - which line most natural and artificial orifices

  • Skin breaks - either as a result of accidental damage or deliberate inoculation/incision (May, 2000)


Chain of infection

  • Source/reservoir of micro-organisms

    • infected person [host] or other source

  • Method of transmission

    • hands, instruments, clothing, coughing, sneezing, dust etc.

  • Point of entry

    • orifices, mucous membranes, skin

  • Susceptible host

    • low resistance to infection (May, 2000)


HAI - common bacteria

  • Staphylococci - wound, respiratory and gastro-intestinal infections

  • Eshericia coli - wound and urinary tract infections

  • Salmonella - food poisoning

  • Streptococci - wound, throat and urinary tract infections

  • Proteus - wound and urinary tract infections (Peto, 1998)


HAI - common viruses

  • Hepatitis A - infectious hepatitis

  • Hepatitis B - serum hepatitis

  • Human immunodeficiency virus [HIV] - acquired immunodeficiency syndrome via infected blood transfusion! [AIDS] (Peto, 1998)


Common types of HAI

(May, 2000)


Universal infection control precautions

  • Devised in US in the 1980’s in response to growing threat from HIV and hepatitis B

  • Not confined to HIV and hepatitis B

  • Treat ALL patients as a potential bio-hazard

  • Adopt universal routine safe infection control practices to protect patients, self and colleagues from infection


Universal precautions

  • Hand washing

  • Personal protective equipment [PPE]

  • Preventing/managing sharps injuries

  • Aseptic technique

  • Isolation

  • Staff health

  • Linen handling and disposal

  • Waste disposal

  • Spillages of body fluids

  • Environmental cleaning

  • Risk management/assessment


Hand washing

  • Single most effective action to prevent HAI - resident/transient bacteria

  • Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken

  • No recommended frequency - should be determined by intended/completed actions

  • Research indicates:

    • poor techniques - not all surfaces cleaned

    • frequency diminishes with workload/distance

    • poor compliance with guidelines/training


Taylor (1978) identified that 89% of the hand surface was missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

Hand washing – areas missed


Personal protective equipment

  • PPE when contamination or splashing with blood or body fluids is anticipated

  • Disposable gloves

  • Plastic aprons

  • Face masks

  • Safety glasses, goggles, visors

  • Head protection

  • Foot protection

  • Fluid repellent gowns (May, 2000)


Sharps injuries

  • Prevention

    • correct disposal in appropriate container

    • avoid re-sheathing needle

    • avoid removing needle

    • discard syringes as single unit

    • avoid over-filling sharps container

  • Management

    • follow local policy for sharps injury (May, 2000)


Aseptic technique

  • Sepsis - harmful infection by bacteria

  • Asepsis - prevention of sepsis

  • Minimise risk of introducing pathogenic micro-organisms into susceptible sites

  • Prevent transfer of potential pathogens from contaminated site to other sites, patients or staff

  • Follow local policy (May, 2000)


Isolation

  • Single room or group

  • Source or protective

  • Source - isolation of infected patient

    • mainly to prevent airborne transmission via respiratory droplets

    • respiratory MRSA, pulmonary tuberculosis

  • Protective - isolation of immuno-suppressed patient (May, 2000)

  • Significant psychological effects (Davies et al, 1999)


Staff health

  • Risk of acquiring and transmitting infection

  • Acquiring infection

    • immunisation

    • cover lesions with waterproof dressings

    • restrict non-immune/pregnant staff

  • Transmitting infection

    • advice when suffering infection

  • Report accidents/untoward incidents

  • Follow local policy (May, 2000)


Linen handling and disposal

  • Bedmaking and linen changing techniques

  • Gloves and apron - handling contaminated linen

  • Appropriate laundry bags

  • Avoid contamination of clean linen

  • Hazards of on-site ward-based laundering

  • NHS Executive guidelines (1995)

  • Follow local policy (May, 2000)


Waste disposal

  • Clinical waste - HIGH risk

    • potentially/actually contaminated waste including body fluids and human tissue

    • yellow plastic sack, tied prior to incineration

  • Household waste - LOW risk

    • paper towels, packaging, dead flowers, other waste which is not dangerously contaminated

    • black plastic sack, tied prior to incineration

  • Follow local policy (May, 2000)


Spillage of body fluids

  • PPE - disposable gloves, apron

  • Soak up with paper towels, kitchen roll

  • Cover area with hypochlorite solution e.g., Milton, for several minutes

  • Clean area with warm water and detergent, then dry

  • Treat waste as clinical waste - yellow plastic sack

  • Follow local policy (May, 2000)


Environmental cleaning

  • Recent concern regarding poor hygiene in hospital environments (NHSE, 1999)

  • Some pathogens survive for long periods in dust, debris and dirt

  • Poor hygiene standards - hazardous to patients and staff (May, 2000)

  • Report poor hygiene to Domestic Services (UKCC, 1992)

  • “Hospitals should do the sick no harm” (Nightingale, 1854)


Risk assessment

  • No risk of contact/splashing with blood/body fluids - PPE not required

  • Low or moderate risk of contact/splashing - wear gloves and plastic apron

  • High risk of contact/splashing - wear gloves, plastic apron, gown, eye/face protection (Rcn, 1995)


Body fluids

  • Cerebrospinal fluid, peritoneal fluid, pleural fluid, synovial fluid, amniotic fluid, semen, vaginal secretions, and

  • Any other fluid containing visible blood e.g., urine, faeces (Rcn, 1995)


Cost of HAI

  • Direct cost to NHS for:

    • extended hospital stay, extra resources, extra treatment, extra equipment, and extra community care costs if discharged needing follow-up

  • Direct cost to patient/family for:

    • pain and scarring, extended stay away from family, working days lost, family income loss, financial strain - increased visiting etc, increased morbidity, increased mortality (ICNA, 1998)


Summary

  • Ignaz Semmelweis in 1847 demonstrated that washing hands saves lives

  • Research indicates that 10% of patients develop HAI costing the NHS £1 billion and 20,000 deaths per year

  • Old bacteria are causing new problems

  • New viral and prion diseases are causing new problems

  • Reluctance to wash hands still the single most important cause of HAI (ICNA, 1998)

  • Growing concern about poor hospital hygiene


Internet sites

  • http://www.icna.co.uk/

  • http://www.nursing-standard.co.uk/

  • http://www.medscape.com/

  • http://www.anes.uab.edu/medhist.htm

  • http://www.shef.ac.uk/~nhcon/

  • http://medweb.bham.ac.uk/nursing/

  • http://www.healthcentre.org.uk/hc/library/default.htm

  • http://www.parliament.uk/documents/upload/POSTpn247.pdf (excellent article)


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