Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible. This course provides the information necessary for healthcare professionals to monitor, control, and prevent infection in healthcare settings.
This course is designed for physicians, physician assistants, nurses, and other healthcare professionals in New York required to complete education to enhance their knowledge of infection control.
NetCE is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.
NetCE designates this enduring material for a maximum of 5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 1 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 5 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
This course is approved by the New York State Department of Health to fulfill the requirement for 3 hours of Infection Control Training as mandated by Chapter 786 of the Laws of 1992. Provider #TP02078. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.
The purpose of this course is to provide a review of current infection control practices and accepted standards, with an emphasis on the application of infection control standards and practices in outpatient and ambulatory settings.
Upon completion of this course, you should be able to:
- Discuss the standards of professional conduct associated with infection control in the healthcare setting.
- Outline the infectious disease process.
- Describe various practices that can result in exposure to bloodborne pathogens.
- Identify effective strategies to prevent or control infection, including precautions, isolation techniques, hand hygiene, standards for cleaning, and safe injection practices.
- Describe the role of surveillance and reporting in an effective infection control program.
- Discuss the impact of communicable diseases in healthcare professionals, including the necessity for preplacement evaluations, periodic health assessments, education, and postexposure prophylaxis.
Lori L. Alexander, MTPW, ELS, MWC, is President of Editorial Rx, Inc., which provides medical writing and editing services on a wide variety of clinical topics and in a range of media. A medical writer and editor for more than 30 years, Ms. Alexander has written for both professional and lay audiences, with a focus on continuing education materials, medical meeting coverage, and educational resources for patients. She is the Editor Emeritus of the American Medical Writers Association (AMWA) Journal, the peer-review journal representing the largest association of medical communicators in the United States. Ms. Alexander earned a Master’s degree in technical and professional writing, with a concentration in medical writing, at Northeastern University, Boston. She has also earned certification as a life sciences editor and as a medical writer.
Carol Shenold, RN, ICP, graduated from St. Paul’s Nursing School, Dallas, Texas, achieving her diploma in nursing. Over the past thirty years she has worked in hospital nursing in various states in the areas of obstetrics, orthopedics, intensive care, surgery and general medicine.
Mrs. Shenold served as the Continuum of Care Manager for Vencor Oklahoma City, coordinating quality review, utilization review, Case Management, Infection Control, and Quality Management. During that time, the hospital achieved Accreditation with Commendation with the Joint Commission, with a score of 100.
Mrs. Shenold was previously the Infection Control Nurse for Deaconess Hospital, a 300-bed acute care facility in Oklahoma City. She is an active member of the Association for Professionals in Infection Control and Epidemiology (APIC). She worked for the Oklahoma Foundation for Medical Quality for six years.
Contributing faculty, Lori L. Alexander, MTPW, ELS, MWC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Contributing faculty, Carol Shenold, RN, ICP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
John M. Leonard, MD
Jane C. Norman, RN, MSN, CNE, PhD
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
- STANDARDS OF PROFESSIONAL CONDUCT
- THE INFECTIOUS DISEASE PROCESS
- HIGH-RISK PRACTICES: EXPOSURE TO BLOODBORNE PATHOGENS
- PRECAUTIONS AND ISOLATION TECHNIQUES
- STANDARDS FOR EQUIPMENT AND ENVIRONMENTAL SERVICES
- SAFE INJECTION PRACTICES
- COMMUNICABLE DISEASE EXPOSURES IN HEALTHCARE PROFESSIONALS
- Works Cited
- Evidence-Based Practice Recommendations Citations
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#98641: Infection Control: The New York Requirement
The development of formal infection control programs in hospitals and other healthcare facilities was spurred by the Joint Commission accreditation standards for infection control, published in 1976. According to the standards, accredited facilities should have a program for the surveillance, prevention, and control of healthcare-associated infections (HAIs) . The most important aspect of infection control is establishing multidisciplinary programs that promote teamwork and foster an organizational culture centered on patient safety.
HAIs are one of the leading causes of death and increased morbidity for hospitalized patients and are a significant problem for healthcare providers . Historically, these infections have been known as nosocomial infections or hospital-acquired infections because they develop during hospitalization. As health care has increasingly expanded beyond hospitals into outpatient settings, nursing homes, long-term care facilities, and even home care settings, the more appropriate term has become healthcare-acquired or healthcare-associated infection.
Many factors have contributed to an increase in HAIs. Advances in medical treatments have led to more patients with decreased immune function or chronic disease. The increase in the number of these patients, coupled with a shift in health care to the outpatient setting, yields a hospital population that is both more susceptible to infection and more vulnerable once infected. In addition, the increased use of invasive devices and procedures has contributed to higher rates of infection .
According to data published in 2014, HAIs develop in an estimated 1 in 25 hospitalized patients (excluding skilled nursing facilities); this number varies from year to year and had previously been estimated at a high of 1 in 10 [1,4,94,95]. There were an estimated 722,000 HAIs in 648,000 adults and children in acute care hospitals in 2011; more than half of infections (65%) occurred outside of intensive care units . Additionally, the infections were the cause of approximately 75,000 deaths and add approximately $28.4 to $33.8 billion in direct medical costs annually [4,5,95]. The most common types of HAIs were pneumonia (22%), surgical site infections (22%), and gastrointestinal infections (17%) . Of the 481 reported pathogens, the most common was Clostridium difficile (12%), followed by Staphylococcus aureus (11%), Klebsiella pneumonia and K. oxytoca (10%), and Escherichia coli (9.5%).
As HAIs have become a cause for increasing concern, many national organizations, state departments of health, and professional organizations have taken additional steps to prevent or control infection in the healthcare environment.
The increased focus on healthcare quality over the past decade has highlighted the need to prevent HAIs as part of overall efforts to enhance patient safety. These efforts have been developed by healthcare quality agencies, professional associations, advocacy organizations, healthcare regulating bodies, and policymakers [6,7,8,9,10,11,12,13]. Prevention of HAIs and of methicillin-resistant Staphylococcus aureus (MRSA) infection are listed among safe healthcare practices established by the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum, and prevention of HAIs was noted by the Institute of Medicine (IOM) to be one of 20 priority areas for enhancing the quality of health care [6,7,12]. In 2004, the Institute for Healthcare Improvement (IHI) established the 100,000 Lives Campaign as a challenge to save 100,000 patient lives through six healthcare interventions, three of which were related to HAIs: preventing central line infections, surgical site infections, and ventilator-associated pneumonia . Building on the success of the 100,000 Lives Campaign, the IHI established the 5 Million Lives Campaign in December 2006, adding six more interventions, one of which is to reduce MRSA infection . In 2010, the Centers for Medicare & Medicaid Services (CMS) launched the Partnership for Patients with the goal of reducing all HAIs 40% compared to 2010 and reducing readmissions due to HAIs by 20% by focusing on transitions from one care setting to another .
Regulatory bodies have also focused on HAIs. Goal 7 of the National Patient Safety Goals developed by the Joint Commission is to reduce the risk of HAIs in hospitals as well as ambulatory care/office-based surgery, long-term care, and assisted living settings . Perhaps the most aggressive campaign against HAIs has come from CMS, which has suspended reimbursement of hospital costs related to three categories of HAIs it considers "reasonably preventable:" catheter-related urinary tract infection, vascular catheter-associated infection, and various surgical site infections [10,11,14]. However, studies have shown that this policy has not been a contributor to any decrease in the rate of HAIs, and a survey indicated that adherence to only a few prevention strategies has increased as a result of the policy [97,98]. The policy also has the potential to lead to increased unnecessary use of antimicrobials in an effort to prevent infections .
The New York Codes, Rules, and Regulations require that certain healthcare professionals who may influence the control and prevention of HAIs complete training or education regarding infection control and barrier precautions . New York State has also established professional standards of conduct to ensure that infection prevention and control practices are adhered to. According to the Rules of the Board of Regents: Part 29, "failing to use scientifically accepted infection prevention techniques appropriate to each profession for the cleaning and sterilization or disinfection of instruments, devices, materials and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment and the handling of sharp instruments" is considered unprofessional conduct . Appropriate infection control techniques include, but are not limited to, wearing appropriate personal protective equipment, adhering to recommendations for Universal and Standard Precautions, following sterilization and disinfection standards, and using the correct equipment in the correct way .
Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible . Healthcare professionals are expected to use scientifically accepted infection prevention techniques appropriate to each profession for handwashing; aseptic technique; cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces; use of protective garb; use of covers for contamination-prone equipment; and handling of sharp instruments [15,16,17].
The results of the Centers for Disease Control and Prevention (CDC) Study of Efficacy of Nosocomial Infection Control suggested that 6% of all HAIs could be prevented by minimal infection control efforts and 32% by "well organized and highly effective infection control programs" [18,19]. A later review estimated that as many as 65% to 70% of cases of catheter-associated infections and 55% of cases of surgical site infections are preventable .
Evidence-based guidelines are at the heart of strategies to prevent and control HAIs and drug-resistant infections and address a wide range of issues from architectural design of hospitals to hand hygiene. These guidelines have been developed primarily by the CDC and the World Health Organization (WHO), infection-related organizations, and other professional societies. Some specialty organizations and quality improvement groups have summarized the guidelines for easier use in practice [2,17,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42]. Adherence to individual guidelines varies but, in general, is low. Historically, 87% of hospitals have failed to implement all of the recommended guidelines for preventing HAIs . Hand hygiene is the most basic and single most important preventive measure, yet compliance rates among healthcare workers have averaged only 30% to 50% [3,31,44,56,57,58]. Decreasing the number of HAIs will require research to better understand the reasons behind lack of compliance with guidelines and to develop strategies that target those reasons.
In addition, there are professional consequences for New York healthcare professionals who do not adhere to appropriate infection control efforts. Healthcare professionals who fail to use scientifically accepted barrier precautions and state-established infection control practices may be subject to charges of professional misconduct . The Office of Professional Medical Conduct may investigate on its own any suspected professional misconduct and is required to investigate each complaint received regardless of the source. The charges must state the substance of the alleged misconduct and the material facts (but not the evidence). A hearing may be called, if warranted. The results of the hearing (i.e., findings, conclusions, determinations, order) will be made public upon issuance. Any professional found guilty of misconduct shall be subject to penalties, including :
Censure and reprimand
Suspension of license or limitation of license to a specified area or type of practice
Revocation of license
Annulment of license or registration
Limitation on registration or issuance of any further license
A fine not to exceed $10,000 upon each specification of charges of which the respondent is determined to be guilty
A requirement that a licensee pursue a course of education or training
A requirement that a licensee perform up to 500 hours of public service in a manner and at a time and place as directed
The education and training of healthcare personnel are prerequisites for ensuring that Standard Precautions are understood and practiced. Education on the principles and practices for preventing transmission of infectious agents should begin during training in the health professions and be provided to anyone who has an opportunity for contact with patients or medical equipment. Education programs for healthcare personnel have been associated with sustained improvement in adherence to best practices .
Adherence to recommended infection control practices decreases transmission of infectious agents in healthcare settings; however, several observational studies have shown limited adherence to recommended practices by healthcare personnel. Improving adherence to infection control practices requires a multifaceted approach that incorporates continuous assessment of both the individual and the work environment. It also requires that the organizational leadership make prevention an institutional priority and integrate infection control practices into the organization's safety culture [17,47,48].
A comprehensive description of the pathogenesis of infection is beyond the scope of this course. However, a broad overview of pathogen-host interaction will aid in the understanding of how infection develops in the healthcare setting.
A healthy human body has several defenses against infection: the skin and mucous membranes form natural barriers to infection, and immune responses (nonspecific and specific) are activated to resist micro-organisms that are able to invade. The skin can effectively protect the body from most micro-organisms unless there is physical disruption. For example, the human papillomavirus can invade the skin, and some parasites can penetrate intact skin, but bacteria and fungi cannot . Other disrupters of the natural barrier are lesions (e.g., chapped, abraded, affected by dermatitis), injury, or in the healthcare setting, invasive procedures or devices .
In addition to breaks in the skin, other primary entry points for micro-organisms are mucosal surfaces, such as the respiratory, gastrointestinal, and genitourinary tracts . The membranes lining these tracts comprise a major internal barrier to micro-organisms due to the antimicrobial properties of their secretions. The respiratory tract filters inhaled micro-organisms, and mucociliary epithelium in the tracheobronchial tree moves them out of the lung. In the gastrointestinal tract, gastric acid, pancreatic enzymes, bile, and intestinal secretions destroy harmful micro-organisms. Nonpathogenic bacteria (commensal bacteria) make up the normal flora in the gastrointestinal tract and act as protectants against invading pathogenic bacteria. Commensal bacteria are a source of infection only if they are transmitted to another part of the body or if they are altered by the use of antibiotics .
HAIs are commonly caused by bacteria, but can also be caused by viruses, fungi, and parasites. These types of infection occur less frequently and often do not carry the same risks of morbidity and mortality as bacterial infections. Viral infections are more common in children than in adults and carry a high epidemic risk . Fungal infections frequently occur during prolonged treatment with antibiotics and in patients who have compromised immune systems . Various pathogens have different levels of pathogenicity, virulence, and infectivity.
The transmission of infection follows the cycle (the "cycle of infection") that has been described for all diseases, and humans are at the center of this cycle [2,51]. In brief, a micro-organism requires a reservoir (a human, soil, air, or water), or a host, in which to live. The micro-organism also needs an environment that supports its survival once it exits the host and a method of transmission. Inherent properties allow micro-organisms to remain viable during transmission from a reservoir to a susceptible host, another essential factor for transmission of infection. The primary routes of transmission for infections are through the air, blood (or body fluid), contact (direct or indirect), fecal-oral route, food, animals, or insects. Once inside a host, micro-organisms thrive because of adherent properties that allow them to survive against mechanisms in the body that act to flush them out. Bacteria adhere to cell surfaces through hair-like projections, such as fibrillae, fimbriae, or pili, as well as by proteins that serve as adhesions . Fimbriae and pili are found on gram-negative bacteria, whereas other types of adhesions are found with both gram-negative and gram-positive bacteria. Receptor molecules in the body act as ligands to bind the adhesions, enabling bacteria to colonize skin and mucous membranes. The virulence of the micro-organism, the integrity of the skin and membrane barriers, and patient status will determine whether colonization is followed by invasive infection. With colonization, there is no damage to local or distant tissues and no immune reaction; with infection, bacterial toxins that break down cells and intracellular matrices are released, causing damage to local and distant tissues and prompting an immune response in the host. Bacteria continue to thrive within a host through strategies that enable them to acquire iron for nutrition and to defend against the immune response. These virulence factors enhance a micro-organism's potential for infection by interrupting or avoiding phagocytosis or living inside phagocytes .
A healthcare environment increases the risk of infection for two primary reasons. First, it is likely that normally sterile body sites will become exposed, allowing pathogens to cause infection through contact with mucous membranes, nonintact skin, and internal body areas . Second, the likelihood of a susceptible host is high due to the vulnerable health status of patients. Especially in an era of decreased hospital stays and increased outpatient treatments, it is the sickest patients who are hospitalized, increasing the risk not only for infection to develop in these patients but also for their infection to be more severe and to be transmitted to others.
Infection is transmitted in a healthcare environment primarily through exogenous and endogenous modes. Exogenous transmission is through patient-to-patient or staff-to-patient contact. Patients who do not have infection but have bacterial colonization can act as vectors of transmission. Staff members can also act as vectors because of colonization or contamination. Endogenous infection occurs within an individual patient through displacement of commensal micro-organisms.
Factors specifically related to the healthcare environment are not common causes of HAIs [2,52,53]. However, consideration should be given to the prevention of infection with environmental pathogens. The CDC revised guideline related to environmental factors for infection provides clear recommendations for infection control measures according to several environment-related categories, including air (normal ventilation and filtration, as well as handling during construction or repair), water (water supply systems, ice machines, hydrotherapy tanks and pools), and environmental services (laundry, housekeeping) .
In general, the spread of infectious disease is prevented by eliminating the conditions necessary for the micro-organism to be transmitted from a reservoir to a susceptible host. This can be accomplished by:
Destroying the micro-organism
Blocking the transmission
Protecting individuals from becoming vectors of transmission
Decreasing the susceptibility of potential hosts
Antiseptic techniques and antibiotics will kill micro-organisms, while proper hand hygiene will block their transmission. Gloves, gowns, and masks remove healthcare professionals from the transmission cycle by protecting them from contact with micro-organisms. Contact Precautions and isolation techniques help patients avoid being vectors of transmission. Lastly, ensuring that patients and healthcare professionals are immune or vaccinated can help decrease the availability of potential hosts.
Healthcare professionals, emergency response personnel, and public safety personnel may be exposed to a variety of bloodborne pathogens, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Exposure may occur percutaneously, parenterally, or through contact with mucous membranes and nonintact skin .
Percutaneous exposures may occur through the handling, disassembly, disposal, or reprocessing of contaminated needles and other sharp objects. They may also be related to the performance of procedures in which there is poor visualization (e.g., blind suturing, placing the nondominant hand next to or opposing a sharp, or performing procedures where bone spicules or metal fragments are produced). Data from the CDC National Surveillance System for Hospital Health Care Workers (NaSH) have shown that approximately 70% of percutaneous injuries occur during use of a sharp, while 15% occur after use and before disposal .
Parenteral exposures (i.e., injection with infectious material) may occur during administration of parenteral medications, sharing of blood monitoring devices (e.g., glucometers, lancets), or infusion of contaminated blood products or fluids. Generally, these exposures are the result of poor adherence to Standard Precautions and infection control guidelines.
Mucous membrane and nonintact skin exposures may occur when blood or body fluids come in direct contact with the eyes, nose, mouth, or other mucous membranes via contaminated hands, open skin lesions, or splashes or sprays of blood or body fluids (e.g., during irrigation or suctioning). Again, following established infection control guidelines greatly reduces the risk of this type of exposure.
The CDC guideline for isolation precautions in hospitals, last updated in 2007, synthesizes a variety of recommendations for precautions based on the type of infection and the route of transmission . As defined by the CDC, Standard Precautions represent measures that should be followed for all patients in a healthcare facility, regardless of diagnosis or infection status. Standard Precautions apply to blood; all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; nonintact skin; and mucous membranes . For patients who are known to have or are highly suspected to have colonization or infection, Contact Precautions should be followed. This type of precaution is designed to reduce exogenous transmission of micro-organisms through direct or indirect contact from healthcare professionals or other patients. Airborne Precautions are used for patients who have or are highly suspected of having infection that is spread by airborne droplet nuclei, such as tuberculosis, measles, or varicella. Droplet Precautions target infections that are transmitted through larger droplets generated through talking, sneezing, or coughing, such as invasive Haemophilus influenzae type b disease, diphtheria (pharyngeal), pertussis, group A streptococcal pharyngitis, influenza, mumps, and rubella .
The CDC guideline includes descriptions of all the elements involved in the four types of precautions, including hand hygiene; the use of personal protection equipment (i.e., gloves, gown, face protection); placement of the patient; handling of patient-care equipment; and environmental services and occupational health. New elements of Standard Precautions added to the 2007 guideline include infection control practices (i.e., use of masks) for special lumbar puncture procedures, safe injection practices (discussed later in this course), and respiratory hygiene/cough etiquette . Recommendations in this area address the importance of educating healthcare professionals about adherence to measures to control the transmission of respiratory pathogens, especially during seasonal outbreaks of viral respiratory tract infections. In addition, the guideline states that efforts should be made to contain respiratory secretions in patients and other individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting. Signs should be posted to instruct patients and visitors with symptoms of respiratory infection to cover their mouths/noses when coughing or sneezing, to use and dispose of tissues, and to perform hand hygiene after contact with respiratory secretions. Masks should be offered to coughing patients and other individuals with symptoms, and such persons should be encouraged to maintain an ideal distance of at least 3 feet from others in common waiting areas.
The following descriptions of precautions are summarized from the 2007 guideline for isolation precautions . The guideline includes recommendations found in the CDC guideline on hand hygiene . Although the 2007 guideline is the most recent version, guidance regarding Ebola virus precautions and isolation has been updated and will be discussed briefly .
The guideline includes recommendations found in the CDC guideline on hand hygiene . Hand hygiene guidelines will be discussed in length later in this course.
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Latex or nitrile gloves are preferable for clinical procedures that require manual dexterity and/or will involve more than brief patient contact. Put on clean gloves just before touching mucous membranes and nonintact skin. When worn in combination with other personal protective equipment, don gloves last.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of micro-organisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces and before going to another patient, and wash hands immediately to avoid transfer of micro-organisms to other patients or environments. Avoid contamination of clothing and skin when removing gloves. Do not reuse gloves or wash gloves for subsequent reuse.
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible (turning outer "contaminated" side of the gown inward), roll gown into a bundle, and discard appropriately. Wash hands to avoid transfer of micro-organisms to other patients or environments. Do not reuse gowns, even for repeated tasks with the same patient.
Use a private room for a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control. If a private room is not available, consult with infection control professionals regarding patient placement or other alternatives.
Handle used patient-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of micro-organisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that single-use items are discarded properly.
Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being followed.
Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents contamination of air, surfaces, and individuals.
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of a needle toward any part of the body. Rather, use either a one-handed "scoop" technique or a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers, which are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.
Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same micro-organism but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, consider the epidemiology of the micro-organism and the patient population when determining patient placement. Consultation with infection control professionals is advised before patient placement.
In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of micro-organisms (e.g., fecal material, wound drainage). Remove gloves before leaving the patient's room, and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room, to avoid transfer of micro-organisms to other patients or environments.
In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, nonsterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove the gown before leaving the patient's environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces, to avoid transfer of micro-organisms to other patients or environments.
Limit the movement and transport of the patient from the room to essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of micro-organisms to other patients and contamination of environmental surfaces or equipment.
When possible, dedicate the use of noncritical patient-care equipment to a single patient (or cohort of patients infected or colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient.
All precautions described for airborne pathogens are in addition to Standard Precautions.
Place the patient in a private room that has (1) monitored negative air pressure in relation to the surrounding areas; (2) 6 to 12 air changes per hour; and (3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. When a private room is not available, place the patient in a room with a patient who has active infection with the same micro-organism, unless otherwise recommended, but with no other infection. When a private room is not available and cohorting is not desirable, consultation with infection control professionals is advised before patient placement.
Wear respiratory protection (N95 respirator) when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have rubeola (measles) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have rubeola or varicella, they should wear respiratory protection (N95 respirator). Persons immune to rubeola or varicella need not wear respiratory protection.
All precautions described for droplet pathogens are in addition to Standard Precautions.
Place the patient in a private room. When a private room is not available, place the patient in a room with a patient(s) who has active infection with the same micro-organism but with no other infection. When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 feet between the infected patient and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open.
In addition to wearing a mask as outlined under Standard Precautions, wear a mask when working within 3 feet of the patient. (Logistically, some hospitals may want to implement a policy of wearing a mask to enter the room.)
Hand hygiene is the most important preventive measure in hospitals, and the Joint Commission mandates that hospitals and other healthcare facilities comply with the Level I recommendations in the CDC guideline for hand hygiene . The CDC guideline states the specific indications for washing hands, the recommended hand hygiene techniques, and recommendations about fingernails and the use of gloves (Table 1) . The guideline also provides recommendations for surgical hand antisepsis, selection of hand-hygiene agents, skin care, educational and motivational programs for healthcare professionals, and administrative measures.
SUMMARY OF CDC RECOMMENDATIONS FOR HAND HYGIENE
|Indications for Hand Hygiene|
|Wash hands with nonantimicrobial or antimicrobial soap and water when they are visibly dirty, contaminated, or soiled. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands.|
|Recommended Handrub Technique|
|Apply to palm of one hand, rub hands together, covering all surfaces until dry.|
|Recommended Handwashing Technique|
|Fingernails and Artificial Nails|
|Keep tips of natural nails to a length of ¼ inch. Do not wear artificial nails during direct contact with high-risk patients (e.g., patients in intensive care unit or operating room).|
|Use of Gloves|
|Use gloves when there is potential for contact with blood or other potentially infectious materials, mucous membranes, or nonintact skin. Change gloves after use for each patient.|
Despite the simplicity of the intervention, its substantial impact, and wide dissemination of the guideline, compliance with recommended hand hygiene has ranged from 16% to 81%, with an average of 30% to 50% [3,31,43,56,57,58]. Among the reasons given for the lack of compliance are inconvenience, understaffing, and damage to skin [1,31,56]. The development of effective alcohol-based handrub solutions addresses these concerns, and studies have demonstrated that these solutions have increased compliance [57,59,60]. The CDC guideline recommends the use of such solutions on the basis of several advantages, including :
Better efficacy against both gram-negative and gram-positive bacteria, mycobacteria, fungi, and viruses than either soap and water or antimicrobial soaps (e.g., chlorhexidine)
More rapid disinfection than other hand-hygiene techniques
Less damaging to skin
Time savings (18 minutes compared with 56 minutes per 8-hour shift)
The guideline suggests that healthcare facilities promote compliance by making the handrub solution available in dispensers in convenient locations (e.g., entrance to patients' room, at the bedside) and provide individual pocket-sized containers . The handrub solution may be used in all clinical situations except for when hands are visibly dirty or are contaminated with blood or body fluids. In such instances, soap (either antimicrobial or nonantimicrobial) and water must be used.
However, there are many other reasons for lack of adherence to appropriate hand hygiene, including denial about risks, forgetfulness, and belief that gloves provide sufficient protection [1,31,56]. These reasons demand education for healthcare professionals to emphasize the importance of hand hygiene. Also necessary is research to determine which interventions are most likely to improve hand-hygiene practices, as no studies have demonstrated the superiority of any intervention . Single interventions are unlikely to be effective .
Several single-institution studies have demonstrated that appropriate hand hygiene reduces overall rates of HAIs, including those caused by MRSA and vancomycin-resistant enterococci [57,58,59,60]. However, rigorous evidence linking hand hygiene alone with the prevention of HAIs is lacking, making it difficult to evaluate the true impact of hand hygiene alone in reducing HAIs . One challenge in evaluating the impact of hand hygiene is that a variety of methodologies (e.g., surveys, direct observation, measurement of product use) have been used to assess compliance, each with its own advantages and disadvantages . Measuring the effect of appropriate hand hygiene alone is also difficult because the intervention is often one aspect of a multicomponent strategy to reduce infection . Lastly, as noted previously, the development of HAIs is complex, with many contributing factors . Although more research is needed to assess the individual impact of appropriate hand hygiene, this basic prevention measure is the essential foundation of an effective infection control strategy and is an element of every infection control guideline [2,17,25,26,28,29,31,32,33,36,38].
Care of patients with Ebola requires Standard, Contact, and Airborne Precautions. Duration of these measures is determined on a case-by-case basis, in conjunction with local, state, and federal health authorities. A single-patient room with the door closed is preferred. A log of all people entering the patient's room is required. Barrier protections against blood and body fluids should be used upon entry into room (i.e., gloves, fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields). Additional protective wear (i.e., double gloves, leg and shoe coverings) should be used during the final stages of illness when hemorrhage may occur. The use of dedicated disposable medical equipment is preferred for patient care. All nondedicated, nondisposable equipment should be cleaned and disinfected after use. If possible, needles, sharps, and aerosol-generating procedures should be avoided as much as possible, and the number of procedures and tests should be limited. Public health officials should be notified immediately if Ebola is suspected.
The infection control manual should contain details on cleaning and disinfecting equipment and the healthcare environment. The procedures should follow those set forth by the CDC in its guidelines for environmental infection control and for disinfection and sterilization [26,30]. These procedures are related to the routine cleaning, disinfection, and reprocessing of equipment; the cleaning and disinfection of environmental surfaces; the cleaning of spills of blood and other body fluids; the cleaning and maintenance of laundry and bedding, carpeting, and cloth furnishings; and the handling of medical waste.
The guideline on disinfection and sterilization published by the CDC in 2008 includes updated evidence-based recommendations on preferred methods for cleaning, disinfecting, and sterilizing medical devices and for cleaning and disinfecting the healthcare environment . The guideline also addresses several new topics, including inactivation of antibiotic-resistant bacteria, bioterrorist agents, emerging pathogens, and bloodborne pathogens; disinfection of patient-care equipment used in ambulatory settings and home care; and new sterilization processes, such as hydrogen peroxide gas plasma and liquid peracetic acid .
Various levels of cleaning and disinfection have been defined, and decontamination and cleaning must be carried out before any of the higher level processes (Table 2) [2,26,51]. The cleaning and disinfection of devices varies according to the Spaulding classification, which categorizes devices as critical (i.e., enters normally sterile tissue or the vascular system), semicritical (i.e., comes into contact with intact mucous membranes and does not ordinarily penetrate sterile tissue), or noncritical (i.e., does not ordinarily touch a patient or touches only intact skin) [51,64]. Critical devices require sterilization, and semicritical devices require high-level disinfection; noncritical devices may be cleaned with low-level disinfection [2,37,51,64].
DEFENITIONS OF LEVELS OF CLEANING AND DISINFECTION
|Decontamination||Use of a 0.5% chlorine solution to reduce the number of pathogenic organisms on the device|
|Cleaning||Use of soap and water to remove all visible dust, soil, blood, or other body fluids|
|Low-level disinfection||Use of disinfectant to destroy pathogenic organisms (may not eliminate resistant bacteria or most viruses or fungi)|
|Intermediate-level disinfection||Use of disinfectant to destroy pathogenic organisms (eliminates most bacteria, viruses, and fungi)|
|High-level disinfection||Use of chemical disinfectants, boiling, or steaming to destroy all micro-organisms|
|Sterilization||Use of high-pressure steam (autoclave), dry heat (oven), chemical sterilants, or radiation to eliminate all forms of viable micro-organisms|
|Reprocessing||A multistep procedure that consists of meticulous cleaning, high-level disinfection with a liquid chemical sterilant or disinfectant, and proper drying|
Endoscopic instruments present a challenge to proper reprocessing because of the complex internal design and long, narrow channels . Reprocessing should be carried out by trained and accredited personnel according to the manufacturer's recommendations, and the process should be monitored regularly for quality control . Guidelines and recommendations for reprocessing of gastrointestinal endoscopes have been developed by several federal agencies, such as the U.S. Food and Drug Administration (FDA) and the CDC, as well as many professional organizations [2,37,65,66,67,68]. The reprocessing procedure should begin immediately after use to prevent secretions from drying [2,26,67,68].
Some inconsistencies across reprocessing guidelines and manufacturer recommendations have been found, primarily with regard to drying . Also, various steps in the procedure have been emphasized as being the most critical. For example, one report notes that meticulous mechanical cleaning is the most important step because it removes the majority of the contaminating bacteria . Another report emphasizes the importance of drying to avoid waterborne bacteria, such as Pseudomonas aeruginosa .
A report of four patients with infection with P. aeruginosa after transrectal ultrasound-guided prostate biopsies raised awareness about the need for thorough cleaning of equipment. Evaluation of the findings on the four patients demonstrated that the infection was caused by contamination of the needle guide as a result of inadequate cleaning (with a brush) and improper rinsing (with tap water) after reprocessing . The report led to the FDA issuing a Public Health Notification on proper reprocessing of such devices .
Reprocessing of bronchoscopes has received less attention, perhaps because of the low risk of infection, but general recommendations, similar to those for gastrointestinal endoscopes, are available [21,71].
Every healthcare facility should have a written housekeeping schedule for the routine cleaning of the environment. Routine cleaning removes so-called visible dirt, which can harbor micro-organisms. Soap and water can be used to remove visible dirt from most surfaces, such as walls, doors, ceilings, and floors. A disinfectant should be used when there are signs of contamination. The level of asepsis in cleaning depends on the likelihood of contamination. WHO suggests classifying areas within a healthcare facility into four zones :
Zone A: No patient contact
Zone B: Care of patients who are not infected and are not highly susceptible
Zone C: Infected patients (isolation units)
Zone D: Highly susceptible patients (protective isolation) or protected areas such as operating suites, delivery rooms, intensive care units, neonatal intensive care, transplant units, oncology units, and hemodialysis units
Cleaning according to this classification should be as follows :
Zone A: Normal cleaning
Zone B: Cleaning procedures that do not raise dust. (Dry sweeping or vacuum cleaners are not recommended.) Use a detergent solution and disinfect any areas with visible contamination with blood or body fluids before cleaning.
Zone C: Cleaning with a detergent/disinfectant solution, with separate cleaning equipment for each room
Zone D: Cleaning with a detergent/disinfectant solution and separate cleaning equipment
Written policies should specify how frequently each area should be cleaned and should note the cleaning agents used for various surfaces and items such as beds, curtains, screens, fixtures, and furniture. In general, all surfaces in the environment (e.g., walls, doors, floors) must be cleaned daily to remove soil. Sinks, toilets, and baths should be scrubbed daily, or more often if needed, with a disinfectant cleaning solution using a separate mop, brush, or cloth. Patient rooms should also be cleaned daily and after each patient is discharged. Surfaces and countertops in procedure rooms, examination rooms, and the laboratory must be cleaned with a disinfectant solution after any activity.
Spills of blood or other body fluid should be removed and cleaned immediately. The area should first be cleaned with a 0.5% chlorine solution and then washed clean with a disinfectant solution. Gloves should be worn while cleaning.
Management of waste is a concern in healthcare facilities, but 75% to 90% of waste poses no risk of infection. The following types of waste are considered to be hazardous :
Infection-associated waste (from isolation units, laboratory cultures, tissue swabs)
Pathologic waste (blood, body fluids, human tissue)
Sharps (needles, scalpels, blades, knives)
Pharmaceutical waste (expired pharmaceutical agents)
Chemical waste (laboratory reagents, solvents)
Heavy metal waste (broken blood pressure gauges, batteries)
As with cleaning, written policies should document the appropriate handling, storage, and transportation of all types of waste.
Infection prevention also includes safe injection practices intended to prevent or reduce the risk of transmission of infectious diseases between one patient and another or between a patient and healthcare provider. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is dangerous for the community .
Unsafe injection practices put patients and healthcare providers at unnecessary risk. A wide variety of procedures, such as the administration of anesthetics for outpatient procedures, the administration of other IV medications, flushing IV lines or catheters, and the administration of IM vaccines, have been associated with unsafe injection . Outbreaks related to these practices indicate that some healthcare personnel do not adhere to basic principles of infection control and aseptic technique. A survey of U.S. healthcare professionals who provide medication through injection found that 1% to 3% reused the same needle and/or syringe on multiple patients .
The following guidelines should be considered with regards to injection practices :
Use aseptic technique to avoid contamination of sterile injection equipment.
Never administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items; they should not be reused for multiple patients.
Use fluid infusion and administration sets (e.g., intravenous bags, tubing, connectors) for one patient only, and dispose appropriately after use.
Use single-dose vials for parenteral medications whenever possible.
If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
Do not keep multidose vials in the immediate patient treatment area, and store in accordance with the manufacturer's recommendations. Discard if sterility is compromised or questionable.
Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
Surveillance is an essential component of an infection control program. The infection control team has traditionally conducted surveillance through open communication with the nursing staff and physicians and meticulous review of patient records and microbiology results. The advent of electronic health systems has enabled some infection control programs to create algorithm-driven surveillance . In addition, newer technology is adding to changes in the way surveillance is conducted. An electronic, laboratory-based marker has been developed and compared with traditional medical record review and hospital-wide detection methods (Study on the Efficacy of Nosocomial Infection Control chart review and intensive care unit detection by NNIS techniques). Analysis with the marker was significantly better than the hospital-wide detection methods and had sensitivity comparable to medical record review .
The infections most commonly targeted for surveillance are those difficult to treat and those associated with substantial costs in terms of morbidity, mortality, or economics . In addition, infections with a predilection for epidemics are a focus. The data gathered should be evaluated in relation to regional and national norms, and temporal trends should also be noted. Continuing analysis of the data allows the infection control team to evaluate the efficacy of programs designed to enhance compliance with hospital-wide strategies to prevent HAIs.
If an occupational exposure to a bloodborne pathogen or infectious material occurs, employers should follow all federal (including the Occupational Safety and Health Administration) and state requirements for recording and reporting. The circumstances surrounding the exposure and postexposure management strategies should be recorded in the exposed person's confidential medical record and should include :
Date and time of exposure
Details of the procedure performed
Details of the exposure
Details about the exposure source
Details about the exposed person and any need for counseling, postexposure management, or follow-up
Medical evaluations before placement may reduce the undue risk of infection to employees, patients, and visitors. A health inventory for all new healthcare professionals who have direct patient/family contact must be documented prior to the beginning of patient/family contact. The inventory should include [15,75]:
A certificate of immunization against rubella and measles (or professionally certified medical exemption from immunization)
A purified protein derivative (PPD) (Mantoux) skin test for tuberculosis prior to employment, and no less than every year thereafter for negative findings. Positive findings require appropriate clinical follow-up but no repeat test.
An annual (or more frequent, if needed) health status assessment to ensure freedom from any health impairment that might pose a risk for other workers, patients, or visitors
Documentation of pre-employment and annual vaccination against influenza
Screening tests are available to determine susceptibility to vaccine-preventable diseases, such as measles, mumps, rubella, and varicella. The results of these tests should be included in personnel immunization records to ensure that susceptible personnel are promptly identified and appropriately vaccinated. All healthcare settings should conduct initial and ongoing risk assessments for the transmission of tuberculosis to determine the types of administrative, environmental, and respiratory-protection controls needed. Part of the assessment should include risk classification to determine the need for a screening program and the frequency of screening. All healthcare professionals with suspected or confirmed tuberculosis disease who have duties that involve face-to-face contact with patients should be included in a screening program .
All healthcare professionals experiencing fever, cough, rash, vesicular lesions, draining wounds, vomiting, or diarrhea require immediate evaluation by a licensed medical professional and possible restriction from patient care activities and return to work clearance . The CDC recommends that all healthcare personal obtain annual influenza vaccination to reduce infection of staff, patients, and family members and to decrease absenteeism . Immunization against hepatitis B and pertussis (Tdap), in addition to all core vaccines, is also recommended . Vaccination of healthcare personnel is considered an essential component of a patient safety program .
Prompt diagnosis and management of job-related illnesses, appropriate postexposure prophylaxis, and implementation of measures to prevent further infection transmission are important aspects of an effective infection control program. Exclusion of personnel from work or patient contact, depending on the mode of transmission and the pathogenesis of the disease, may also be necessary. In these cases, personnel should avoid contact with susceptible persons and should be encouraged to report illnesses or exposures, including any that occur outside the healthcare setting. Notification of emergency response personnel possibly exposed to selected infectious diseases is mandatory .
Education on best practices is a crucial aspect of preventing HAIs and is a recommendation in all infection control guidelines [2,9,17,25,26,28,29,31,32,33,36,38]. Education should highlight the effect of prevention measures on the rates of HAIs, enhance knowledge about currently available guidelines, and provide instruction on carrying out guideline recommendations. Research has also suggested that education about prevention strategies may be more effective if patterns of care and levels of risk are incorporated into recommendations . Numerous studies have shown that knowledge and practices related to HAIs and guidelines are improved after educational programs. The combination of a self-study module (with pretest and post-test), in-service lectures, posters, and fact sheets on the prevention of intravascular device-related bloodstream infections and appropriate practices led to substantial reductions in the prevalence of such infections [78,79]. A small study showed that intensive care nurses' knowledge and practices were enhanced by education on the prevention of ventilator-associated pneumonia . A Canadian study demonstrated that rates of nosocomial MRSA infection significantly decreased after a mandatory infection control education program on MRSA that included discussion of hospital-specific MRSA data and case-based practice .
It is important that all education campaigns, whether they target healthcare professionals, facility staff (e.g., janitorial staff), or the patient populations, take into consideration the special needs of the intended audience. Compounding this issue is the high rate of individuals with limited English proficiency. According to the U.S. Census Bureau data from 2013, more than 60 million Americans (or 21%) speak a language other than English at home, and approximately 42% of these individuals speak English less than "very well" . Even those who do speak English well may prefer to receive education in another language.
When a healthcare provider has been exposed to particular infectious agents, it is important that recommended postexposure management guidelines are followed. This should reduce the risk of infection and of transmitting the infection to others .
Transmission of bloodborne pathogens due to occupational exposure of healthcare professionals has occurred in needlestick accidents (0.3% risk) and blood splashes to the mucous membranes (0.09% risk) . Needlestick is the most common route,but the risk of infection even through this route is low, and most exposures do not result in infection [83,84]. The risk for transmission increases based on the source patient's viral load and the quantity of blood transferred (e.g., a needle visibly contaminated with blood; a large-gauge hollow-bore needle; a procedure that involved the needle entering directly into the patient's artery or vein; a deep puncture from a contaminated needle). In order to decrease the risks associated with bloodborne pathogen exposures, postexposure prophylaxis should be initiated as soon as possible after the incident.
Recommendations for HBV postexposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source as well as the vaccination and vaccine-response status of the exposed person .
Immune globulin and antiviral agents (e.g., interferon with or without ribavirin) are not recommended for postexposure prophylaxis of HCV. In this instance, the HCV status of the source and the exposed person should be determined. For healthcare professionals exposed to an HCV-positive source, follow-up HCV testing should be performed to determine if infection develops .
Healthcare professionals exposed to hepatitis viruses should refrain from donating blood, plasma, organs, tissue, or semen . When based only on exposure to HBV- or HCV-positive blood, modifications to an exposed healthcare professional's patient-care responsibilities are not necessary. Acutely infected healthcare professionals should be evaluated according to current guidelines; healthcare professionals chronically infected with HBV or HCV should follow all recommended infection control practices .
This section is from the Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis as published by the CDC on September 25, 2013 in Infection Control and Hospital Epidemiology .
The following recommendations apply to situations where healthcare professionals have had exposure to a source person with HIV or where information suggests that there is likelihood that the source person is HIV-infected. Because most occupational HIV exposures do not result in the transmission of HIV, potential toxicity should be carefully considered when prescribing postexposure prophylaxis. The 2013 update focused on tolerability, side effects, toxicity, safety in pregnancy and lactation, pill burden, and frequency of dosing to maximize adherence to a postexposure prophylaxis (PEP) regimen . When possible, these recommendations should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission, due to the complexity of selecting appropriate treatment.
The preferred regimen for PEP provided in the U.S. Public Health Service Guidelines for management of healthcare professionals' exposures to HIV is a basic regimen that should be appropriate for most HIV exposures: emtricitabine and tenofovir dispensed together as Truvada, a fixed-dose combination tablet, 1 mg once daily, plus raltegravir, 400 mg twice daily . This preparation is available as a starter packet that should be stocked at every healthcare facility where exposure to HIV is possible. As discussed, the regimen has been selected for its tolerability and safety profile. There are several alternative regimens that may be selected due to individual patient concerns. For example, tenofovir is associated with renal toxicity, and an alternative nucleoside/nucleotide reverse-transcriptase inhibitor pair, such as zidovudine plus lamivudine (available as Combivir) would be selected for patients with renal disease .
Healthcare professionals with occupational exposure to HIV should receive follow-up counseling, postexposure testing, and medical evaluation regardless of whether they receive PEP. The 2013 guideline highlights the importance of follow-up within 72 hours to allow the initial shock to fade and to provide greater opportunity for full understanding of the risks and benefits of PEP; confirmation testing to ensure the necessity of PEP; increase adherence to PEP; monitoring for adverse reactions and side effects; and treating comorbidities and altering the regimen . This window provides an opportunity to discuss the importance of preventing secondary transmission of HIV in the 6 to 12 weeks following initial infection. HIV-antibody testing should be performed for at least six months postexposure (e.g., at 6 weeks, 12 weeks, and 6 months). It is unclear whether an extended follow-up period (e.g., 12 months) is indicated for individuals not coinfected with HCV and HIV. If PEP is used, drug-toxicity monitoring should be performed at baseline and again two weeks after starting PEP. Clinical judgment, based on medical conditions that may exist in pre-exposure and/or as a result of the regimen, should determine the scope of testing. If the source patient is found to be HIV negative, PEP should be discontinued immediately .
Healthcare professionals with known or presumed exposure to Mycobacterium tuberculosis should be asked whether they have experienced any signs or symptoms of tuberculosis (i.e., coughing for more than three weeks, loss of appetite, unexplained weight loss, night sweats, bloody sputum, hoarseness, fever, fatigue, or chest pain). Because a blood assay for M. tuberculosis (BAMT) conversion likely indicates recent infection, a BAMT result should be obtained to exclude tuberculosis . If either the symptom screen or the BAMT result is positive, the exposed healthcare professional should be promptly evaluated for tuberculosis. If tuberculosis is excluded, additional medical and diagnostic evaluations for latent tuberculosis infection, including an assessment of the extent of exposure, should be obtained [76,85]. Healthcare professionals with active tuberculosis should be excluded from duty until proved noninfectious .
According to the CDC and Hospital Infection Control Practices Advisory Committee (HICPAC), postexposure measles vaccine should be administered to measles-susceptible personnel who have had contact with persons with measles within 72 hours postexposure . Furthermore, adherence to Airborne Precautions (for suspected and proven cases) is also necessary. Healthcare professionals without evidence of immunity who are not vaccinated after exposure should be removed from all patient contact and furloughed from day 5 after first exposure through day 21 after last exposure .
The CDC and HICPAC have also established postexposure protocols for mumps. The mumps vaccine should be administered to all personnel without documented evidence of mumps immunity, unless otherwise contraindicated [75,86]. Routine serologic screening is not necessary unless the healthcare professional considers screening cost-effective or requests it. Susceptible personnel who are exposed to mumps should not work from the 12th day after first exposure through the 25th day after last exposure or, if symptoms develop, until five days after onset of parotitis .
The CDC and HICPAC guideline indicates that antimicrobial prophylaxis against pertussis should be immediately offered to personnel who have had unprotected, intensive contact with a patient who has clinical syndrome that suggests pertussis and whose cultures are pending [75,86]. Other healthcare personnel should either receive postexposure antimicrobial prophylaxis or be monitored daily for 21 days after exposure and treated at the onset of signs and symptoms . Prophylaxis may be discontinued if results of cultures or other tests are negative for pertussis and the clinical course suggests an alternate diagnosis.
Susceptible personnel who are exposed to rubella should be excluded from duty from the 7th day after first exposure through the 23rd day after last exposure [75,86]. Those who acquire rubella should not work until seven days after the beginning of the rash.
The Advisory Committee on Immunization Practices (ACIP) recommends postexposure prophylaxis (with vaccination or varicella-zoster immunoglobulin [VZIG], depending on immune status) of exposed healthcare personnel without evidence of immunity . Healthcare professionals who have onset of varicella should be furloughed until all lesions have dried and crusted. Personnel exposed to varicella who are not known to be immune (by history or serology) should be excused from work beginning on the 8th day after first exposure until the 21st day after last exposure.
Immunocompetent personnel with localized zoster should refrain from the care of high-risk patients until lesions are crusted. They may continue to care for other patients with lesions covered . Susceptible personnel exposed to zoster should not engage in patient contact from the 8th day after first exposure through the 21st day after last exposure (or 28th day if VZIG was given) [75,86].
Serologic screening is indicated for exposed personnel who have not had varicella or are unvaccinated; screening for immunity to varicella may be considered for exposed, vaccinated personnel whose antibody status is not known [75,86]. If the initial test result is negative, retest five to six days postexposure to determine whether an immune response occurred.
All exposed susceptible personnel should receive postexposure prophylaxis . If VZIG is given, exclude personnel from duty from the 8th day after first exposure through the 28th day after last exposure.
Although the most frequent routes of transmission of noroviruses are direct contact and food and waterborne routes, several reports suggest that noroviruses may be transmitted through infectious small-particle aerosols (e.g., vomitus, fecal material) over distances further than 3 feet, typically within a defined airspace (e.g., a patient's room) [87,88,89,90]. It is hypothesized that the aerosolized particles are inhaled and subsequently swallowed. Because of its propensity for transmission within healthcare facilities, and its ability to have a disruptive impact in healthcare facilities, norovirus is an "epidemiologically important organism" .
The average incubation period for gastroenteritis caused by noroviruses is 12 to 48 hours, with a clinical course lasting 12 to 60 hours. There are no recommendations for postexposure prophylaxis for healthcare personnel with norovirus infection. However, recommendations for healthcare personnel who have symptoms consistent with norovirus infection include exemption from work for a minimum of 48 hours after the resolution of symptoms and exclusion of nonessential staff from areas in which outbreaks of norovirus gastroenteritis have occurred [17,91].
Cohorting of affected patients to separate airspaces and toilet facilities may help interrupt transmission during outbreaks. Contact Precautions should be used for diapered or incontinent persons for the duration of illness or to control outbreaks. Consistent environmental cleaning and disinfection is important, with focus on restrooms even when apparently unsoiled. Persons who clean heavily contaminated areas may benefit from wearing masks, as the virus can be aerosolized .
Routine voluntary, confidential testing has been recommended for all healthcare providers, particularly for those whose clinical practice places them at higher risk for exposure and transmission . The New York Department of Health has developed a policy regarding HIV testing of healthcare professionals (Table 3) . It is important to note that New York State Public Health Law protects the confidentiality and privacy of anyone who has been tested for, exposed to, or treated for HIV . In addition, according to the Americans with Disabilities Act, an individual is considered to have a disability if he or she has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment . Persons with HIV disease, both symptomatic and asymptomatic, have physical impairments that substantially limit one or more major life activities and are, therefore, protected by the law. Persons who are discriminated against because they are regarded as being HIV-positive are also protected.
NEW YORK DEPARTMENT OF HEALTH POLICY FOR TESTING POSSIBLE HIV SOURCES IN THE HEALTHCARE SETTING
Postexposure prophylaxis (PEP) is recommended for healthcare professionals following exposure to blood or visibly bloody fluid or other potentially infectious material associated with potential HIV transmission.
If HIV serostatus of the source is unknown, voluntary HIV testing of the source should be sought. In New York State, specific informed consent for HIV testing is required.
Rapid testing with an approved fourth-generation antigen/antibody combination assay is strongly recommended for the source patient and for those organizations subject to OSHA regulations; rapid testing (versus standard testing) is mandated for occupational exposures. Rules regarding confidentiality and consent for testing are identical to those for other HIV tests. Plasma HIV RNA testing is recommended in certain instances.
If the rapid test result is positive, the result should be given to the source patient. To establish a diagnosis of HIV infection, the test must be confirmed by an antibody-differentiation assay, which should be performed as soon as possible.
If the result from testing the source patient is not immediately available or a complete evaluation of the exposure is unable to be made within two hours of the exposure, PEP should be initiated while source testing and further evaluation are underway.
In 2010, the Society for Healthcare Epidemiology of America (SHEA) updated its guidelines for the management of healthcare professionals who are infected with bloodborne pathogens . According to these guidelines, healthcare providers with HBV, HCV, and/or HIV with greater viral loads (≥104 genome equivalents/mL for hepatitis viruses, ≥5 x 102 genome equivalents/mL for HIV) should be restricted from performing activities associated with a definite risk for provider-to-patient transmission of bloodborne pathogens, such as most surgeries, organ transplantation, and interactions with patients prone to biting . These providers may engage in procedures for which the risk of transmission is insignificant (e.g., history taking, regular dental preventive procedures, minor surface suturing) or unlikely (e.g., locally anesthetized ophthalmologic surgery, percutaneous cardiac procedures, breast augmentation, minor oral surgery). Routine double gloving is also recommended .
Infected healthcare professionals with lower viral burdens (<104 genome equivalents/mL of hepatitis viruses, <5 x 102 genome equivalents/mL for HIV) may engage in all clinical activities . However, all healthcare providers with a bloodborne pathogen must obtain advice from an expert review panel about continued practice, undergo follow-up routinely by an appropriate public health official, receive follow-up by a personal physician who has expertise in the management of the infection, and adhere to strict infection control procedures . Those with low viral burdens should undergo testing twice per year to demonstrate maintenance of viral level.
An effective infection control team is critical to reducing the incidence of HAIs in a healthcare facility. All departments within a healthcare facility should be represented on this team to ensure widespread adherence to prevention measures. The responsibilities of an infection control team are to conduct surveillance of infections; ensure compliance with infection control guidelines, including those for management of drug-resistant organisms; and establish response and control plans for outbreaks and epidemics. Most important is the development of an organizational culture that fosters a focus on patient safety and that emphasizes education on HAIs and infection control for healthcare professionals and patients and their families.
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