Infection Control: The New York Requirement

Course #98643 - $25 • 5 Hours/Credits


Self-Assessment Questions

    1 . Which of the following categories of healthcare-associated infections (HAIs) does the Centers for Medicare & Medicaid Services consider to be reasonably preventable?
    A) HIV infection
    B) Ventilator-associated pneumonia
    C) Catheter-related urinary tract infection
    D) Methicillin-resistant Staphylococcus aureus (MRSA) infection

    STANDARDS OF PROFESSIONAL CONDUCT

    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 [19]. 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 [16,17,21]. 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 [22,23]. The policy also has the potential to lead to increased unnecessary use of antimicrobials in an effort to prevent infections [24]. Additionally, one study found that many acute care hospitals commonly listed the reimbursement restricted HAIs as "present on admission," which mitigated the impact intended by CMS [25].

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    2 . Which of the following statements regarding prevention of HAIs is TRUE?
    A) An estimated 70% of HAIs are preventable.
    B) Adherence to prevention guidelines is generally low.
    C) Most professionals comply with hand hygiene guidelines.
    D) There are few evidence-based guidelines for the prevention of infection in healthcare facilities.

    STANDARDS OF PROFESSIONAL CONDUCT

    The results of the 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" [29,30]. 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 [31].

    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 [2,28,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53]. 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 [54]. Hand hygiene is the most basic and single most important preventive measure, yet compliance rates among healthcare workers have averaged only 30% to 50% [3,25,42,55,56,57,58]. 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.

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    3 . For which of the following pathogens is the skin not an effective barrier?
    A) Candida spp.
    B) Human papillomavirus
    C) Haemophilus influenzae
    D) Mycobacterium tuberculosis

    THE INFECTIOUS DISEASE PROCESS

    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 [63]. 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 [64].

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    4 . Which of the following statements about the pathogenesis of infection is TRUE?
    A) Commensal bacteria are always a source of infection.
    B) Infection with parasites is as common as infection with bacteria.
    C) Viral nosocomial infections are more common in adults than in children.
    D) Fungal infections frequently occur during prolonged treatment with antibiotics.

    THE INFECTIOUS DISEASE PROCESS

    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 [65]. 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 [2].

    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 [1]. Fungal infections frequently occur during prolonged treatment with antibiotics and in patients who have compromised immune systems [2]. Various pathogens have different levels of pathogenicity, virulence, and infectivity.

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    5 . The greatest risk of morbidity and mortality is associated with infection with
    A) fungi.
    B) viruses.
    C) bacteria.
    D) parasites.

    THE INFECTIOUS DISEASE PROCESS

    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 [1]. Fungal infections frequently occur during prolonged treatment with antibiotics and in patients who have compromised immune systems [2]. Various pathogens have different levels of pathogenicity, virulence, and infectivity.

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    6 . Percutaneous exposure to a bloodborne pathogen may occur during
    A) blood splashes.
    B) handling contaminated needles.
    C) infusion of contaminated fluids.
    D) sharing of blood monitoring devices.

    HIGH-RISK PRACTICES: EXPOSURE TO BLOODBORNE PATHOGENS

    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, 15% occur after use and before disposal, and 3% occur during or after disposal [70].

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    7 . Airborne Precautions should be used for a patient with
    A) pertussis.
    B) diphtheria.
    C) meningitis.
    D) tuberculosis.

    PRECAUTIONS AND ISOLATION TECHNIQUES

    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, the route of transmission, and the healthcare setting [28]. 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 [28]. 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 [28].

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    8 . When adhering to Droplet Precautions, healthcare professionals should
    A) wear a mask when working within 3 feet of the patient.
    B) wear an N95 respirator when entering the room of the patient.
    C) ensure that the patient's room has 6 to 12 air changes per hour.
    D) not enter the room of the patient if they are susceptible to the disease.

    PRECAUTIONS AND ISOLATION TECHNIQUES

    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.)

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    9 . Hands should be washed after
    A) removing gloves
    B) contact with a patient's skin.
    C) contact with body fluids or excretions, nonintact skin, or wound dressings.
    D) All of the above

    PRECAUTIONS AND ISOLATION TECHNIQUES

    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.
    Specific Indications
    Wash hands before patient contact and before putting on gloves for insertion of invasive devices that do not require surgery (e.g., urinary catheters, intravascular devices).
    Wash hands after:
    • Contact with a patient's skin

    • Contact with body fluids or excretions, nonintact skin, or wound dressings

    • Removing gloves

    Recommended Handrub Technique
    Apply to palm of one hand, rub hands together, covering all surfaces until dry.
    Recommended Handwashing Technique
    • Wet hands with water, apply soap, and rub hands together for at least 15 seconds.

    • Rinse and dry with disposable towel.

    • Use towel to turn off faucet.

    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.
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    10 . With regard to hand hygiene,
    A) compliance is usually more than 80%.
    B) antibacterial soap is more effective than alcohol-based handrub solutions.
    C) reasons given for noncompliance include inconveniences, understaffing, and skin damage.
    D) the impact as an individual strategy in reducing healthcare-associated infections is well documented.

    PRECAUTIONS AND ISOLATION TECHNIQUES

    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% [3,42,54,56,57,58]. Among the reasons given for the lack of compliance are inconvenience, understaffing, and damage to skin [1,42,56,72]. The development of effective alcohol-based handrub solutions addresses these concerns, and studies have demonstrated that these solutions have increased compliance [57,73,74]. The CDC guideline recommends the use of such solutions on the basis of several advantages, including [42]:

    • 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 [42]. In one small survey of hand hygiene practices, healthcare workers indicated that they would be more likely to clean their hands as recommended if alcohol-based handrub solution was located near the patient [75]. 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 [1,42,56]. 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 [76]. Single interventions are unlikely to be effective [76]. Studies indicate that multimodal interventions (e.g., education, observation, provision of supplies, administrative support, reminders, surveillance, performance feedback) may be more effective in raising compliance [76,77,78].

    Several single-institution studies have demonstrated that appropriate hand hygiene reduces overall rates of HAIs, including those caused by MRSA and vancomycin-resistant enterococci [57,58,73,74]. 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 [79]. 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 [80]. 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 [58]. Lastly, as noted previously, the development of HAIs is complex, with many contributing factors [58]. 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 [2,28,36,37,39,40,42,43,44,47,49].

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    11 . Intermediate-level disinfection is defined as
    A) use of a 0.5% chlorine solution to reduce the number of pathogenic organisms on the device.
    B) use of disinfectant to destroy pathogenic organisms (eliminates most bacteria, viruses, and fungi).
    C) use of high-pressure steam (autoclave), dry heat (oven), chemical sterilants, or radiation to eliminate all forms of viable micro-organisms.
    D) a multistep procedure that consists of meticulous cleaning, high-level disinfection with a liquid chemical sterilant or disinfectant, and proper drying.

    STANDARDS FOR EQUIPMENT AND ENVIRONMENTAL SERVICES

    DEFINITIONS OF LEVELS OF CLEANING AND DISINFECTION

    LevelDefinition
    DecontaminationUse of a 0.5% chlorine solution to reduce the number of pathogenic organisms on the device
    CleaningUse of soap and water to remove all visible dust, soil, blood, or other body fluids
    Low-level disinfectionUse of disinfectant to destroy pathogenic organisms (may not eliminate resistant bacteria or most viruses or fungi)
    Intermediate-level disinfectionUse of disinfectant to destroy pathogenic organisms (eliminates most bacteria, viruses, and fungi)
    High-level disinfectionUse of chemical disinfectants, boiling, or steaming to destroy all micro-organisms
    SterilizationUse of high-pressure steam (autoclave), dry heat (oven), chemical sterilants, or radiation to eliminate all forms of viable micro-organisms
    ReprocessingA multistep procedure that consists of meticulous cleaning, high-level disinfection with a liquid chemical sterilant or disinfectant, and proper drying
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    12 . According to Spaulding classification, a device that enters the vascular system is
    A) critical.
    B) noncritical.
    C) less critical.
    D) semicritical.

    STANDARDS FOR EQUIPMENT AND ENVIRONMENTAL SERVICES

    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) [2,37,66]. 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) [66,83]. Critical devices require sterilization, and semicritical devices require high-level disinfection; noncritical devices may be cleaned with low-level disinfection [2,48,66,83].

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    13 . According to World Health Organization classification, an isolation unit in a healthcare facility should be cleaned
    A) using normal cleaning procedures.
    B) using procedures that do not raise dust.
    C) after disinfection of any areas with visible contamination with blood or body fluids.
    D) using a detergent/disinfectant solution, with separate cleaning equipment for each room.

    STANDARDS FOR EQUIPMENT AND ENVIRONMENTAL SERVICES

    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 [2]:

    • 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 [2]:

    • 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

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    14 . Which of the following is NOT an aspect of safe injection practices?
    A) Using aseptic technique
    B) Keeping multidose vials in the immediate patient treatment area
    C) Using a sterile needle and syringe when a multidose vial is used
    D) Using single-dose vials for parenteral medications whenever possible

    SAFE INJECTION PRACTICES

    The following guidelines should be considered with regards to injection practices [28]:

    • 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.

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    15 . After an occupational exposure to an infectious agent, which of the following should be recorded in the exposed person's confidential medical record?
    A) Date and time of exposure
    B) Details about the exposure source
    C) Details about necessary follow-up
    D) All of the above

    SURVEILLANCE

    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 [93]:

    • 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

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    16 . Healthcare professionals experiencing all of the following symptoms require immediate evaluation by a licensed medical professional, EXCEPT:
    A) Rash
    B) Vomiting
    C) Vesicular lesions
    D) Nasal congestion

    COMMUNICABLE DISEASE EXPOSURES IN HEALTHCARE PROFESSIONALS

    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 [95]. The CDC recommends that all healthcare personnel obtain annual influenza vaccination to reduce infection of staff, patients, and family members and to decrease absenteeism [97]. Immunization against hepatitis B and pertussis (Tdap), in addition to all core vaccines, is also recommended [98]. Vaccination of healthcare personnel is considered an essential component of a patient safety program [97].

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    17 . Healthcare professionals exposed to hepatitis viruses
    A) may safely donate semen.
    B) should be administered ribavirin and interferon.
    C) should refrain from patient-care responsibilities.
    D) should consider receiving hepatitis B immune globulin (HBIG).

    COMMUNICABLE DISEASE EXPOSURES IN HEALTHCARE PROFESSIONALS

    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 [93].

    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 as soon as possible (preferably within 48 hours) after the exposure, using one of two options: test for HCV RNA (preferred), or test for anti-HCV and then if positive, test for HCV RNA [106]. If the source patient is known or suspected to have recent behavior risks for HCV acquisition (e.g., injection drug use), or if the risk cannot be reliably assessed, the initial testing should include a nucleic acid test for HCV RNA. Persons with recently acquired acute infection typically have detectable HCV RNA levels as early as one to two weeks after exposure [106]. For healthcare professionals exposed to an HCV-positive source, follow-up HCV testing should be performed to determine if infection develops [93,106]. The timing and type of follow-up testing recommended is included in guidance from the CDC published in 2020 [106].

    Healthcare professionals exposed to hepatitis viruses should refrain from donating blood, plasma, organs, tissue, or semen [93]. 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 [93].

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    18 . Susceptible personnel who are exposed to mumps should not work
    A) until proven noninfectious.
    B) until 3 days after parotitis develops.
    C) from the 12th day through the 26th day after last exposure or, if symptoms develop, until nine days after onset of parotitis.
    D) from the 4th day through the 28th day after last exposure, unless symptoms develop.

    COMMUNICABLE DISEASE EXPOSURES IN HEALTHCARE PROFESSIONALS

    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 [95,98]. 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 26th day after last exposure or, if symptoms develop, until nine days after onset of parotitis [95].

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    19 . According to the New York Department of Health policy regarding HIV testing,
    A) rapid testing is not mandated for occupational exposures.
    B) specific informed consent for HIV testing is not required.
    C) if a rapid test result is positive, the test must be confirmed by an ELISA test.
    D) rules regarding confidentiality and consent for testing in the occupational setting are identical to those for other HIV tests.

    COMMUNICABLE DISEASE EXPOSURES IN HEALTHCARE PROFESSIONALS

    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.

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    20 . In hospitalized adult patients, sepsis is primarily the result of infection with
    A) fungal organisms.
    B) gram-positive bacteria.
    C) gram-negative bacteria.
    D) group B streptococcus.

    SEPSIS

    Healthcare-associated infections are a major cause of sepsis among severely ill patients. Increased risk of nosocomial infection is associated with the presence of underlying chronic disease, alteration in host defenses, prolonged hospital stay, and the presence of invasive catheters or monitoring devices [142]. Pulmonary, urinary tract, gastrointestinal, and wound infections predominate [143,144]. In hospitalized adult patients, the etiology of sepsis has shifted from being predominantly gram-negative nosocomial infections (Escherichia coli, Klebsiella spp., Enterobacter spp., and Pseudomonas aeruginosa) to gram-positive infections (Staphylococcus aureus, Streptococcus pneumoniae, and Streptococcus pyogenes) [145]. The incidence of sepsis caused by gram-positive infections has increased by 26.3% per year over the last three decades [146]. Multidrug-resistant pathogens, such as S. aureus, now account for more than half of all sepsis cases. S. aureus is singly responsible for 40% of ventilator-associated pneumonia episodes and most cases of nosocomial pneumonia [146,147]. Group B streptococcus is a leading cause of neonatal sepsis in the United States [148].

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