NOSOCOMIAL

INFECTION

Nosocomial infections (NCI)

"nosus" = disease
"komeion" = to take care of
Infections that occur during hospitalization
but are not present nor incubating upon
hospital admission

History of Nosocomial Infection

Ignaz Semmelweis, (1840s)
demonstrated importance of
hand hygiene
No progress for next century
1976, the Joint Commission on
Accreditation of Healthcare
Organizations - standards for
infection control
Nosocomial infection still on the
increase - emerging infection

Major Sites of Nosocomial

Infections

Urinary tract infection

Bloodstream infection
Pneumonia (ventilator-associated)
Surgical site infection

CAUSES OF HCAI
Virtually all microorganisms can
cause nosocomial infections
Viruses
Bacteria
Fungi
Parasites

SOURCES OF INFECTION
Endogenous
source is the normal flora or
colonisers of skin and other
epithelial surfaces

Exogenous
other persons (cross-infection)
inanimate objects (fomites)

TYPES BY ORIGIN
1.Endogenous:
Caused by the organisms that are present as
part of normal flora of the patient

2. Exogenous:
caused by organisms acquiring by exposure to
hospital personnel, medical devices or hospital
environment

The inanimate environment is a

reservoir of pathogens
X represents a positive Enterococcus
culture

The pathogens are ubiquitous

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with
a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

SPREAD OF INFECTONS
Air-borne
Skin scales, droplet nuclei

Contact
Direct
Hands & clothing
Droplet contact followed by autoinoculation
Clinical equipment
Indirect
Bedpans, bowls, jugs, etc

SPREAD OF INFECTONS
The hands are the most important
vehicle of transmission of
HCAI

Nosocomial Infections

Exogenous Infections

Endogenous Infections

Nosocomial Infections

Chain of Transmission

Universal Precautions

PRACTISE STANDARD
PRECAUTIONS

CONTROL OF HCAI
Hand hygiene is the
single most
important
measure for control
of nosocomial
infections

TYPES OF HAND HYGIENE

PROCEDURES
Hand washing
Hand washing is usually limited to hands and wrists
Hands are washed for a minimum of 10 15 seconds with soap
(plain or antimicrobial) and water
Transient micro-organisms are mechanically removed by rinsing.

Hand antisepsis/decontamination
Hand antisepsis removes or destroys transient micro-organisms and
confers a prolonged effect.
Two ways:
Wash hands and forearms with antimicrobial soap and water, for
15-30 seconds
Decontaminate hands with a waterless, alcohol-based hand gel
or hand rub for 15-30 seconds. Appropriate for hands that are
not soiled with protein matter or fat.

TYPES OF HAND HYGIENE

PROCEDURES
Surgical hand antisepsis
Removes or destroys transient micro-organisms and
confers a prolonged effect.
Hands and forearms are washed thoroughly with an
antiseptic soap for a minimum of 2-3 minutes.
Hands are dried using a sterile towel.
Required before performing invasive procedures.

HAND WASHING TECHNIQUE

Source: World Health Organization. Regional Office for Western Pacific.

Hands Spread Disease

PROTECT YOURSELF
THROUGH IMMUNISATION
Immunisation
BCG
Hepatitis B
Tetanus
Rubella
Varicella
Influenza

Why disinfection and sterilization?

Contagious diseases
Hospital infection (e.g., OR, ID ward)
or other opportunistic infection
Lab contamination, etc.
Microbes:
- usually easy to grow in environment;
- but also can be inhibited or killed by certain
environmental (physical or chemical)
factors/conditions.

Terminology

Disinfection
Sterilization
Bacteriostasis
Antisepsis
Asepsis

Disinfection
Process of reducing or eliminating living
pathogenic microorganisms in or on
materials, so they are no longer a health
hazard.
For example: use of alcohol before drug
injection.

Sterilization
Process of destroying all microbial
forms. A sterile object is one free of all
microbial forms, including bacterial
spores.
More thorough than disinfection

Bacteriostasis
Process of inhibiting the growth of
microorganisms, in vivo (mostly) or in
vitro
For example: bacteriostatic antibiotics

Antisepsis
Process of inhibiting or preventing
growth of microbes, mostly in vitro and
not bactericidal or sporicidal
For example: use of chemical agents on
skin, other living tissues or
food/beverage.

Asepsis
A state where no living microorganism
exists.
For example: OR (Operating Room)

Controlling Microorganisms with

Physical Conditions

High Temperature (heat)

Radiation
Ultrasound
Filtration
Low Temperature
Desiccation

Dry heat protein oxidation

Incineration

most thorough (>500)

disposals and corpes

Flaming (burner)
test tube opening, transferring loop

Hot air sterilization/Baking

160-170, 2h
Glassware, syringes, needles, etc

Infrared heat: similar to baking

Moist heat denaturing proteins and melt lipids

Autoclaving
Most commonly used and effective
121 (103.4kPa), 15-20min
killing both vegetative organisms and
endospores

Boiling

100 (105 with 2% Na2CO2) , 15-20min

cidal for vegetative cells but not necessarily spores

Regular Steam (Arnold Sterilizer)

100 , 15-20min
cidal for vegetative cells but not necessarily spores

 Pasteurization
to kill pathogens in readily perishable objects (milk,
wine)
flash method : 71.6, 15s
holding method : 62.9, 30 min

Fractional sterilization
alternating exposure and cooling time for a
consecutive period:
Steam heating (100, 30 min) 30 for endospores to
germinate 100, 30 min to kill germinated endospores
30-37 overnight for remaining endospores to
germinate 100, 60 min to kill last remaining
germinated endospores
for sugar- or milk-containing culture media

Moist Heat vs Dry Heat

Moist heat

Dry heat

Penetrating potency

higher

lower

Temp for protein clotting

lower

higher

Extra heat released

from condensation

yes

no

Sterilizing potency: Moist heat >> Dry heat

Radiation
Ultraviolet (UV) radiation
mechanism: blockage of DNA replication by forming
thymidine dimmers
microbicidal activity of UV depends on:
length of exposure
wavelength: 200-300 nm, with the best effect of 265-266nm
bulb life (4000hr)

very poor penetrating power

for air or surface disinfection
(OR, ID ward, labs)
causing eye damage, burns
and mutation in skin cells

 Ionizing Radiation
X-rays, gamma rays and high-speed electrons
generating more energy and penetrating power
than UV
to sterilize pharmaceuticals, disposable medical
supplies (e.g., syringes, gloves, catheters, sutures)
and foods

Microwave
penetrating non-metal materials (glass, plastics)

 Ultrasound
more effective for gram-negative bacteria
Lack of thoroughness survivors remain

Filtration
sterilize heat- or chemical-sensitive solutions
not effective for virus, ricketia, mycoplasma

Seitz filter

 Desiccation
static effect by inhibiting microbial enzymes
not effective against endospores
mainly for food reservation

Low Temperature (-20 -70)

inhibits microbial growth by slowing down
microbial metabolism
a special form: lyophalization (freeze-drying),
used for long-term (years) reservation of bacteria
stocks
fast freezing + drying
protecting agents (glycerol, serum)

Control Microorganisms with

Chemical Agents
(Disinfectants and Antiseptics)

Antimicrobial modes of action of

disinfectants and antiseptics
Denaturation of bacterial proteins by disrupting
hydrogen and disulfide bonds
phenol (high conc.), alcohol, heavy-metal (high conc.),
acids, alkalies, aldehydes)
Damage to bacterial membrane (lipids and/or proteins),
causing leakage of intracellular molecules
phenol (low conc.), surfactants, dyes
Interference of bacterial enzyme and metabolism
oxidants, heavy-metals (low conc.), alkylating agents

Effectiveness of antimicrobial agents are

affected by :
The concentration/intensity and nature of the
disinfectant;
Length of exposure;
Species and number of the microbe(s);
Temperature and humidity;
Acidity (pH);
Presence of organic substances;
Presence of chemical antagonists
The nature of the material bearing the microbes

Summary 1. Application of chemical

disinfectants
Patient excretion Chlorines, 5% carbonic acid, 2% Lysol
Skin (hands)

Mucosa

2% Lysol,
0.2-0.4% peroxyacetic acid for HBV,
70% ethyl alcohol,
2% mercurochrome

oral - 3% peroxide;
uri-reproductive - 0.010.05%Chlorhexidine,
0.1%
potassium permanganate ;
newborn eyes - 1% silver nitrate

Drinking water

Chlorines

Toilets, sewage

quicklime [Ca(OH)2]

Air (OR, ID ward)

formalin steam (12.5-25ml/m3,12-24h),

formalin 40ml + potassium permanganate
30g/m3;
HBV ward- peroxyacetic acid 3g/m3 90min

Glassware, china,
Rubber, metal
devices

0.5% iodophores, 0.2-0.4% peroxyacetic

acid

Summary 2. Potency levels of chemical

disinfectants
Potency

Definition Examples

High

Killing all microbes including glutaric dialdehyde

endospores and TB formaldehyde peroxyacetic acid
epoxy ethane

Medium

Killing all non-spore microbes alcohol, chlorines,

including TB
iodophores

Low

Killing vegetative bacteria

chlorhexidine
and lipophilic (enveloped)
bromogeramine
viruses, but resisted by
endospores, TB and hydrophilic
(non-enveloped) viruses

Summary 3. Spore-killing effects of chemical

disinfectants

Spore-killing disinfectants
glutaric dialdehyde, formaldehyde, Iodines,
H2O2, epoxy ethane

Non spore-killing disinfectants

alcohols, phenols, chlorhexidine,
bromogeramine

Medical Microbiology

Disinfection and Sterilization

For the course of Medical Microbiology for MBBS
foreign students, Class 2006/2011, SYSU

September 18, 2007

Mengfeng Li , M.D.
Department of Microbiology, Zhongshan School of
Medicine, SYSU, Guangzhou, China
limf@mail.sysu.edu.cn