HOSPIAL ACQUIRED INFECTION (HAI) / NOSOCOMIAL INFECTION

 Definition:
It is defined as i) the infections acquired in the hospital by a patient admitted for a reason other than the infection in
context, ii) the infection should not be present or incubating at the time of admission and iii) the symptoms should
appear at least after 48 hours of admission. This also include:
• Infections that are acquired in the hospital but symptoms appear after discharge
• Occupational infections among staff of the health care facility
• Infections in a neonate that results while passage through the birth canal

 Factors affecting HAI

1) Immune status of the individual
2) Hospital environment
3) Hospital organisms
4) Diagnostic or therapeutic interventions
5) Transfusions
6) Poor hospital administration
 Sources of infection:
a) Endogenous source: involving the patient’s own flora
b) Exogenous source: environmental sources, health-care workers and other patients

 Microorganisms implicated in HAI’s:

a) ESKAPE pathogens: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii,
Pseudomonas aeruginosa, Enterobacter species
b) Others: Escherichia coli, SARS-CoV 2, Legionella pneumophila, Candida albicans, Clostridium difficile diarrhoea

 Modes of transmission of infection:

1) Contact transmission
2) Droplet transmission
3) Airborne transmission

 Major types of HAI:

1) Catheter associated urinary tract infection (CAUTI)
2) Central-line associated blood stream infection (CLABSI)
3) Ventilator-associated pneumonia
4) Surgical site infection
 PREVENTION OF HAI

STANDARD PRECAUTIONS TRANSMISSION BASAED

OR
1. Hand Hygiene SPECIFIC PRECAUTIONS
2. Personal protective equipment
3. Biomedical waste
1. Contact precautions
4. Spillage cleaning
2. Droplet precautions
5. Disinfection of patient care items
3. Airborne precautions
6. Environment cleaning
7. Safe use and disposal of sharp
8. Respiratory hygiene and cough etiquette
 STEPS OF SPILL MANAGEMENT
Blood spill and body fluid management produces substantial risk for blood borne viruses
such as Hepatitis B, C and HIV
The following steps need to be sequentially followed for the management of blood or body
fluid spillage-
1. Any spillage should be attended immediately
2. Mark the spill area, place the wet floor sign
3. Wear appropriate PPE
4. Confine the spill and wipe immediately with an absorbent towel or cloth, which is
spread over the spill to solidify the blood or body fluid. Then it is disposed of as an
infectious waste
5. Clean with hypochlorite (freshly prepared)
For large spills (>10 cm size) : Use 1:10 dilution of 5% hypochlorite (5000 ppm) i.e 0.5%
For small spills (<10 cm size) : Use 1:100 dilution of 5% hypochlorite (500 ppm) i.e 0.05%
1. Allow the disinfectant to remain wet on the surface for at least a contact time of 10 mins
2. Rinse the area with clean water to remove the disinfectant residue
 HICC Constitution
The Hospital Infection control committee (HICC) provides a forum for multidisciplinary input and co-operation and
information sharing, required for hospital infection control and prevention. The HICC is advisory to the MS and makes its
recommendations to the MS. It consists of representations from relevant departments/health sectors as follows:

1. Chairperson, usually the Medical Superintendent

2. Secretary, mostly the head of Microbiology
3. Hospital infection Control officer (HICO), generally a representative from the Department of Microbiology
4. Hospital Infection control nurse
5. Head of all clinical (medical and surgical) departments
6. Nursing Superintendent
7. Head of the staff clinic
8. Operation Room supervisor
9. In-charge of CSSD
10. In-charge of Bio-medical waste
11. In-charge of pharmacy
12. In-charge of hospital linen and laundry
13. In-charge of hospital kitchen
14. Epidemiologist
15. In-charge of engineering department of hospital
 FUNCTIONS OF HICC

HICC supervises the implementation of the hospital infection control program. The
various functions of the committee include:

1. HAI Surveillance
2. Develops a system
3. Antimicrobial stewardship programme
4. Policies
5. Education
6. Staff health
7. Outbreak management
8. Communication with Other departments
9. Reviews risk associated with technologies
10.HICC meetings
 INTRODUCTION TO NEEDLE STICK INJURY

• Needle stick injury is one of the commonest Occupational hazard in our profession
• It is of two types: a) Percutaneous injury. b) Splash injury
• Splash injury may be contact with mucous membranes, contact with non-intact skin,
contact with intact skin for prolonged duration
• Agents transmitted are Hepatitis B virus, Hepatitis C virus and HIV.
• The risk of transmission is highest for HBV (30%), HCV (3%) and then comes HIV
(0.3%)
• The infectious specimens for Needle stick injury are classified under two headings: a)
Infectious specimens. b) Non-infectious specimens
• The infectious specimens include body fluids like blood, genital secretions like semen
and vaginal secretions, CSF, synovial fluid, pleural fluid, peritoneal fluid etc
• The non infectious specimens include faeces, nasal secretions, saliva, sputum,sweat,
tears etc
 PRECAUTIONS TO PREVENT NEEDLE STICK INJURY

The following precautions are taken during the handling of the needle to prevent
needle stick injury:
 Hand hygiene and appropriate use of PPE during handling
 Work surfaces must be disinfected with 1% sodium hypochlorite solution
 Health care workers (HCW) must be immunised against HBV
 Spillage of blood and other body fluids must be promptly cleaned and the surface
disinfected with 10% sodium hypochlorite
 Needles should never be reused
 Never recap needles by holding the cap in hand
 Proper way of disposal must be done after needle use
 Used Needles should not be kept in bedside or trolleys specially keeping them
open
 Use of safety lock syringes, retractable lancets, needleless IV systems prevents NSI
 POST EXPOSURE MANAGEMENT

1) First Aid
2) Report to the designated nodal officer
3) Take the first dose of post-exposure prophylaxis (PEP) for HIV
4) Testing for Blood borne viruses (BBV)
5) Decision on PEP for HIV and HBV
6) Documentation and recording of exposure
7) Informed consent and counselling
8) Follow-up testing of Health care workers (HCW)
9) Precautions during the follow up period
 FIRST AID: MANAGEMENT OF EXPOSED SITE

Do’s Dont’s

• Earlier the first aid, lesser is the chance of transmission • Do not panic
of BBV • Do not place the pricked finger in the mouth by any
• For splash injury: Irrigate thoroughly the site vigorously means
with water at least for 5 mins • Do not squeeze blood from the wound
• Spit fluid out immediately if gone into mouth several • Do not use antiseptics and detergents
times
• If wearing contact lenses, leave them in place while
irrigating. Once the eye is cleaned, remove the contact
lens and clean them in a normal manner
 Revised NACO guidelines for Post Exposure prophylaxis (2018)
Exposure code (EC) Source HIV status code (SC) PEP Recommendation
1, 2 or 3 Negative Not warranted

1 1 Not warranted

1 2 PEP recommended for 28 days

Primary TL+LR regimen: Fixed dose

2 1
combination of 5 tablets daily
Tenofovir (300mg) + Lamivudine (300mg)
2 2 Lopinavir (200mg) + Ritonavir (50mg)

Alternative TLE regimen: Fixed dose

3 1 or 2 combination of Tenofovir (300mg) +
Lamivudine (300mg) + Efavirenz (600mg)
2 or 3 Unknown (in area of high prevalence)

The first dose of PEP should be started within 2 hours and definitely within 72 hours. It is not recommended beyond 72 hours
EXPOSURE CODE (EC) :
1) EC-1: (Mild exposure) : Mucous membrane/non-intact skin exposure with small volume or less duration
2) EC-2: (Moderate exposure) :
 Mucous membrane/non-intact skin with large volumes/splashes for several minutes or more duration
 Percutaneous superficial exposure with solid needle or superficial scratch
3) EC-3: (Severe exposure) :
 Large volume transfer
 By hollow needle, wide bore needle or deep puncture
 Visible blood on device
 Needle used in patient’s artery or vein

SOURCE HIV STATUS CODE (SC) :

1. SC-1: HIV positive, asymptomatic or low viral load (<400 copies/ml)
2. SC-2: HIV positive, symptomatic (advanced AIDS or primary HIV infection), high viral load
3. SC Unknown: Status of the patient is unknown and neither the patient nor his/her blood is available for testing
4. HIV negative: Tested negative according to NACO strategy
PEP not required in following situations:

1. If exposed person is HIV positive: Exposed persons who are HIV positive should not be administered PEP but
should be referred to ART clinic for councelling and initiation of ART.
2. If the exposure is on an intact skin
3. If source is HIV negative
4. Exposure with low risk specimens like saliva, tears, stool, urine, vomit etc.
5. For EC-1 and SC-1
6. Source unknown if HIV prevalence is low
7. In case of delay in reporting exposure >72hours

Side effects and compliance to PEP:

1. At initial phase: Nausea, diarrhoea, muscular pain, headache

2. At later course: Anaemia, leokopenia or thrombocytopenia
3. For most side effects except jaundice or liver tenderness, PEP should never be discontinued
4. Compliance of >95% to the PEP schedule is required to maximize efficacy. Hence, the person should be
councelled to continue the PEP to minimize the side effects.
 PERSONAL PROTECTIVE EQUIPMENT

 PPE or Personal protective equipment is used to cover the whole body of the health
care worker or the person who is handling an infectious case so that the concerned
person can protect ownself from any disease or exposure.
 PPE consists of gown, gloves, masks, face shield or eye protective cover and proper
covering of foot
 All the components of PPE must be weared and opened in particular defined ways to
prevent any contamination thereafter.
 The wearing of PPE is known as Donning and opening is known as Doffing
 Donning: Gown first – Mask or Respirator – Goggles or Face shield – Gloves
 Doffing: Gloves first – Face shield or goggles – Gown – Mask or respirator
 There should not be any open space in a PPE
 Torn or Defective PPE kits should never be used
 HAND HYGIENE
 Hands are the most important source of infection in hospitals. Hence, hand hygiene is the most important step
which helps in the prevention of transmission of many infections.

 Types of Hand hygiene methods:

a) Hand Rub: Alcohol based (70%-80% ethyl alcohol) and chlorhexidine (0.5%-4%) based hand rub are used.
Duration of contact is 20-30 seconds.
b) Hand Wash: Antimicrobial soaps (liquid, gel and bars) are available containing 4% chlorhexidine. Duration of
contact is 40-60 seconds
c) Surgical Hand Scrub: Indicated prior to any surgical procedure using 4% chlorhexidine hand wash.

 Indications of hand hygiene (WHO):

a) Before touching a patient
b) Before clean/aseptic procedures
c) After body fluid exposure/risk
d) After touching a patient
e) After touching patients surroundings
STEPS OF HAND WASHING
BIO-MEDICAL WASTE
MANAGEMENT
 BIOMEDICAL WASTE MANAGEMENT RULE, INDIA, 2016 (amendment done in 2018)

Category Type of waste Type of Bag or Container Treatment or Disposal

YELLOW 1) Human anatomical waste
2) Animal anatomical waste
3) Soiled waste
4) Expired or discarded medicines
5) Chemical solid and liquid waste
6) Discarded linen contaminated with body fluids
7) Microbiology, other laboratory wastes, blood
bags
RED Infectious plastic wastes like tubings, bottles,
intravenous tubes, catheter, urine bags,
vaccutainers with needle cut, gloves, syringes
Yellow coloured non chlorinated
plastic bags.
In case of liquid wastes separate
collection system is used leading to
effluent treatment system.
In case of laboratory wastes
specifically microbiology wastes
separate collection in autoclave
proof bag is used
Red coloured non chlorinated plastic
bags or containers
options
Incineration/Plasma pyrolysis/Deep
burial.
Chemical wastes are pretreated
before mixing with other water.
Microbiology wastes are autoclaved
before disposal.
1) Autoclaving/microwaving/
hydroclaving+ shredding
2) Mutilation/sterilisation
+shredding

WHITE Waste sharps including metal sharp like needles Puncture-proof, leak-proof, tamper- 1) Autoclaving/dry heat sterilisation
of syringes, scalpels, blades, needles from needle proof containers +shredding/mutilation
(TRANSLUCENT) tip cutter or burner 2) Encapsulation in meta container
or cement concrete
3) Sanitary landfill/designated
concrete waste sharp pit
BLUE 1) Glasswares (broken or discarded contaminated Puncture proof and leak-proof Disinfection or through Autoclaving/
glass including vials and ampoules) container microwaving/hydroclaving and then
2) Metallic body implants sent for recycling