Hospital Infection Control Manual Aiims Bhopal

CONTRIBUTORS
Dr. Shashank Purwar Mr. Ajay Kumar Ghodela

Chairperson Senior Nursing Officer
HICC Infection Control Nurse
AIIMS Bhopal AIIMS Bhopal
Dr. Navinchandra M. Kaore Mr. Anil Kumar

Member Secretary Senior Nursing Officer
HICC Infection Control Nurse
Dr. Lily Podder Mr. Ramlakhan Singh

Associate Professor Senior Nursing Officer
College of Nursing Infection Control Nurse
AIIMS Bhopal
Dr. Anurag Bhai Patidar Mr. Hansraj Phageria

Associate Professor Senior Nursing Officer
Mrs. Geeta Bhardwaj Mr. Naeem Akhtar

Assistant Professor Senior Nursing Officer
Mrs. Aparna Vajpeyee Mrs. Khushboo Patel

Nursing I/C & Senior Nursing Officer Assistant Nursing Superintendent
Infection control Nurse AIIMS Bhopal
AIIMS Bhopal
Mr. Hansraj Kumawat Mr. Rohit Kumar

Senior Nursing Officer Senior Nursing Officer
Infection Control Nurse AIIMS Bhopal
AIIMS Bhopal
CONTENT MODERATORS
Dr. Shashank Purwar Dr. Arneet Arora
Medical Superintendent (Off.) Prof & Head, FMT
Dr. Pramod Sharma Dr. Abhishek Goyal

Addl. Prof Additional Professor
Department of Pediatric Surgery Department of Pulmonary Medicine
Dr. Rehan Ul Haq Dr. Girish Bhatt

Professor & Head Additional Professor
Department of Orthopedics Department of Pediatrics
Dr. Md. Yunus Dr. Anshul Rai

Department of TEM Department of Dentistry
Dr. Shyam Lal Dr. Sunaina Tejpal Karna

Department of General Surgery Department of Anesthesiology
Dr. Saurabh Saigal Dr. Jyoti Nath Modi

Additional Professor Associate Professor
Department of Anesthesiology Department of OBGY
Dr. Lakshmi Prasad Dr. Devashish Kaushal

Department of Hospital Administration Department of Urology
Dr. Murali M Dr. Syrpailyne Wankhar

Faculty In-Charge In charge
Drug & Pharmacy store Biomedical Division
Dr. Navinchandra M Kaore Dr. Jayanthi Yadav

Additional Professor Professor
Department of Microbiology Department of FMT
Dr. Manal Md. Khan Dr. Saikat Das

Additional Professor Additional Professor
Department of Burn & Plastic Surgery Department of Radiotherapy
Dr. Alkesh Kumar Khurana Dr. Ajay Haldar

Additional Professor Additional Professor
Department of Pulmonary Medicine Department of OBGY
Dr. Keerti Swarnkar Dr. Gunjan Chouksey
Department of Pediatrics Department of Dentistry
Dr. T. Karuna Dr. Mahendra Atlani

Department of Microbiology Department of Nephrology
Dr. Manoj Nagar Dr. Abhishek Singhai

Associate Professor Associate Professor
Department Of TEM Department of General Medicine
Dr Sumit Raj Dr. Pankaj Prasad

Department of Neurosurgery Department of CFM
Dr. Ajeet Pratap Maurya Dr. Ujjawal Khurana

Department of General Surgery Department of Pathology
Dr Kawal krishen Pandita Dr. Zainab Ahmad

Department of Hospital Administration Department of Anesthesiology
Dr. Samendra Kumar Karkhur Dr. Kumar Madhavan

Assistant Professor Assistant Professor
Department of Ophthalmology Department of Urology
Dr. Maxie Martis Dr. Arati Ankushrao Bhabde

Associate Professor Joint Member Secretary HICC
Nursing College Assistant Professor
Department of Microbiology
CONTENT APPROVED BY
Chairman
HICC committee
Directors Message
EXECUTIVE DIRECTOR’S MESSAGE
On behalf of team AIIMS Bhopal, it is my pleasure to announce the release of AIIMS Bhopal Infection
Control Manual. This momentous occasion signifies Institute’s commitment for ensuring safety and well-
being of healthcare professionals and patients we serve.
We understand the critical importance of maintaining a safe environment to provide our patients with
the highest standard of care and infection control is paramount in healthcare settings. To achieve the
same our dedicated team of healthcare workers has worked tirelessly to prepare this manual drawing
reference majorly from national guidelines which serves as a valuable resource for preventing and
managing infections within our hospital.
This manual encompasses a wealth of information, including guidelines, best practices, and protocols, all
aimed at reducing the risk of infections and enhancing the quality of care.
I encourage all members of our healthcare community, from doctors and nurses to support staff, to
familiarize themselves with the contents of this manual and incorporate its principles into their daily
routines. Doing so can collectively contribute to a safer and healthier environment for everyone who
enters our hospital's doors.
I want to extend my appreciation to the dedicated professionals who have been instrumental in
developing this manual, helping us in our mission of providing quality healthcare. Together, we can
ensure that AIIMS Bhopal remains a haven for healing and recovery.
Best wishes.
Executive Director & CEO

AIIMS Bhopal
MEDICAL SUPERINTENDENT’S MESSAGE
The AIIMS Bhopal Hospital Infection Control Committee (HICC) was first constituted in September 2014
and having worked as Member Secretary of AIIMS Bhopal HICC since then to April 2023, it gives mixed
feelings to write message in capacity of officiating Medical Superintendent, who by virtue of the post
becomes Chairperson of HICC.
The AIIMS Bhopal HICC always remained very proactive and AIIMS Bhopal Disinfectant Policy came out
as early as in 2015 and was first amongst all AIIMS to establish a dedicated Targeted Infection
Surveillance Unit (TISU). Continued commitment of its members made HICC an entity which always
remained hand-on and believed in on-the floor working, since its inception and we hit the ground
running when SARS CoV-2 challenged the entire world in 2020. We could tide over the pandemic
without a single mortality amongst our large force of healthcare workers and students despite Madhya
Pradesh being among the worst affected states and our 960 beds hospital stretched to the limits. The
credit for the same goes entirely to housekeeping staff, infection control nurses, resident doctors,
faculty members and the Institute leadership.
Regular audits of hand hygiene, devise utilization, VAP, CLEBSI, CAUTI and other indicators of hospital
infection and the eight hourly pictorial descriptive reports by Infection Control Nurses, which to best of
my knowledge are unique to AIIMS Bhopal, have been the cornerstones of AIIMS Bhopal HICC
functioning. A recent feather in the AIIMS Bhopal HICC cap was its recognition for its role in reporting
medical devises adverse events.
I cannot pay enough gratitude specially to our housekeeping and nursing staff including Infection
Control Nurses who despite having many adversities worked tirelessly through SARS CoV-2 pandemic
and taught new lessons in Infection Control practice sand helped us in making AIIMS Bhopal HICC
manual which was work in progress for last one and half years. It is very heartening to see it ready to be
released and my heartfelt gratitude and congratulations to all contributors with the sincere hope that
the AIIMS Bhopal HICC manual and other Infection Control Practice (ICP) policies will be periodically
updated and put to good use by all healthcare workers.
Best wishes.
Dr. Shashank Purwar

Professor of Microbiology
Offcg. Medical Superintendent
AIIMS Bhopal
VISION AND MISSION OF AIIMS BHOPAL
The Government of India has launched the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY)
under the Ministry of Health and Family Welfare establishing new AIIMS across India.
AIIMS Bhopal established in the year 2010.
Vision
To realize inceptional mandate as under by contributing in:
 Correcting regional imbalances in the availability of affordable and reliable tertiary
health care services.
 Augmenting facilities for quality medical education with focus on postgraduate medical
education and creating a critical mass of doctors.
 Conducting research in the country relevant to the central India and beyond.
Mission
 To provide affordable quality tertiary health services to the public of central India.
 To extend excellent undergraduate and postgraduate medical education opportunities
at par with highest standard in the field.
 To provide research opportunities of par excellence with national and international
collaboration.
HOSPITAL INFECTION CONTROL MANUAL
CONTENTS
S.No. Chapter Name Page No.

1. Organization of Infection Control Programme at AIIMS Bhopal 1-6
2. Fundamentals of Healthcare-Associated Infections 7-15
 Chain of infection.
 Colonization and infection.
 Types of healthcare-associated infections.
 Routes of transmission.
 Basic concepts for prevention of HAI
 Bundle approach for prevention and control of HAI
3. Surveillance, monitoring and reporting of hospital acquired Infections (HAIs) 16-23
4. Procedures and Practices for IPC 24-56
 Standard precautions
 Hand hygiene
 Personal protective equipment
 Respiratory hygiene and cough etiquette
 Prevention of injuries from sharp
 Safe handling of patients care equipments
 Principles of Asepsis
 Environmental infection control
 Transmission-based precautions
5. Control of Environment for infection prevention 57-81
 Cleaning and sanitation
 Bio-Medical Waste Management.
6. IPC in special units or situations 82-114
 Operation Theatres
 Surgical units
 ICUs
 Maternal and Neonatal units
 Outpatient and Emergency area
 Dialysis unit
 Clinical Laboratory
 Isolation Units/ Septic wards
7. Preventing infections among Health Care Workers 115-141
 Biological hazards
 Human factors effecting safety
 Training and education of HCWs
 Safe work practice
 Occupational health programme
8. CSSD work Protocols 142-149
9. Annexure 150-169
10. Reference 170-171
Contents Page A
List of Figures
S.No. Figure Page No.
1. My 5 Moments of Hand hygiene & steps of Hand rub & Hand wash. 25
2. Steps of surgical Hand rubbing 28
3. Donning & Removing a Surgical Mask. 32
4. Donning of N-95 Mask. 32
5. Removing N-95 Mask. 32
6. Poster of Cough etiquette displayed in AIIMS Bhopal 34
7. Skin preparation with antiseptic solution 39
8. My 5 Movements of Hand hygiene Focus on caring for a patient with urinary 40
catheter
9. My 5 Movements of Hand hygiene Focus on caring for a patient with a central 43

venous catheter
10. My 5 Movements of Hand hygiene Focus on caring for a patient with an 49

endotracheal tube
11. Example of a cleaning strategy from cleaner to dirtier areas & moving in a 60
systematic manner around the patient care area
12. Direction of cleaning in patient care areas like Ward & OTs 61
13. High Touched surfaces 63
14. Placement of foggers in room 70
15. Biomedical Waste Segregation Bins in ward 78
16. Posters of BMW displayed at site of segregation 78
17. BMW Collection Trolley & collection of waste from patient care areas by waste 79
handlers.
18. Collection Trolley& collection of waste from patient care areas by waste handlers, 79
pre treatment of waste &Bar coding
19. Bio-Medical Waste Transportation Trolley of CBWTF 80

20. Wearing the gown 84
21. Removing of gown 85
22. Donning of sterile gloves 86
23. Removing sterile gloves 87
24. Point of care risk assessment 139
25. Functional area of CSSD 142
Contents Page B
GLOSSARY
ABHR Alcohol-Based Hand Rubs
AIIMS All India Institute of Medical Sciences
AMR Antimicrobial Resistance
AMSP Antibiotic Stewardship Programme
ARI Acute Respiratory Infection
BAL Bronchoalveolar Lavage
BARC Bhabha Atomic Research Centre
BBF Blood and Body Fluid
BMW Biomedical Waste
BSI Bloodstream Infection
CAUTI Catheter-Associated Urinary Tract Infection
CDC Centers for Disease Control and Prevention
CFU Colony-Forming Unit
CHG Chlorhexidine Gluconate
CLABSI Central Line-Associated Bloodstream Infection
CME Continuing Medical Education
CMV Cytomegalovirus
CRBSI Catheter-Related Bloodstream Infection
CRE Carbapenem Resistant Enterobacterales
CRP C- Reactive Protein
CSSD Central Sterile Supply Department
CVC Central Venous Catheter
DGHS Directorate General of Health Services
DVT Deep Venous Thrombosis
EtO Ethylene Oxide
EVD Ebola Virus Disease
FSSAI Food Safety and Standards Authority of India
GBS Group B Streptococcus
GLP Good Laboratory Practices
GLOSSARY Page I
HAI Healthcare-Associated Infection

HAP Healthcare-Associated Pneumonia
HBV Hepatitis B Virus
HCF Healthcare Facility
HCV Hepatitis C Virus
HCW Healthcare Worker
HD Haemodialysis
HDU High-Dependency Unit
HEPA High-Efficiency Particulate Air
HICC Hospital Infection Control Committee
HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HLD High-Level Disinfectant
HVAC Heating Ventilation and Air-Conditioning System
ICMR Indian Council of Medical Research
ICN Infection (Prevention and) Control Nurse
ICU Intensive Care Unit
IDSA Infectious Disease Society of America
IPA IsoPropyl Alcohol
IPC Infection Prevention and Control
IPHS Indian Public Health Standard
JCI Joint Commission International
LAI Laboratory-Associated Infection
LMICs Low- And Middle-Income Countries
MDRO Multidrug-Resistant Organism
MDR-TB Multidrug-Resistant Tuberculosis
MERS-CoV Middle East Respiratory Syndrome Coronavirus
MRSA Methicillin-Resistant Staphylococcus aureus
MSU Mid-Stream Urine
NABH National Accreditation Board for Hospitals and Healthcare Providers
NACO National AIDS Control Organization
NCDC National Centre for Disease Control
GLOSSARY Page II
NCDC National Centre for Disease Control

NDM New Delhi Metallo Lactamase
NHSN National Healthcare Safety Network (US)
NICU Neonatal ICU
NSI Needle sticks injury
NPI Needle prick injury
OPA Orthophthaldehyde
OPD Outpatient Department
OT Operation Theatre
PAPR Powered Air-Purifying Respirator
PEEP Positive End-Expiratory Pressure
PEP Post-Exposure Prophylaxis
PMN Polymorphonuclear
PPE Personal Protective Equipment
PUD Peptic Ulcer Disease
RA-RM Risk Assessment and Risk Management
RO Reverse Osmosis
RSV Respiratory Syncytial Virus
SAP Surgical Antimicrobial Prophylaxis
SARS Severe Acute Respiratory Syndrome
SARS-CoV SARS Coronavirus
SOP Standard Operating Procedure
SSD Sterile Supply Department
SSI Surgical-Site Infection
STG Standard Treatment Guideline
UTI Urinary Tract Infection
VAC Ventilator-Associated Condition
VAE Ventilator-Associated Event
VAP Ventilator-Associated Pneumonia
VRE Vancomycin-resistant enterococci
VHF Viral Hemorrhagic Fever
GLOSSARY Page III

HOSPITAL INFECTION CONTROL MANUAL 1
CHAPTER
Organization of Hospital Infection
Control Programme at AIIMS Bhopal
1. Introduction
An effective infection prevention and control is central to providing high-quality healthcare for patients
and a safe working environment for those who work in healthcare settings. It is important to minimize
the risk of the spread of infection to patients and staff in the hospital by implementing a good infection
control programme.
1.1 Components of Hospital Infection Control Program

There are three main components of the Hospital Infection Control Programme.
1. Preventive Measures
2. Surveillance
3. Training
Preventive Measures Training
Surveillance
1.1.1 Preventive Measures

a. Standard Precautions.
b. Isolation Precautions under certain special circumstances or outbreak situation. E.g., COVID-19,
combating Swine Flu, MRSA outbreak in any unit etc.
c. Immunization of Healthcare Workers (HCWs).
d. Sterilization, disinfection and decontamination of medical instruments and environment.
e. Appropriate use of Personal Protective Equipment (PPE).
f. Spill management.
g. Reporting and Management of accidental injuries by sharps.
h. Hospital Bio Medical Waste Management.
i. Environmental Management Practices.
1.1.2 Surveillance
a. Passive- Reported by individual outside the Hospital infection control team
b. Active- Finding Incidence and prevalence of HAIs (Health Care Acquired/Associated Infections)
1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 1

Surveillance
Passive Active
(Reporting by individual outside (To detect)
Infection Control Team)
Medical Records Reporting by

Laboratory Based Prevalence of HAIs Incidence of HAIs
(post discharge) physician & nurses
1.1.3 Training
a. Sensitization of infection control programme and practices to all cadres of HCWs.
b. Organize and impart periodic in-house training to HCWs.
c. Send members of the Hospital Infection Control Committee (HICC), Infection Control Team (ICT),
Physicians and Nurses to apex institute for training and create master trainers.
d. Organizing regular workshops, symposium, CME and conference on infection control for hospital
staff.
1.2 Hospital Infection Control Committee (HICC) at AIIMS Bhopal
1.2.1 Objectives of HICC

I. To minimize healthcare associated infections among patients, staffs, and visitors.
II. To minimize development of antimicrobial resistance and promote rational use of antimicrobials
by antimicrobial stewardship program.
The Constitution of 1stHospital Infection Control Committee (HICC) AIIMS, Bhopal (DIR/AIIMS-
BPL/OO/2021/315 dated 19/06/2021) The Committee is as Follows
S.No. Name Of Committee Member Position

1 The Director Chairperson
2 Dr. Arneet Arora, Prof. & HoD of FMT Co-Chairperson
3 Medical Superintendent Member
4 Dr. Rehan Ul-Haq, Prof. & HoD of Orthopaedics Member
5 Dr. Md. Yunus, Prof. & HoD of TEM Member
6 Prof. Shyam Lal Department of General Surgery Member
7 Dr. Saurabh Saigal, Addl. Prof. Dept. of Anaesthesiology Member
8 Dr. Lakshmi Prasad, Addl. Prof. Dept. of Hospital Administration Member

9 Dr. Pramod Sharma, Addl. Prof. Dept. of Paediatrics Surgery Member

10 Dr. Abhishek Goel, Addl. Prof. Dept. of Pulmonary Medicine Member
11 Dr. Girish C. Bhat, Assoc. Prof. Dept. of Paediatrics Surgery Member
12 Dr. Anshul Rai, Assoc. Prof. Dept. of Dentistry Member
13 Dr. Sunita Tej Pal, Assoc. Prof. Dept. of Anaesthesiology Member
14 Dr. Jyoti Nath Modi, Assoc. Prof. Dept. of OBGY Member
15 Dr. Debasis Kaushal, Assoc. Prof. Dept. of Urology Member
16 Dr. Vaibhav Ingle, Asst. Prof. Dept. of General Medicine Member
17 Dr. Lily Podder, Assoc. Prof. College of Nursing Member
18 SNO Designated as Infection Control Nurse Member
19 Chairperson, OT Committee Member
20 Dr. SyrpailyneWankher, I/c Bio-Medical Division Member
21 Faculty I/c Housekeeping Services Member
22 Faculty I/c Dietary Services/Hospital Kitchen Member
23 Dr. Murali M as Faculty I/c for Drugs and Pharmacy Stores Member
24 Dr. Navinchandra Kaore, Addl. Prof. Dept. of Microbiology Joint Member
Secretary
25 Dr. Shashank Purwar, Addl. Prof. Dept. of Microbiology and TISU Member Secretary
representative
The committee was reconstituted wide DIR/AIIMS-BPL/OO/HICC Committee/2023/600 dated
02/05/2023
S.No. Name Of Committee Member Position

1 The Medical Superintendent (Ex Officio) Chairperson
2 Dr. Jayanthi Yadav, Professor, Dept. of FMT Member
3 Dr. Manal Md. Khan, Additional Professor, Dept. of Burn & Plastic Member
Surgey
4 Dr.Alkesh Khurana, Additional Professor, Dept. of Pulmonary Medicine Member
5 Dr. Ajay Halder, Additional Professor, Dept. of OBGY Member
6 Dr. Saikat Das, Additional Professor, Dept. of Radiotherapy Member
7 Dr. Keerti Swarnkar, Additional Professor, Dept. of Pediatrics Member
8 Dr. T. Karuna, Additional Professor, Dept. of Microbiology Member
9 Dr. Mahendra Atlani, Associate Professor, Dept. of Nephrology Member
10 Dr. Manoj Nagar, Associate Professor, Dept. of TEM Member
11 Dr. Sumit Raj, Associate Professor, Dept. of Neurosurgery Member
12 Dr. Abhishek Singhai, Associate Professor, Dept. of General Medicine Member
13 Dr. Ajeet Pratap Maurya, Associate Professor, Dept. of General Surgery Member
14 Dr. Ujjawal Khurana, Associate Professor, Dept. of Pathology & Lab Member
Medicine
15 Dr. Kawal Krishen Pandita, Associate Professor, Dept. of Hospital Member
Administration
16 Dr. Pankaj Prasad, Associate Professor, Dept. of CFM Member
17 Dr. Zainab Ahmad, Associate Professor, Dept. of Anaesthesiology Member
18 Dr. Gunjan Choksey, Associate Professor, Dept. of Dentistry Member
19 Dr. Samendra Kumar Karkhur, Assistant Professor, Dept. of Member

Ophthalmology
20 Dr. Kumar Madhavan, Assistant Professor, Dept. of Urology Member
21 Dr. Maxie Martis, Associate Professor, Nursing College Member
22 Infection Control Nurses Member
23 Faculty-in-Charge Bio Medical Waste Management Member
21 Faculty-in-ChargeHousekeeping Services Member
22 Faculty-in-ChargeDietary Services/Hospital Kitchen Member
23 Faculty-in-ChargeDrug and Pharmacy Store Member
24 Dr.Arati Ankushrao Bhadade, Assistant Professor, Dept. of Microbiology Joint Member
Secretary
25 Dr.Navinchandra M. Kaore, Additional Professor, Dept. of Microbiology Member Secretary
1.2.2 Meetings of HICC

The infection control team meets at least quarterly or more frequently as necessary. The member
secretary maintains documentation of meetings and recommendations. The Infection control Nurse
takes rounds and report to ANS (Assistant Nursing Superintendent), and Member secretary Dr.
Navinchandra M. Kaore, Addl. Prof. Dept. of Microbiology.
1.2.3 Responsibilities of HICC

a. To develop and prepare various infection control policies and protocols.
b. To promote, implement, and monitor optimum infection control practice at all levels of the
health facilities.
c. To review and approve an annual programme for surveillance and prevention of HCAI.
d. To review epidemiological surveillance data and identify the areas for interventions.
e. To ensure appropriate staff training regarding infection control and prevention.
f. To review risks associated with new technologies and monitor infectious risks of new devices
and products.
g. To provide expert advice, analysis, and leadership in outbreak investigation and control.
h. To conduct research on Infection Control (IC).
1.3 Infection Control Team at AIIMS Bhopal

Under the umbrella of HICC, there is an Infection Control Team (ICT) responsible for day-to-day
infection control activities.
1.3.1 Responsibilities of the Infection Control Team (ICT)

 Advise staff on all aspects of infection control and maintain a safe environment for patients and
staff.
 Advice management of patients who are at risk.
 Carry out targeted surveillance of healthcare-associated infections and act upon data obtained
e.g. investigates clusters of infection above expected levels.

 Recommend antibiotic policy for different areas of the hospital.

 Provide a manual of policies and procedures for aseptic, isolation and antiseptic techniques.
 Investigate outbreaks of infection and take corrective measures.
 Provide relevant information on infection problems to management.
 Assist in training of all new employees as to the importance of infection control and the relevant
policies and procedures.
 Have written procedures for maintenance of cleanliness.
 Surveillance of infection, data analyses, and implementation of corrective steps. This is based on
reviews of lab reports, reports from nursing in charge etc.
 Surveillance of Biomedical Waste management.
 Supervision of isolation procedures.
 Monitors employee health program.
 Addresses all infection control and employee health requirements as specified by Central laws,
State laws and NABH.
1.3.2 Duties of Infection Control Nurse (ICN)

• The duties of the ICN are primarily associated with ensuring the practice of infection control
measures by healthcare workers. Thus, the ICN is the link between the HICC and the wards/ICUs,
etc. in identifying problems and implementing solutions.
• ICN conducts Infection control rounds daily and maintains the registers.
• ICN is involved in education of practices, minimizing healthcare-associated infections, and hand
hygiene among Healthcare workers.
• Maintains registers and data of Sharps/Needle stick injuries and Post–exposure prophylaxis.
• Initiates and ensures proper immunization for Hepatitis B Virus Immunoglobulin and HBs Ag
vaccine in consultation with a microbiologist (Member HICC) in case of suspected exposure to
any hospital worker.
• Ensures that all positive culture cases are tracked and for each positive culture from the inpatient
unit, a hospital infection information sheet or surgical site infection sheet is filled and kept record
for each positive culture case. All probable cases of healthcare-associated infections and
anomalous/irrational use of antibiotics must be discussed in HICC meetings.
• Track the indicators of infection control and present the data to the HICC meetings on a regular
basis.
• Conducts special tasks given to him/her as per components and objectives of the hospital
infection prevention and control.
1.3.3 Infection Control Officer (ICO)

The microbiologist serves as the Infection Control Officer.
1.3.4 Duties of Infection Control Officer (ICO)

• The ICO supervises the surveillance of healthcare-associated infections as well as preventive and
control programs.
• Co-ordinate with the chairperson and HICC in planning infection control programs and measures.

• Keep track of any developing outbreaks.

• Participate and guide in research activities related to infection control practices and publish
them.
• Developing guidelines for appropriate collection, transport &and handling of specimens.
• Ensuring laboratory practices meet appropriate standards.
• Ensuring safe laboratory practices to prevent infection among staff.
• Performing antimicrobial susceptibly testing following internationally recognized methods &and
providing summary reports of the prevalence of resistance.
• Monitoring sterilization, disinfection & the environment where necessary.

CHAPTER
Fundamentals of Healthcare
Associated Infections (HAIs)
2.1 Introduction
Healthcare-associated infection (HAI), also referred to as "Nosocomial" or "Hospital-acquired" infection,
is an infection occurring in a patient during the process of care in a hospital or other healthcare facility
that was not present or incubating at the time of admission. They usually manifest after 48 hours of
admission or within 30 days after having received health care (up to 90 days in case of breast cardiac or
joint surgeries including implants) and include infections acquired in the hospital and appearing after
discharge, as well as occupational infections amongst Health Care Workers (HCW) e.g. Needle stick
injuries.
2.2 Burden of HAI

Healthcare-associated infections (HAI) are among the most common adverse events in the healthcare
delivery system and pose a major public health problem impacting morbidity, mortality, and quality of
life. As per the World Health Organization (WHO), up to 7% of patients in developed and 10% in
developing countries tend to acquire at least one HAI at any given time. These infections also present a
significant socioeconomic burden.
2.3 Economic Impact

HAIs cause significant economic impact at the patient and healthcare facility levels, which can largely be
prevented through effective infection prevention and control (IPC) practices.
The economic loss is in terms of -
A. Direct cost due to increased length of hospital stay and management of HAI.
B. Indirect cost to patient and relatives due to loss of jobs or paid working days.
C. Intangible cost due to –
a) Psychological cost ( anxiety, grief, disability)
b) Pain and suffering
c) Change in social life or daily activities
2.4 Risk factors for healthcare-associated infections:

The risk factors contributing to HAIs are patient-related, Healthcare Worker-related and device or
procedure-related.
1. Low resistance of patients to infections.
2. Contact with infectious persons.
3. Invasive procedures/ interventions.
4. Inappropriate antimicrobial usage.
5. Drug resistance of endemic microbes.
6. Contaminated environment
2. Fundamentals of Healthcare Associated Infections (HAIs) Page 6

2.5 Epidemiological Chain of Healthcare Associated Infection (HAI):
Infectious
Agent
Susceptible
Reservoir
Host
chain of
infection
Mode of
Portal of Exit
Transmission
Table 2.1:- Elements of Chain of infection
Elements Remarks
Infectious Agent The microorganism capable of causing the infection is known as the infective agent.
Infective agents include bacteria, viruses, fungi, protozoa, helminths, and prions.
The ability of a microorganism to cause infection depends upon its ability to invade,
proficiency in overcoming the host defenses, its pathogenicity, degree of virulence,
and the infectious dose. Equally important is the agent’s capability to survive in the
environment and its resistance to antimicrobials.
Reservoir Reservoir is the source of the infectious agent where it lives and multiplies. These can
be animate (humans, animals) or inanimate (the environment, contaminated food
and water).
Human reservoirs can be
Symptomatic (exhibiting signs and symptoms of the disease)
Asymptomatic (without signs and symptoms)
Carriers (presence of organisms for varying periods without signs or symptoms).
Asymptomatic cases and carriers are more likely to transmit the disease as
precautions may not be taken since it is not known that the person is harboring the
organisms. Thus, standard precautions should be taken in all situations while dealing
with patients, even when the diagnosis is not known.
Portal of exit Portals of exit are necessary for the organism to exit one person’s body and be
transmitted to another person. The portal of exit can be the excretions/secretions of
the respiratory tract, gastrointestinal tract, genital tract, blood, or any other body
fluid.
Mode of Transmission can occur by:
transmission Portal of contact– direct contact through hands or indirectly through an inanimate

object;
Droplets – large-sized droplets released by sneezing, coughing, or even talking;
Airborne route– through very small particles that can travel from room to room via air
currents;
Common vehicle– where a contaminated vehicle serves as the means of spreading
infection to several persons, such as food in a salmonella epidemic or blood in a
blood-borne epidemic (hepatitis B); and
Inoculation– a percutaneous injury with a contaminated needle or other sharp
resulting in direct inoculation of the organism into the bloodstream.
Portal of entry Similar to the portal of exit, it is the site of entry of the organism into the body, such
as the mucous membrane of the respiratory, genital, gastrointestinal, or urinary tract,
conjunctiva, and skin.
A susceptible host is a person who is susceptible to the infection or lacking in
Susceptible host resistance to the infective organism. Host factors that influence susceptibility to
infection are:
~Age – Individuals at extremes of age are more susceptible to infection, e.g., neonates
and old people
~Socioeconomic status, such as health literacy, nutritional status
~Co-morbidities such as diabetes, cancer
~Immunization status
~Medications such as immunosuppressive agents and chemotherapeutic agents
~Pregnancy
~Interventions and devices– surgery, intubation, mechanical ventilation, urinary
catheterization, vascular catheterization
~Host factors– related to the host that prevent the entry and establishment of
Infective agents, including Endogenous organisms inhabiting body sites such as the
gastrointestinal tract, skin, respiratory tract, and genital tract that prevent the
establishment of pathogenic organisms at that site
~Natural antibodies
~Natural barriers include intact skin, mucous membranes, facial planes, cough reflex,
and gastric acid secretion.
2.6 Colonization and infection:

Colonization refers to the presence of organisms in the body without causing any cellular damage or
response on the host’s part. Infection occurs when the organism causes cellular damage and a host
response. Colonization with one organism may prevent the establishment of another more virulent
organism at that body site. Colonizing organisms can be a part of the normal flora for a particular body
site. Still, causes infection at another body site; for example, E. coli is a normal flora of the intestinal
tract, but it can cause infection in the urinary tract.
Removing the normal flora can cause abnormal organisms to colonize a body site, e.g., antibiotics kill
organisms such as drug-sensitive E. coli and allow drug-resistant organisms to colonize. Colonization can
precede infection if the host defenses are altered or impaired in some way. This can happen if the
patient is on immunosuppressive drugs has undergone surgery or interventions such as catheterization
and intubation.

2.7 TYPES OF HEALTHCARE-ASSOCIATED INFECTIONS:

Most commonly encountered HAI are:
1. Central Line Associated Blood Stream Infections (CLABSI)
2. Ventilator Associated Pneumonia (VAP)
3. Catheter Associated Urinary Tract Infection (CAUTI)
4. Surgical-site infection (SSI)
5. Gastrointestinal infection
Of these first 3 are termed as Device Associated Infections
2.7.1 Healthcare-associated bloodstream infections

Healthcare-associated bloodstream infections are serious infections that can be associated with high
mortality, which may be more than 50% for some microorganisms. These infections are often associated
with intravascular catheters.
Infection can occur at the catheter's entry site or along the catheter's subcutaneous tract (line), known
as tunnel infection. This type of infection largely depends on the care taken during insertion and
handling of the intravascular catheter. The duration for which catheters are in place is also important.
Both central and peripheral lines can be a source of infection.
2.7.2 Healthcare-associated pneumonia

Pneumonia is one of the most serious of HAIs. Ventilator-associated pneumonia (VAP) is the most
important infection in patients on ventilators in intensive care units. It has a high case fatality rate and is
often associated with serious co-morbidities. It is defined as a lower respiratory tract infection that
appears during or after hospitalization of a patient who was not incubating the infection on admission.
The diagnostic criteria are:
 Fever
 Cough with purulent sputum
 New infiltrate on radiology
 Gram-staining of sputum/ET aspirate and bacteria
Healthcare-associated pneumonia is acquired by inhaling respiratory droplets or aerosols or aspiration
of colonized or pharyngeal and gastric secretions in conditions of low gastric acidity. Infection can also
be acquired through the pharynx during suction procedures due to inadequate hand washing and
inappropriate disinfection of respiratory devices.
Risk factors:
 Age: very young or very old
 Coronary bypass surgery
 Abdominal surgery
 Existing pulmonary neurological disease
 Decreased clearance of respiratory secretions due to coma, sedation, etc.
 Invasive devices bypass natural defenses such as mechanical ventilation, intubation,
tracheotomy, and enteral feeding.
 Medications such as antibiotics, antacids, immunosuppressive agents, and chemotherapy.

2.7.3 Urinary tract infection:

Urinary tract infections (UTIs) are the most common and account for 35–45% of all HAIs. The majority of
these infections are associated with the use of an indwelling urinary catheter.
Diagnosis is based on the clinical symptoms of fever, suprapubic tenderness, frequency of urination and
dysuria, and the presence of bacteria in the urine in significant quantity. The patient’s urine culture
shows no more than two species of organisms identified, at least one of which is a bacterium of ≥105
CFU/ml. An indwelling catheter in the urinary tract may give rise to bacteriuria or mild infection or even
result in severe infections such as pyelonephritis and septicemia. The source of organisms can be the
patient’s flora (endogenous infection) or exogenous through the hands of staff or contaminated
instruments. Contamination of the drainage bag and retrograde flow of contaminated urine into the
bladder can also cause UTI.
The urine specimen for culture must be collected using aseptic precautions. The urine specimen should
be obtained aseptically from a sample port in the catheter tubing or by aseptic aspiration of the tubing.
For non-catheterized patients, a clean, voided specimen is acceptable. Catheter tips and specimens from
the urine bag should not be cultured.
Risk factors
 Indwelling urinary catheter
 Instrumentation of the urinary tract
 Poor aseptic preparation during insertion of catheter
 Poor catheter maintenance
 Advanced age
 Female gender
 Severe underlying illness
2.7.4 Surgical-site infection:

This is the infection of the surgery site, earlier called wound infection. The incidence of surgical-site
infections (SSIs) varies from 0.5% to 15%, depending on the type of operation and underlying status of
the patient. The main risk factor is the extent of contamination during the procedure (clean, clean,
contaminated, contaminated, dirty), which largely depends on the surgery site, the operation length,
and the patient’s general condition.
SSI usually occurs within 30 days of the operative procedure and up to 90 days in case of breast cardiac
or joint surgeries, including implants.
SSI can be superficial, incisional, deep incision, or organ/ space.
 Superficial SSI
o Drainage of pus from the superficial incision
o Pain, tenderness, localized swelling, redness or heat
 Deep/organ space SSI

o Infection appears within 30 days of the procedure or up to 90 days in the case of an

implant or foreign body such as a prosthetic heart valve joint prosthesis.
o Pus discharge from the deep incision
o Spontaneous dehiscence or “gaping” of wound
o Fever >38 °C, localized pain or tenderness
Specimens for culture include pus, wound swabs, drainage fluid, and exudates.
Risk factors
The non-modifiable variables include age and gender. A systematic review of 57 studies from both high-
income countries and low- and middle-income countries (LMICs) identified the following factors
associated with an increased risk of SSI in adjusted analysis.
 High body mass index

 Severity score classification of wound
 Diabetes
 Prolonged duration of surgery
The following are other potential factors that can be improved to increase the likelihood of a positive
surgical outcome.
 Nutritional status
 Cessation of tobacco use
 Correct use of surgical prophylaxis
 Intra-operative technique
Other potential site of infection
 Skin and soft tissue

 Brain and meninges
 Eye and ear (sinusitis, conjunctivitis)
 Reproductive organs (endometrial and other infections following childbirth)
2.7.4 Gastrointestinal infections:

These are common infections in pediatric wards and the community. Introduced in the hospital through
an infected patient, such infections can spread rapidly in the pediatric unit through contaminated
environments, toilets, and inadequate hand washing.
Infectious diarrhea is confirmed when a bacterial or viral etiology is demonstrated. Diarrhea may also
occur due to non-infectious causes such as medications. In many cases, the cause of diarrhea cannot be
diagnosed. The infection is transmitted through the fecal-oral route. It may be acquired from
contaminated food or water, infected patients or staff, or contact with an environment contaminated
with organisms or instruments entering the alimentary tract such as endoscopes.

Healthcare-associated diarrhea often presents as an outbreak. The index case or asymptomatic carrier
introduces the infection in the ward which then leads to person-to-person spread.
Common organisms causing gastrointestinal infections:

Salmonella spp., Shigella spp., Campylobacter spp., Clostridioides difficile, E. coli,Aeromonas and
Plesiomonas spp., Vibrio spp., Cryptosporidium spp., Giardia lamblia,Entamoeba histolytica, Rotavirus,
Norwalk (Noro) and similar viruses (e.g. Astrovirus),Adenoviruses.
Risk factors
 Extremes of age, achlorhydria, antibiotic therapy oral or systemic, decrease in normal flora,
overgrowth of resistant or sensitive pathogens, gastrointestinal procedures such as insertion of
a nasogastric tube, endoscopy.
 Factors conducive to person-to-person spread such as overcrowding of units, understaffing, and
inadequate hand-washing facility.
2.8 Routes of transmission:

1. Contact transmission
2. Droplet transmission
3. Airborne transmission
4. Vector-borne transmission
2.8.1 Contact Transmission

Contact is the most common mode of transmission and usually involves transmission by touch or via
contact with blood or body fluids or secretions. Contact may be direct or indirect.
Direct transmission occurs when infectious agents are transferred from one person to another, e.g. a
patient’s blood entering a healthcare worker’s (HCW’s) body through an unprotected cut in the skin.
Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate
object or person, e.g. an HCW’s hands transmitting infectious agents after touching an infected body site
on one patient without performing hand hygiene before touching another patient or an HCW coming
into contact with fomites (e.g., bedding) or feces and then with a patient.
Examples of infectious agents transmitted by contact include MDROs such as Methicillin-resistant Staph.
aureus (MRSA) and carbapenem-resistant Gram-negative bacteria, C. difficile, Norovirus, Ebola virus,
HIV, hepatitis B and C viruses, and highly contagious skin infections/ infestations (e.g., impetigo,
scabies), etc.
2.8.2 Droplet transmission

Droplet transmission occurs when an infected person coughs, sneezes or talks, or during certain
procedures. Droplets are infectious particles >5 microns in size. The force of expulsion and gravity limits
the droplet distribution range and is usually <1 meter. Droplets can also be transmitted indirectly to
mucosal surfaces (e.g. via hands). Examples of infectious agents that are transmitted via droplets include
influenza virus, Bordetella pertussis and meningococcus.

2.8.3 Airborne transmission

Airborne dissemination may occur via particles containing infectious agents that remain suspended in air
over time and distance. Small-particle aerosols (<5 microns) are created during breathing, talking,
coughing, or sneezing and secondarily by evaporating larger droplets in low humidity conditions.
Certain procedures, particularly those that induce coughing, can promote airborne\ transmission. These
include diagnostic sputum induction, bronchoscopy, airway suctioning, endotracheal intubation, positive
pressure ventilation via facemask, and high-frequency oscillatory ventilation.
Aerosols containing infectious agents can be dispersed over long distances by air currents (e.g.
ventilation or air-conditioning systems) and inhaled by susceptible individuals who have not had any
contact with the infectious person. Infectious agents transmitted via the airborne route include the
measles virus, chickenpox (varicella) virus, and M. tuberculosis.
2.8.4 Vector-borne transmission

Vector-borne transmission refers to the transmission of microorganisms by vectors such as mosquitoes.
It can be prevented by appropriately constructing and maintaining an HCF, having closed or screened
windows, and proper housekeeping.
Examples of vector-borne diseases include malaria, dengue, and chikungunya.
2.9 Basic concept in the prevention of HAI:

HAIs can be prevented by breaking the epidemiological triad. Introducing a barrier between the
susceptible host and the infecting organism is the most effective way to prevent HAI. Most HAIs can be
prevented through readily available and relatively inexpensive strategies such as compliance with
recommended infection prevention practices like—
 Hand hygiene
 Appropriate use of personal protective equipment (PPE)
 Aseptic techniques
 Cleaning and decontamination of soiled instruments followed by appropriate use of established
sterilization and disinfection practices.
 Appropriate disposal of biomedical waste (BMW).
 Appropriate environmental cleaning and disinfection practices
 Ensuring safety in operating rooms and other high-risk areas.
 Maintaining a safe working environment and safe work practice
 Bundle care approach.
Bundle approach for prevention of HAIs:

HAI Care bundles include a set of evidence-based measures that need to be implemented together to
prevent and control HAIs in patient care. Together they have a greater effect on the outcome than the
isolated implementation of individual measures.

Bundles for the prevention of central line-associated bloodstream infections (CLABSIs), catheter-
associated urinary tract infections (CAUTIs), Ventilator associated pneumonia (VAP) and Surgical Site
Infections (SSIs) have shown significant impact on prevention of HAIs.

CHAPTER
Surveillance, Monitoring and Reporting
of Healthcare-Associated Infections
(HAIs)
3.1 Introduction
Among the principal duties of the HICC is to document the state of healthcare-associated infections
(HAI) and processes related to their prevention and control in the hospital. Through the HICC, the
hospital will define institutional objectives for surveillance that align with national objectives, establish
priorities for surveillance according to the scope of care provided by the facility, determine the type of
data to be collected, apply existing national definitions and methods, detect outbreaks and coordinate
an appropriate response, promote practices for the prevention and control of healthcare-associated
infections and related aspects of organizational culture without retaliation, and produce and
disseminate information on healthcare-associated infections and other related events to local
stakeholders and health authorities.
In this chapter, the main objectives and methodology for the surveillance of prioritized HAIs are
described. The responsibilities of the ICO are to detect cases (numerators) and identify the exposed
population (denominators), keep records, and consolidate and analyze collected data.
3.2 Surveillance of Healthcare-Associated Infections

List of the responsibilities of staff dedicated to the monitoring and control of HAIs:
1. Review the charts of patients with exposure factors to detect infections.

2. If an infection is suspected, use case definition criteria to classify it as such, if appropriate.
3. Record infection information for all confirmed cases (numerators): pneumonia, urinary tract
infection, surgical site infection, or bloodstream infection (dates and etiologic agents).
4. For patients with confirmed HAI, record epidemiological information to establish numerators:
patient identification, name(age, sex), hospital identification, bed, primary underlying disease,
date of ICU admission, date of ICU discharge, reason for discharge, and length of exposure to
mechanical ventilation, indwelling urinary catheter, or central venous catheter.
3.2.1 Areas of surveillance

The surveillance is currently being conducted in the following areas.
1. High Dependency Units (HDU)

2. Surgical and Medical Intensive Care Unit (SICU/MICU)
3. Neonatal Intensive Care Unit (NICU)
4. Post Operative wards of each surgical department
5. All surgical OPDs (for follow up of post discharge surgical site infections)
3. Surveillance, Monitoring & Reporting of Healthcare Associated Infections (HAIs) Page 16

3.2.2 Infections under surveillance

1. Mechanical ventilator-associated pneumonia.
2. Indwelling urinary catheter-associated symptomatic urinary tract infection.
3. Central venous catheter-associated, laboratory-confirmed bloodstream infection.
4. Surgical site infections
General Concepts: The surveillance of device-associated infections in intensive care units should be
active, selective, prospective, and patient-based.
Case-finding: A properly trained infection prevention and control professional (IPCP) will identify
patients suspected of having a device-associated infection and collect the corresponding denominator
data.
Numerator: The infection prevention and control professional will find infections incurred during the
patient’s stay using different sources, including temperature charts, antibiotic use, cultures performed,
physician’s instructions, and the suspicion of attending clinicians.
3.2.3 Case confirmation:

In patients suspected of having a device-associated infection, the infection prevention and control
professional will confirm the infection based on case definition criteria using records from the
laboratory, pharmacy, patient admission, discharge, transfer, and radiology imaging, and patient charts,
including interviews, physical exam notes, and notes taken by physicians and nurses. Laboratory
surveillance data should not be used in isolation unless all possible criteria for diagnosing an infection
are determined by laboratory evidence alone.
Data collection on the infection should be completed for all confirmed cases.
Numerators: Pneumonia, Urinary tract infection, or Bloodstream infection (dates and etiologic agents).
Denominator: The infection prevention and control professional will record the device day, counting the
number of patients with mechanical ventilation, indwelling urinary catheters, or central venous
catheters.
3.2.4 Devices inserted outside the unit under surveillance:

Infections that develop within 2 calendar days of a patient’s arrival and that are related to devices
inserted outside the intensive care unit will not be counted in the numerator. Retrospective chart
reviews should be used only when patients have been discharged before all necessary information can
be obtained.
3.2.5 Frequency of surveillance:

It is recommended that surveillance for outcome measures (BSI,UTI,VAP,SSI)be carried out by daily
monitoring in intensive care units and for process measures as ( Bundle care, Central line insertion
practices, Central line maintenance practices, Urinary catheter care, and others) at least twice a week.
Data should be consolidated monthly for the hospital’s use and forwarded to all the stakeholders.

3.2.6 Objectives of Surveillance

a) Describing the status of healthcare-associated infections (HAIs)(i.e., incidence and/or
prevalence, type, etiology, severity, attributed burden of disease)
b) Identification of high-risk populations, procedures, and exposures
c) Early detection of outbreaks.
d) Assessment of the impact of interventions
3.3 Phases of Surveillance

To perform epidemiological surveillance to provide useful and consistent information, one must comply
with the following phases:
1. Definition of events
2. Data Collection
3. Consolidation and data analysis
4. Dissemination of results
3.3.1 Definition of events

Healthcare-associated infections (HAI): A healthcare-associated infection (also known as a Nosocomial
infection) is an infection that is not present or incubating at the time of admission to a healthcare
setting but which is observed during the patient’s hospital stay or after the patient’s time of discharge.
Operationally, for surveillance purposes, Healthcare-associated infection is defined as follows: Infection

which is acquired after 2 calendar days of stay in the hospital and was not Present on admission (POA)
for surveillance, the updated definitions released by the National Healthcare Safety Network (NHSN)in
the first month of every calendar year, will be used.
Manual Mechanical ventilator-associated pneumonia is diagnosed through a combination of radiologic,

clinical, and laboratory criteria.
Criteria for VAP

A. Radiological data: Two or more serial chest x-rays with at least one of the following:
 New or progressive and persistent infiltrate
 Consolidation
 Cavitations,
B. Signs and symptoms
B1: At least one of the following signs or symptoms:
 Fever (>38 °C) with no other recognized known cause
 Leukopenia (<4000 WBC/mm) or leukocytosis (>12,000 WBC/mm)
 For adults >70 years old, altered mental status with no other recognized cause, and
B2: At least one of the following:
 New onset of purulent sputum, or change in character of sputum, or increased respiratory
secretions, or increased suctioning requirements
 New onset or worsening cough, or dyspnea, or tachypnea
 Rales or bronchial breath sounds
 Worsening gas exchange e.g. O2desaturations (e.g. PaO2 /FiO2 < 240), increased oxygen
requirements, increased mechanical ventilator demand.

C. Lab findings (At least one of the following)
 Organism identified from blood /or pleural fluid

 Positive quantitative/semi-quantitative culture from BAL /Endotracheal aspirate
 ≥5% BAL- obtained cells contain intracellular bacteria on direct microscopic Gram’s
stain
 Definitive diagnosis of fungal infection through histopathology/cultures; definitive
diagnosis of Bordetella/Legionella/Mycoplasma/Chlamydia/Viral pneumonia through
molecular /serological tests
 For immunocompromised patients, isolation of a matching Candida spp.from blood
and sputum/Endotracheal aspirate/BAL will also be taken as positive laboratory
confirmation.* (isolation of any coagulase –negative Staphylococcus species, any Enterococcus spp. and
any Candida species, as well as a report of “yeast” that is not otherwise specified, will not be considered a
pathogen from the cultures obtained from above samples. The only exception is Candida spp. isolated in
immunocompromised patients.)
For cases of ventilator-associated pneumonia, a patient has to be intubated and ventilated at the time
of onset of symptoms or have been ventilated up to 2 calendar days before the onset of infection.
Ventilator-associated pneumonia should be designated when reporting data.
For Diagnosis of VAP the above algorithm will be used: At least one each of the following components:
A+B1+B2+C =VAP
An event timeframe will be constructed for each case (a 14-day calendar day timeframe, with the event
date as Day 1). During this time, the VAP event for which the case definition was met is considered to be
occurring, and no new infections of that same type can be reported.
Definition of Immunosuppressed patients

 All patients currently being treated for malignant disease with immunosuppressive
chemotherapy or
 Radiotherapy, and for at least six months after terminating such treatment
 All patients who have received a solid organ transplant and are currently on immunosuppressive
 treatment
 Patients who have received a bone marrow transplant until at least 12 months after finishing all
 Immunosuppressive treatment, or longer where the patient has developed graft-versus-host
disease.
 All patients receiving systemic high-dose steroids until at least three months after treatment has
stopped.
 Patients receiving other types of immunosuppressive drugs
 Patients with immunosuppression due to HIV infection

Indwelling urinary catheter-associated symptomatic urinary tract infection:
Catheter-associated Urinary tract infections (CAUTI) are diagnosed through a combination of clinical and
laboratory criteria. UTIs will be counted only for patients with an indwelling urinary catheter or an
infection related to its use. In other words, the patient had a urinary catheter inserted at the time of, or
within seven days before, the onset of infection.
Microbiologically-confirmed UTI case

 Patient must have a clinical sign or symptom of UTI
 Patient must have a positive urine culture w/high levels of bacteria
 Urine culture must not be contaminated
Criteria for HAI –UTI and CAUTI
UTI
 The Date of the Event does not occur during the Event Timeline of a previous UTI
 The Date of Event occurs > two calendar days after hospital admission (where Date of Hospital
admission=Day 1)
 The Date of Event occurs >2 calendar days after ICU admission (where Date of ICU
admission=Day 1)
 A single urine culture with more than 2 organisms identified is considered to be contaminated
and should not be used for UTI surveillance
 The urine culture must have at least one organism with ≥105 CFU/ml
 Patient has at least one of the following signs or symptoms during the seven-day infection
window period (Fever (>38°C)/Suprapubic tenderness/ Urinary urgency/Urinary
frequency/Dysuria)
 The date of the event (DOE) will be the date of the first case definition criteria – urine culture
collection or sign/symptom – whichever occurred first in the infection window period(IPW)
 An event timeframe will be constructed for each case (a 14-day calendar day timeframe, with
the date of the event as Day 1). During this time, the UTI event for which the case definition
was met is considered to be occurring, and no new infections of that same type can be
reported.
CAUTI
If a patient meeting the HAI UTI case definition has a Foleys catheter in place at any time on the
date of the event or the day before the date of the event and it was in place for > 2 calendar
days, then the HAI-UTI case will be meeting the criteria for CAUTI.

Reporting of the first positive urine culture and all positive urine cultures that occur during the
Event time frame will be done.
Event Timeframe = 14 days after the date of the event (where the date of event = day 1)
Criteria for HAI- BSI and CLABSI Bloodstream infections are classified according to clinical and
laboratory criteria for HAI surveillance. A bloodstream infection is considered either primary or
secondary, depending on whether it is caused by an infection at another site. Only laboratory-
confirmed, primary, secondary bloodstream infections and central line-associated bloodstream
infections (CLABSI) intravascular catheter-associated bacteremia will be recorded for HAI-BSI
surveillance.
Criteria for HAI- BSI and CLABSI

Laboratory-confirmed bloodstream infections must meet at least one of the following criteria:
First the Collection date of blood culture in the surveillance unit for the patient is recorded
Inclusion Criterion for all HAI BSI
The Date of the Event does not occur during the Event Timeframe of a previous primary BSI
The Date of Event occurs >2 days after hospital admission (where Date of Hospital admission=Day 1)
The Date of Event occurs >2 days after ICU admission (where Date of ICU admission=Day 1)
Criteria A: For recognized pathogen isolated from blood culture
On meeting the above inclusion criteria, the positive blood culture collection date will be the date of
the event for primary BSI.
An event timeframe will be constructed for each case (a 14-day calendar day timeframe, with the date
of the event as Day 1). During this time, the BSI event for which the case definition was met is
considered to be occurring, and no new infections of that same type can be reported.
Criteria B: For common Commensal organisms isolated:
Organism(s) identified in blood is not related to an infection at another site

Common commensal is identified by culture from two or more blood specimens collected on separate
occasions
iii) The patient must have at least one of the following signs or symptoms during the infection
Patients > 12 months (Fever >38°C / Hypotension)
Patients ≤ 12 months (Fever >38°C / Hypotension/Hypothermia<36°C /Apnea/Bradycardia
The date of the event (DOE) will be the date of the first case definition criteria –blood culture
collection or sign/symptom – whichever occurred first in the infection window period (IPW)
An event timeframe will be constructed for each case (a 14-day calendar day timeframe, with the
date of the event as Day 1). During this time, the BSI event for which the case definition was met is
considered to be occurring, and no new infections of that same type can be reported.

Criteria C: CLABSI (Central line-associated Bloodstream infection)If a patient meeting HAI BSI case
definition has a central venous catheter in place at any time on the date of the event or the day
before the date of the event and it was in place for > 2 calendar days; then the HAI- BSI case will be
meeting the criteria for CLABSI.
Criteria D: Secondary Bloodstream infection-If a positive, matching culture is obtained
From another body site(s) during the Secondary BSI Attribution Period (SBAP) then it is considered
secondary BSI.
Secondary BSI Attribution Period = 14 days before the date of the event to 7 days after the date of
event (where the date of event = day 1)
Reporting
3.3.2 of the first positive blood culture and all positive blood cultures that occur during the Event
Data collection
time frame for primary
The epidemiological BSIs will be
surveillance done. of healthcare-associated infections (HAIs) should be active
system
because the data collection is based on the detection of HAIs in clinical and laboratory services by
Event Timeframe = 14 days after the date of the event (where the date of event = day 1)
trained personnel and with enough time to spend searching for HAIs. It is selective for only selected
patients being BSIs,
For secondary monitored
no Eventbytime
having (risk
frame factors) for HAIs. The HICC will implement incidence
is created.
surveillance, where patients are monitored over a period of time for the presence or absence of HAIs.
The incidence of HAI is the number of new cases that occur in the defined population during a specified
time period.
The incidence rate is the number of new cases of HAI that appear in the population at risk during a
specific time period.
3.3.3 Consolidation and data analysis

Data should be consolidated monthly for the hospital’s use and forwarded quarterly to the Ministry of
Health following its analysis. The indicators for calculating ICU Healthcare-associated Infections rates
are.
Table 3.1: Formulae for calculation of HAIs Rates.
HAI Infection Rates Formulae
VAP Rate No. of VAP cases/ Total no. of ventilator days X 1000
BSI Rate No. of BSI cases/Total no. of patient days X 1000
CLABSI Rate No. of CLABSI cases/Total no. of central line days X 1000
UTI Rate No of UTI cases/ Total no. of patient days X 1000
CAUTI Rate No. of CAUTI cases/ Total no. of catheter days X 1000
SSI Rate No. of SSI/ No. of surgeries done X 100
No. of the device (Foley's catheter/ central line/ ventilator) days
DUR (Device Utilization Ratio)
/No. of patient days

3.3.4 Dissemination of results

The information of the surveillance system of HAI should be provided and discussed monthly to the
monitored services. A monthly report should be prepared and discussed during the HICC meetings.

CHAPTER
Procedure and Practice for IPC
4 Standard precaution
Standard Precautions are a set of infection control practices that healthcare personnel use to reduce
transmission of microorganisms in healthcare settings.Standard Precautions protect both healthcare
personnel and patients from contact with infectious agents.
All Patients
Irrespective
of their Standard All
Blood/Body
Infective fluids
Status Precaution Exposures
All Sharps
Components of Standard Precautions are:-
1. Hand hygiene
2. Personal protective equipment (PPE)
3. Respiratory hygiene and cough etiquette
4. Prevention of injuries from sharp
5. Safe handling of patients care equipment
6. Injection safety and use of injection device
7. Asepsis
8. Environmental infection control
4.1 Hand hygiene

Hands are the main source of transmission of infection in health care setting. Hand hygiene is therefore
most important measures to avoid transmission of harmful germs and to prevent the transmission of
health care associated infection. Hand hygiene removes dust/soil, organic material and transient
microorganisms from the skin and reduces the risk of cross-contamination.
4. Procedure and Practice for IPC Page 24

Objective - To prevent transmission of health care associated infection by promoting hand hygiene
among heath care workers.
Purpose - To avoid transmission of harmful germs and to prevent transmission of health care
associated infection.
When to perform hand hygiene - Perform hand hygiene while caring for patients using “Five
Moments Approach”recommended by WHO and as mentioned below:
a. Before touching the patient

b. Before any clean/aseptic procedures
c. After body fluid exposure risk
d. After touching the patient
e. After touching the patient surroundings
Figure 4.1:- My 5 Moments of Hand hygiene & steps of Hand rub & Hand wash.

How to perform hand hygiene
Hand hygiene may be performed by following methods depending upon the indications.
• With soap & • With ABHR • With

water • 20-30sec antimicrobial
• 40-60 sec solution & water
• 3-5 mins
Surgical Hand
Hand Wash Hand Rub
Aspesis
4.1.1 Hand washing with soap and water
Use plain or preferably antimicrobial soap for hand washing .
Indication for hand washing-
a) When there is visible contamination of blood, body fluid, dirt and organic material
b) After exposure to spore forming pathogen
c) After using toilet washroom
d) Before and after meal
Procedure for hand washing

To effectively reduce the growth of germs on hands, hand washing must last 40–60 seconds and should
be performed by following all steps
a) Wet hands under running water.

b) Wash hand by applying soap for 30-60 seconds by following 6 steps techniques.
c) Rinse hands with running water.
d) Dry thoroughly with a single-use towel.
4.1.2 Hand rubbing using alcohol-based preparation

Use alcohol-based hand rubs (ABHR), when hands are not visibly soiled or tap and running water is
unavailable.
Indication for hand rubbing
a) Before and after touching the patients

b) After contact with blood, body fluid, mucus membrane and wound dressing
c) Before and after handling any invasive device for patient
d) Before and after giving medication to the patient
e) Before removing sterile and non-sterile gloves

Procedure for hand rubbing
1) Apply a palmful of alcohol-based hand rub to cover all surfaces of the hand and wrists.
2) To be rubbed into hands for a minimum of 20 seconds and until your hands are dry.
4.1.3 Surgical hand scrub

 Hand scrubbing with an antiseptic agent before beginning a surgical procedure reduces the
number of microorganisms and inhibits the growth of microorganisms on hands under the
gloves.
 Chlorhexidine or povidone-iodine-containing soaps are the most commonly used products for
surgical hand scrub.
 The antimicrobial efficacy of alcohol-based formulations is better than other preoperative
surgical hand preparation methods.
 The hand rubbing techniques for surgical hand preparation must be performed on clean and dry
hands.
Procedure for Surgical hand washing -
a) Remove rings, watches, and bracelets before the surgical hand scrub begins.
b) Fingernails are kept short and well-maintained.
c) Hands and forearms must be free of open lesions and breaks in skin integrity.
d) Wear complete operating room attire, including a mask, cap, and goggles if required.
e) Keep clothing away from sinks and splashes.
f) Turn on water and wet hands and forearms.
g) Apply antiseptic hand wash solutions.
h) Lather hands and forearms for at least one minute from fingertips to three inches above elbows,
starting with hands to the forearm, forearm to the elbow. (as shown in Figure 4.2)
i) Wash hands thoroughly, using the following six steps to facilitate the eradication of all bacteria
and 10 seconds/step. (as shown in Figure 4.2)

Figure 4.2:- Steps of surgical Hand rubbing

4.2 Personal Protective Equipment (PPE)

Personal protective equipment (PPE) refers to physical barriers which are used to protect mucous
membranes, airways, mouth, nose, eye, skin, feet, and clothing from contact with infectious agents.PPE
includes gloves, gowns/aprons, masks, respirators, goggles, face shields, head cap and shoe cover.
Glove
Shoe Goggle
cover
PPE
Head
Mask
cap
Face Gowns/
shields Apron
Objectives
To promote and practice the use of personal protective equipment, appropriate for the task while
providing patient care by all the healthcare providers.
Purpose
To protect healthcare workers from infectious materials
4.2.1 Types of PPE-

A. Gloves
It protects both patients and healthcare workers from exposure to infectious agents that may be carried
on hands. Wearing disposable gloves is part of the standard safety precaution. As a part of PPE, gloves
prevent contact with blood, body fluids, and mucus membranes. Gloves are single-use items and are
changed after each procedure to minimize the risk of infection further.
Gloves should be chosen according to the following factors:-
 Choose sterile gloves when both health care worker and patient safety is required,
whereasclean gloves can be used when only health care worker safety is required.
 One or two pair requirements can be assessed based on the risk of exposure involved.
Types and indications for wearing gloves-

Gloves
Heavy
Clean non- Sterile/single
duty/utility used gloves
sterile gloves
gloves
 Clean non-sterile gloves
It is used for observation, handling items visibly soiled with blood, body fluid secretion, and
excretion, when non-intact skin on HCW hand.
 Sterile/single used gloves
It is used for aseptic procedures.
 Heavy duty/utility gloves
It is used for the decontamination of large equipment, cleaning of floors, walls, beds, bedside
lockers, etc. It is reused after cleaning.
B. Aprons and Gowns
It protects the healthcare workers’ arms and exposed body areas and prevents contamination of
clothing with blood, body fluids, and other potentially infectious material.
It is used to protect susceptible patients from infection and also HCWs from contamination of cloths.
Indication for wearing apron and gown -
 When there is close contact with patient, material or equipment that leads to contamination of
skin and clothing with infectious agents.
 When there is close contact with blood, body fluids and body secretions.
Type of apron or gown required-
The type of apron or gown required depends on the degree of risk of contact with infectious material
and the potential for blood and body substances to penetrate through to clothes or skin.
Clean non-sterile apron/gown- It protects skin and prevents soiling of cloths during the procedure,
bringing the HCW into contact with blood, body fluid, and secretions.
Fluid-resistant apron/gown is worn when procedure and patient care activities generate splashing or
spray of blood and body fluids.

C. Facial protection
Facial protection includes a face shield or goggles and a surgical mask to protect the conjunctiva of the
eye, nose, and mouth during the procedure, which producesa splash/spray of blood, body fluid, and
other body secretions. Eye protection should also be used while caring for patients with respiratory
symptoms such as coughing and sneezing since sprays of secretions may occur.
Objectives protect the mucous membranes of the eyes when conducting procedures that are likely to
generate splashes of blood, body fluids, secretions, or excretions.
Types of facial protection and uses -
Goggles- Used to protect eyes during activities that generate blood, body fluid, and cough and also
during suctioning.
Face shield- Used to protect the face, nose, mouth, and eyes when irrigating a wound suctioning
copious secretions a face shield can be used as a substitute for goggles.
D. Respirators
It is used when dealing with patients infected with highly communicable respiratory pathogens and
when droplet precaution is required.
Purpose- These protect from inhalation of infectious aerosols (e.g. M. tuberculosis).
Types of respirators-
 Particulate respirators- Close-fitting mask capable of filtering 0.3-micrometer particles and worn
when attending active pulmonary tuberculosis patients.
 Half- or full-face elastomeric respirators
 Powered air-purifying respirators (PAPRs)
Indication for surgical mask -
 Use surgical masks on coughing patients to limit the potential dissemination of respiratory
pathogens.
 Use surgical masks as a part of standard precautions to keep splashes or sprays from reaching
the mouth and nose of the person exposed.
 While caring for patients on droplet precautions.
Indication for N-95 mask-
 When dealing with patients infected with highly transmissible respiratory pathogens while
following droplet precautions (e.g. HCW dealing with open tuberculosis cases/ influenza
patients)

Figure 4.3:- Donning & Removing a Surgical Mask.
How to don N-95 Mask-
 Select a fit-tested respirator

 Place over nose, mouth, and chin
 Fit flexible nose piece over nose bridge
 Secure on the head with elastics
 Adjust to fit
 Perform a fit check-
Inhale—The respirator should collapse.
Exhale—Check for leakage around the face
Figure 4.4:- Donning of N-95 Mask.

Removing N-95 Mask-
 Always remove it just outside the patient room.

 Lift the bottom elastic over your head first
 Then lift off the top elastic
 Discard and perform hand hygiene.
Figure 4.5:- Removing N-95 Mask.

E. Footwear /Shoe cover
 Protective footwear should be used when handling biomedical waste as unnoticed cuts and
wounds are quite common in the legs. Footwear is also essential to protect legs from ‘sharps’
injury.
 Shoe cover must be worn before entering to the ICU, Operating Theatre, Dialysis, CSSD, and
HDU.
 Do not reuse disposable caps/ shoe covers. Discard them after each use in an appropriate
container.
 Personal footwear should be changed when entering clean areas such as OTs, labor rooms, and
ICUs.
F. Hair covers/Head cap-
 To protect hair against exposure to the patient’s blood, body fluids, and body secretions during
the procedure.
 Long hair must be secured with a rubber band and hair cover worn to protect the hair and to
protect the patient from falling hair.
4.3 Respiratory hygiene and cough etiquette:

 Respiratory hygiene and cough etiquette are the measures taken by the patients, their
family members, and friends with any signs and symptoms of respiratory infection to
prevent other people from infection.
 It also applies to any persons with signs of illness including cough, congestion,
rhinorrhea, or increased production of respiratory secretions when entering health care
facilities.
Element of Respiratory hygiene and cough etiquette
 Educating the health care workers, patients, and visitors.
 Educate them to cover their mouth and nose during coughing or sneezing.
 Discard the tissue after use to the nearest dust bin.
 Perform hand hygiene after coughing or sneezing and also after contact with respiratory
secretion and contaminated objects and materials.
 Make a distance of 6 ft. from a person with respiratory infection.
 If a handkerchief or tissues areunavailable, patients should be instructed to cover their nose and
mouth with their arm during coughing and sneezing.
 Healthcare personnel are advised to take droplet precautions (i.e., wear a mask) and hand
hygiene when examining and caring for patients with signs and symptoms of respiratory
infections.
 Healthcare personnel with a respiratory infection are advised to avoid direct patient contact,
especially with high-risk patients. If possible, wear a mask during providing care to the patients.
 Posters elaborating on cough etiquette and hand hygiene must be displayed at OPDs,
emergency and visitor waiting areas.

The following information should be displayed in patient-care areas to educate patients, visitors, and
healthcare workers.
 Respiratory infections like COVID-19, M. tuberculosis, influenza and SARS etc., are transmitted
through cough, sneeze, or unclean hands.
 Avoid close contact with people with signs and symptoms of respiratory infection.
 Stay at home if you are sick.
 Cover your mouth and nose while coughing and sneezing.
 In the absence of a handkerchief or tissues, cover your nose and mouth with your arm during
coughing and sneezing.
 Frequent hand washing with soap and water, if unavailable,then sanitize with alcohol-based
hand rub.
 Avoid frequent touching of your eyes, nose and mouth.
 Clean and disinfect frequently touched surfaces at home, especially when someone is ill.
 Get good sleep of 6-8 hours at night, eat healthy food and fruits, drink plenty of water and be
physically active.
Figure 4.6:- Poster of Cough etiquette displayed in AIIMS Bhopal

4.4 Prevention of injuries from sharp:

Safe handling and disposal of sharps is a vital component of the Standard Precautions approach to
reduce the risk of transmission of blood-borneviruses.
Good practices involve
a. Proper size of sharp container with adequate size opening and covering
b. Labeling of the sharp container as “SHARP CONTAINER” and biohazards symbol
c. Sharp container should not be more than 2/3rd full
d. Sharp containers should be properly sealed before sending it to final segregation.
e. Every health care worker should be aware of first aid measures following sharp injury
General consideration to prevent sharp injury
a. Follow standard safety precautions during activities and procedures

b. All patients, blood and body fluid and sharp should be considered infectious until proven to be
negative
c. Use PPE while handling all potentially infectious material
d. Hand washing with soap and water before donning and after doffing
e. Avoid using open footwear where sharp instruments or needles are handled
f. For all clinical procedures, close open wounds, skin lessens, and all broken skin with
waterproof dressing or gloves if possible
g. Working area should be disinfected using 0.1% sodium hypochlorite solution
h. All health care workers should have complete HBV vaccine at the time of joining the
institute and thereafter
Handling sharps-
Handling of sharp is the most hazardous activity done by a healthcare worker during their duty. Sharp
should be handled cautiously to avoid injury during use and disposal.
 Avoid unnecessary use of sharp and needles. Disposable needles should be used.
 Handle hollow bore needle with care because it causes deep injuries
 Never recap needle by hand, and if not possible, then use single scoop technique
 Never break or bend the needle by hand
 Used sharps should be disposed of immediately in designated puncture-proof containers
(labeled with a biohazard symbol); they should not be left at bedside tables and trolleys
 Never pass used sharp object from one person to another person
 It is the responsibility of the person using the sharp to dispose of it safely.
 If needle stick injury occurs or any injury by sharp immediate contact should be done to the
ward in-charge and BMW department for further management
 Needle collection tray in needle destroyer must be emptied in the morning or more frequently if
required. It should never be overfilled

 While handling sharps, the sharp end of instruments shall be positioned away from oneself and
others.
4.5 Safe handling of patient care equipment

(e.g. - items soiled with blood and body fluids)
 Items in contact with the patient should be disinfected and sterilized before using for another
patient.
 Items soiled with blood and body fluid must be sterilized and disinfected to prevent infection to
other patients.
 Disinfection and cleaning of all equipment, including the patient's bedside, should be done by
HCWs trained in appropriate cleaning procedures.
 Responsibility and accountability for cleaning and disinfection should be assigned to ward in-
charges and nursing officers.
 Hospital infection control policy for appropriate cleaning, disinfection and sterilization for all
equipment that comes in contact with patient's blood and body fluids should be strictly
followed.
 Heavy-duty gloved and strong utility gloves should be worn during cleaning and disinfection.
 Soiled patient care equipment should be handled carefully to prevent skin and mucus
membrane exposure.
 Disposable patient care equipment should be discarded in appropriate bins according to the
Hospital infection control policy and not be reused.
4.6 Injection safety and use of injection device

Injection safety is an important aspect of standard precaution.
 Use a new injection set for every procedure and every patient
 Inspect the packaging for any break or bend in needle and syringe
 Discard the device if the package has been punctured, torn, or damaged by exposure to
moisture or if the expiry date has passed.
Single-dose and multi-dose vial
 Use a single-dose vial for each patient if possible

 Open only one vial of a particular medication at a time in each patient'sbedside.
 Do not store multi-dose vials in the open ward or general patient-care area
 Before use, examine the vial for any turbidity and discoloration, and if present, discard it
 Never leave a needle or cannula inserted into a medication vial via the rubber stopper
 Discard a multi-dose vial after 28 days from the date of opening, even if it is within the expiry
date
 Single-dose vials for reconstitution should be used instead of fluid or solution bags for routine
injection.

Labeling
After reconstitution of a multi-dose vial, label the final medication container with:
 Date and time of preparation

 Final concentration
 Expiry date and time
 Name and signature of the person reconstituting the drug.
For multi-dose medications that DO NOT require reconstitution, add a label with:
 Date and time of first piercing the vial

 Name and signature of the person first piercing the vial
Injection preparation and administration -
Injection should be prepared in designated cleaned areas where body and blood fluid contamination is
unlikely to happen.
Practical guidance on administering injections -
 Perform hand hygiene

 Aseptic technique should be followed for all injection
 Wipe the top of the vial with 70% alcohol using a swab or cotton wool ball
 Use a sterile syringe and needle, withdraw the medication from the ampoule or vial
 Don’t allow the needle to touch any contaminated area
 Don’t reuse the needle even if the syringe is changed
 Don’t use the same needle and syringe for several multi-vials
 Ensure one needle and syringe for one patient only
 Don’t restore the leftover constituted medication for further use
 If the dose cannot be administered immediately for any reason, cover the needle with the cap
using a one-hand scoop technique
4.7 Asepsis –
 Asepsis is the absence of pathogenic (disease-producing) microorganisms.

 Aseptic technique refers to practices/procedures that help reduce the risk of/for infection.
 The two types of aseptic techniques are medical and surgical.
Principles of asepsis:
4.7.1 Infection prevention and control in surgical units –
Aseptic protocols
A. Personnel

 Hand/ forearm antisepsis for surgical team members is of crucial importance.

 Nails should be kept short, and all jewelry, artificial nails, or nail polish should be removed
before surgical hand preparation.
 Surgical hand antisepsis should be performed using either a suitable antimicrobial soap or ABHR
before donning sterile gloves.
 A preoperative surgical hand scrub should be done for at least 5 minutes using an appropriate
antiseptic scrub. Hands and forearms should be cleaned up to the elbows
B. Scrubs
 “Scrubs” refers to the sanitary clothing worn by the OT staff, usually comprising a short-sleeve,
v-neck shirt and loose-fitting, drawstring pants.
 The design of scrubs minimizes places where contaminants can hide, and they are easy to
launder.
 Scrubs should be changed after likely contamination and should always be cleaned in a
healthcare laundering facility
C. Surgical attire
 The surgical attire includes gloves, gowns, caps, masks, eye protection, waterproof aprons, and
footwear. It protects the patient from the risk of infection from the surgical team's hair, skin,
clothes, and respiratory secretions.
 The surgical attire also protects the surgical team from the risk of exposure to the patient's
blood and tissues during the operation.
D. The sterile field
 It is important to maintain a sterile field to prevent contamination of surgical incisions.

 A sterile field is the area prepared around the surgical procedure site and where the sterile
instruments and other items needed during the operation are placed.
 It is created by placing sterile towels or sterile drapes on the prepared procedure site on the
patient and includes a stand nearby.
 Only sterile objects and persons in surgical attire (scrubbed team) are allowed within this field.
 Areas above the chest and below the waist of the scrubbed team are considered non-sterile.
Items outside and below the draped area are considered non-sterile.
 The field is considered non-sterile if a non-sterile object or non-scrubbed person comes within
the sterile field.
Maintenance of the sterile field

 Place only sterile items within the sterile field.
 Open, transfer, and dispense items without contaminating them.
 The outer cover of sterile items is considered unsterile and should not be placed within the
sterile field.

 Scrubbed persons should not touch non-sterile objects.

 Non-sterile items or personnel should not enter the sterile field.
 Never touch a sterile item with bare hands.
 If a sterile barrier has been made wet, is cut, or torn, it is considered non-sterile.
 If there is a doubt whether the sterile field has been breached, consider it non-sterile.
Skin preparation and use of antiseptic agents:
 Gross contamination at the incision site should be removed before the antiseptic skin
preparation.
 Antiseptic skin preparation should be applied in concentric circles moving away from the
proposed incision site to the periphery, allowing sufficient prepared area to be
included.(as shown in Figure 4.7)
Cleanest to
dirty area
Figure 4.7: Skin preparation with antiseptic solution
4.7.2 Infection prevention and control in Intensive Care units (ICUs)
Intensive care unit (ICU) patients are particularly vulnerable and at five- to ten times higher risk of HAI.
With defenses compromised due to various invasive devices such as peripheral and central lines, urinary
catheters, and mechanical ventilators, they are particularly prone to device-relatedinfections. Patients in
the ICU are also exposed to broad-spectrum antibiotics and are susceptible to multidrug-resistant
organisms such as Acinetobacter spp. and Pseudomonas spp.
Infection prevention and control practices

Standard precautions should be applied for all patients in the ICU. In addition,transmission-based
precautions should be applied to standard precautions to prevent infections where the transmission
route is known.
ICU footwear:
 Special well-fitting footwear with impervious soles should be worn in the ICU. Shoes should be
preferred over slippers.
 Footwear should be regularly cleaned to remove splashes of blood and body fluids.
 The ICU footwear must not be taken out of the ICU to other areas of the hospital

4.7.3 Prevention of Device-Associated Infections

Many types of invasive devices and procedures to treat patients and help them recover. Bacterial
colonization of indwelling devices like catheters or ventilators leads to the development of an infection
as well as results in malfunctioning. Hence, Device Associated Healthcare Infections (DAIs) are one of the
most common causes of morbidity and mortality among hospitalized patients, especially in intensive
care units. The three most commonly occurring DAIs is:
A. Catheter-Associated Urinary Tract Infections (CAUTI)

B. Central Line Associated Blood Stream Infections (CLABSI)
C. Ventilator Associated Pneumonia (VAP)
A. Prevention of catheter-associated urinary tract infection (CAUTI)

 CAUTI is defined as a urinary tract infection (significant bacteriuria plus symptoms and/
or signs attributable to the urinary tract with no other identifiable source) in a patient with
current urinary tract catheterization or who has been catheterized in the past 48 hours.
 There are several strategies with varying levels of evidence to prevent CAUTI before and
after the placement of urinary catheters. These generally include appropriate use, aseptic
insertion and maintenance, early removal, and hand hygiene.
Figure 4.8:- My 5 Movements of Hand hygiene Focus on caring for a patient with urinary catheter

Appropriate Indications for using Indwelling Catheters

 Anatomic/ physiologic obstruction to urine flow (acute urinary retention or bladder outlet
obstruction)
 Patients undergoing surgeries on genitourinary tract
 Anticipated prolonged duration of surgeries (catheters should be removed after surgery)
 When accurate urinary output measurements are required in critically ill patients.
 Patients anticipated receiving large volume infusions or diuretics during the surgery.
 Patients with sacral or perineal wounds suffering from incontinence
 Patients requiring prolonged immobilization (e.g. lumbar/ spinal fractures)
 To improve comfort for end-of-life care if needed
Not Recommended for-
 Routine bladder irrigation with antimicrobials

 Routine instillation of antiseptics or antimicrobials in drainage bags
 Routine use of Antibiotic coated catheters (reserved for patients with the highest risk of
complications associated with bacteriuria)
 Routine use of prophylactic antimicrobial agents before catheter insertion.
B. Prevention of central line-associated bloodstream infection (CLABSI)

Central line-associated bloodstream infection (CLABSI) may be caused by cutaneous microorganisms
that contaminate the catheter during insertion or migrate along the catheter track or by microorganisms
from the hands of HCWs during interventions.
The most frequently implicated organisms are: Coagulase-negative staphylococci, particularly Staph.
epidermidis. Other organisms are Staph. aureus, Candida spp., Enterococci and Gram-negative
organisms.
It is essential that the best evidence-based practices be followed for prevention of catheter related or
associated bloodstream infections.
Preventing Central Line-Associated Bloodstream Infections:

Five Components of Care:
I. Hand hygiene
II. Maximal barrier precautions
III. Chlorhexidine skin antisepsis
IV. Optimal catheter site selection, with avoidance of using the femoral vein for central venous
access in adult patients
V. Daily review of line necessity, with prompt removal of unnecessary lines.

Hand hygiene
Barrier
Daily review
precautions
CLABSI
Prevention
Catheter site Skin

selection Antisepsis
I. Hand Hygiene
One way to decrease the likelihood of central line infections is to use proper hand hygiene. Washing
hands or using an alcohol-based waterless hand cleaner helps prevent contamination of central line sites
and resultant bloodstream infections.
When caring for central lines, appropriate times for hand hygiene include:
a) Before and after palpating catheter insertion sites (Note: Palpation of the insertion site should
not be performed after the application of antiseptic unless aseptic technique is maintained.)
b) Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter.
c) When hands are obviously soiled or if contamination is suspected
d) Before and after invasive procedures
e) Between patients
f) Before donning and after removing gloves
g) After using the bathroom

Figure 4.9:- My 5 Movements of Hand hygiene Focus on caring for a patient with a central venous
catheter
II. Maximal Barrier Precautions
 A key change to decrease the likelihood of central line infections is to apply maximal barrier
precautions in preparation for line insertion.
 For the operator placing the central line and for those assisting in the procedure, maximal
barrier precautions mean strict compliance with hand hygiene and wearing a cap, mask, sterile
gown, and sterile gloves. The cap should cover all hair and the mask should cover the nose

andmouth tightly. These precautions are the same as for any other surgical procedure that
carries a risk of infection.
III. Chlorhexidine Skin
Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic
agents, such as povidone-iodine solutions.
The technique is as follows:
 Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol.

 Hold the applicator down to allow the solution to saturate the pad.
 Press the sponge against the skin, and apply chlorhexidine solution using a back-and-forth
friction scrub for at least 30 seconds. Do not wipe or blot.
 Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).
IV. Optimal Catheter Site Selection, with Avoidance of using the Femoral Vein
for Central Venous Access in Adult Patients
 Percutaneously inserted catheters are the most commonly used central catheters.
 The subclavian vein site is associated with a lower risk of CLABSI than the internal jugular vein.
However, the risks and benefits of infectious and non-infectious complications must be
considered on an individual basis when determining which insertion site to use.
 The femoral site is associated with a greater risk of infection in adults; however, this may be
limited to overweight adult patients.
 Whenever possible, the femoral site should be avoided, and the subclavian line site may be
preferred over the jugular site for non-tunneled catheters in adult patients. This
recommendation is based solely on the likelihood of reducing infectious complications.
 Subclavian placement may have other associated risks.
Note: The bundle requirement for optimal site selection suggests that other factors (e.g., the potential
for mechanical complications, the risk of subclavian vein stenosis, and catheter operator skill) should be
considered when deciding where to place the catheter. In these instances, teams are considered
compliant with the bundle element as long as they use a rationale construct to choose the site. The core
aspect of site selection is a physician's risk/benefit analysis as to which vein is most appropriate for the
patient. It is not the intent of the bundle to force a physician to take an action that he or she feels is not
clinically appropriate.
V. Daily Review of Central Line Necessity with Prompt Removal of Unnecessary

Lines
 Review for the necessity of central lines on daily basis.

 This will prevent unnecessary delays in removing lines that are no longer clearly needed for the
care of the patient.

Central Line Maintenance

 Closed medication system and two-person process for all dressing change and tubing change
 Perform hand hygiene with hospital-approved alcohol-based products or antiseptic-containing
soap before and after accessing a catheter or changing the dressing
 Maintain aseptic technique when changing intravenous tubing and when entering the catheter,
including ‘scrub the hub’ for 5–15 seconds.
 Evaluate the catheter insertion site daily for signs of infection and to assess dressing integrity. At
a minimum, if the dressing is damp, soiled, or loose, change it aseptically and disinfect the skin
around the insertion site with an appropriate antiseptic
 Daily review of catheter necessity with prompt removal when no longer essential
CDC recommendations --
For Clinicians:
 Follow proper insertion practices

 Perform hand hygiene before insertion.
 Adhere to aseptic technique.
 Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile full
body drape).
 Choose the best insertion site to minimize infections and noninfectious complications based on
individual patient characteristics.
 Avoid femoral site in obese adult patients.
 Prepare the insertion site with >0.5% chlorhexidine with alcohol.
 Place a sterile gauze dressing or a sterile, transparent, semipermeable dressing over the
insertion site.
 For patients 18 years of age or older, use a chlorhexidine-impregnated dressing with an FDA-
cleared label that specifies a clinicalindication for reducing CLABSI for short-term non-tunneled
catheters unless the facility is demonstrating success at preventing
 CLABSI with baseline prevention practices.
Handle and maintain central lines appropriately-
 Comply with hand hygiene requirements.

 Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis.
 Scrub the access port or hub with friction immediately prior to each use with an appropriate
antiseptic (chlorhexidine, povidoneiodine, an iodophor, or 70% alcohol).
 Use only sterile devices to access catheters.
 Immediately replace dressings that are wet, soiled, or dislodged.
 Perform routine dressing changes using aseptic technique with clean or sterile gloves.
 Change gauze dressings at least every two days or semipermeable dressings at least every
seven days.
 For patients 18 years of age or older, use a chlorhexidine-impregnated dressing with an FDA-
cleared label that specifies aclinical indication for reducing CLABSI for short-term non-tunneled
catheters unless the facility is demonstrating successat preventing CLABSI with baseline
prevention practices.

 Change administration sets for continuous infusions no more frequently than every 4 days but
at least every seven days.
• If blood or blood products or fat emulsions are administered change tubing every 24
hours.
• If propofol is administered, change tubing every 6-12 hours or when the vial is changed.
• Promptly remove unnecessary central lines
• Perform daily audits to assess whether each central line is still needed.
For Healthcare Organizations:
 Educate healthcare personnel about central line indications, proper insertion and maintenance
procedures, andappropriate infection prevention measures.
 Designate personnel who demonstrate competency ininserting and maintaining central lines.
 Periodically assess knowledge of and adherence to guidelines for all personnel involved in
inserting and maintaining central lines.
 Provide a checklist to clinicians to ensure adherence to aseptic insertion practices.
 Reeducate personnel regularly about central line insertion, handling and maintenance, and
whenever related policies, procedures, supplies, or equipment changes.
 Empower staff to stop non-emergent insertion if proper procedures are not followed.
 Ensure efficient access to supplies for central line insertion and maintenance (i.e. create a
bundle with all needed supplies).
 Use hospital-specific or collaborative-based performance measures to ensure compliance with
recommended practices.
Supplemental strategies for consideration:
 Antimicrobial/Antiseptic-impregnated catheters
 Antiseptic impregnated caps for access ports
C. Prevention of ventilator-associated pneumonia (VAP)
Ventilator-associated pneumonia (VAP) is a common healthcare-associated infection occurring in 10%–

20% of patients mechanically ventilated in the ICU. VAP occurs because the obtunded, endotracheally
intubated patient is at risk of inoculating the lower respiratory tract with microorganisms.
The source of the potential inoculates includes the oropharynx, subglottic area, sinuses, and
gastrointestinal (GI) tract. Access to the lower respiratory tract occurs around the endotracheal tube
(ETT) cuff. Interventions to prevent VAP aim either to prevent repeated micro aspiration, colonization of
the upper airway and GI tract with potentially pathogenic organisms, or contamination of
ventilator/respiratory equipment.
Bundles of care are evidenced-based practices that are grouped together to encourage the consistent
delivery of these practices. These bundles are common in the ICU and have been developed for the
prevention of VAP.
Recommended Bundle of Interventions for the Prevention of VAP

Elevation of
Head of Bed
Safe Daily
Nutrition Sedation
Interruption
DVT Bundle of Use of

Prophylaxis Drainage
VAP
Avoidance
Gastric Ulcer
of Circuit
Prophylaxis
Changes
Oral
Hygiene
1. Elevation of Head of Bed (30°–45°)
Aspiration of oropharyngeal or gastric contents is implicated in the pathogenesis of VAP. Nursing the
mechanically ventilated patient in a semi-recumbent position aims to prevent aspiration of gastric
content.
2. Daily Sedation Interruption and Assessment of Readiness to Extubate
 Minimizing the duration of mechanical ventilation can decrease the chances of developing VAP
and should be practiced by Sedation interruption on daily basis.
 Two strategies that have been used to reduce the duration of mechanical ventilation are daily
sedation interruption (DSI) and daily spontaneous breathing trials (SBT).
 Strategy of DSI to prevent over-sedation and liberation from mechanical ventilation through SBT
has proved beneficial.
 Assess daily the patient readiness to extubate.
3. Use of Subglottic Secretion Drainage
Secretions that pool above the ETT but below the vocal cords are a potential source of pathogens that
could cause VAP. Since conventional suction methods cannot access this area, ETT tubes that have a
designated suction catheter for this space allows this pool to be drained.

4. Avoidance of Scheduled Ventilator Circuit Changes
Humidified gases condense in the ventilator circuitry and are at risk of becoming contaminated.
Frequent circuit changes are associated with an increased incidence of VAP, probably due to the
excessive manipulation of the ventilator circuit. The circuits to be changed whenever visibly soiled.
5. Oral Hygiene
Recent evidence has called into question the widespread use of oral chlorhexidine to decontaminate the
oropharynx. Oral chlorhexidine use has been associated with a reduction in respiratory tract infections
in the ICU in high profile meta-analyses.
6. Gastric Ulcer Prophylaxis
Raising the pH of the stomach contents promotes colonization with potentially pathogenic organisms
and so basically remains a balance of risk between GI bleeding and developing VAP.
7. Deep Venous Thrombosis Prophylaxis
Sedated ventilated patients are at significantly increased risk for DVT. Hence, DVT prophylaxis is an
important component of standard care of these patients. Similar to stress ulcer prophylaxis, DVT
prophylaxis has not been demonstrated to reduce the risk of VAP. It remains part of the Ventilator
Bundle in order to prevent other serious complications that could increase the morbidity and mortality
of these patients.
8. Safe Nutrition
Initiate Safe Enteral Nutrition within 24–48 hours of ICU Admission.
Pediatric VAP Bundle:

1. Elevate the head of the bed
2. Properly position oral or nasal gastric tubes
3. Perform oral care
4. Eliminate the routine use of instill for suctioning

Figure 4.10:- My 5 Movements of Hand hygiene Focus on caring for a patient with an endotracheal
tube.
Additional evidence-based components of care:
 Hand hygiene
 Practices that promote patient mobility and autonomy
 Avoiding invasive ventilation whenever possible

4.8 Environmental infection control:

A. Patient placement in Wards/Cubicles -
Appropriate placement of patients is important in preventing the transmission of infections in the

hospital setting.
Single Rooms
Spacing btw
Beds Highly
transmissible
1–2 meters disease
Cohorting Anterooms
sharing patients
with the same For use of PPE
infection
General principles
Spacing between beds
In open-plan wards, there should be adequate space between each bed to reduce the risk of cross-
contamination/infection occurring from direct or indirect contact or droplet transmission. Space
between beds should be 1–2 meters or 6 feet.
Single rooms
Single rooms reduce the risk of transmission of infection from the source patient to others by reducing
direct or indirect contact transmission.
A Single room should have hand-washing, toilet, and bathroom facilities.
Placement with regular admissions
There should be a policy for cleaning the room after patient discharge (terminal cleaning) and before
admission.
All patient-care items used by the previous patient should be removed and replaced with clean items,
e.g. bed linen, waterproof covering, oxygen humidifiers, face mask, etc.
Patient-care equipment and articles should be cleaned, disinfected or sterilized.

B. Transport of patients -
Appropriate precautions should be taken during transportation to reduce the risk of transmission of
microorganisms to other patients, HCWs, or the hospital environment (surfaces or equipment).
Precautions during transport of patients
 Place a surgical mask on the face of a patient with pulmonary tuberculosis during transit.
 Care should be taken of drainage and shunts and IV lines as these are potential sources for
contamination of the environment, trolleys, etc., during transportation, and also a source of
infection for the patient. Closed sterile drainage is to be maintained at all times.
 Shunts and IV lines should be covered with sterile dressing during transportation.
 A trolley should have the facility for hanging IV bottles and tying urine bags below bladder level,
which helps properly drain urine and prevents stagnation of urine.
 Spills of blood and body fluids should be taken care of immediately.
 Routine cleaning schedules for trolleys and wheelchairs should be maintained.
Policy for visitors
Although instructing and preparing visitors for patients in isolation is time-consuming and often
frustrating, their presence is valuable to the patient's emotional well-being.
 Before entering the room, visitors must enquire at the nurses' station for instructions and gown
and mask if indicated. Visitor's footwear bags should not be allowed inside critical care areas.
 Minimum Visitors are allowed inside intensive units for control of infections.
 Visitors should wash their hands well with soap and water before entering and when leaving the
room.
 Visitors are not allowed to sit on the patient's bed.
4.9 Transmission based precautions:

This refers to specific precautions which are to be followed in situations where standard precautions
may not be sufficient to interrupt the specific transmission of diseases depending upon their mode of
transmission. These precautions are taken in addition to standard precautions not as a replacement and
are also known as additional precautions.
Categories of Transmission based Precautions
Standard Precautions Contact Precautions

Infection control
practices Transmission based
Droplet Precautions
Precautions
Airborne Precautions

4.9.1 Contact precautions
Contact transmission of microorganisms during patient care is responsible for the majority of HAIs in
patients and healthcare staff.
Indication:-
These precautions are to be applied while offering a care to patients suffering from following conditions
or infected with following microorganisms.
 Abscess/wound infection: major, draining
 Bronchiolitis
 Burkholderiacepacia: patient with cystic fibrosis, infection or colonization
 Conjunctivitis: acute viral
 Gastro-enteritis: C. difficile, Rotavirus, diapered or incontinent person for other infectious
agents
 Diphtheria: cutaneous
 Hepatitis, type A and E virus: diapered or incontinent person
 Herpes simplex virus: muco-cutaneous, disseminated or primary, severe, and neonatal
 Human metapneumovirus
 Impetigo
 Lice (pediculosis)
 Multidrug-resistant organisms: infection or colonization – by MRSA, VRE, CRE, MDR GNBs
 Para-influenza virus
 Poliomyelitis
 Pressure ulcer: infected
 Respiratory infectious disease: acute, infants and young children
 Respiratory syncytial virus: in infants, young children and immune compromised adults
 Rubella: congenital
 Scabies
 Leprosy
 Gonorrhea
 Staphylococcal disease: furunculosis, scalded skin syndrome, burns.
Contact transmission can be direct or indirect.
A. Direct transmission This occurs when infectious agents are transferred from one person to another
without a contaminated intermediate object or person.
For example, blood or other body substances from an infectious person may come into contact with a
mucous membrane or breaks in the skin of another person.
B. Indirect transmission- This involves the transfer of an infectious agent through a contaminated
intermediate object (fomite) or person.
These include:
 Hands of Health care workers.

 Clothing after care of an infected patient.

 Patient-care devices that are shared between patients without cleaning and disinfection.
 Environmental surfaces that are inadequately disinfected
Hand Hygiene Follow all 5 moments all the time.

Use Chlorhexidine based hand rubs instead of alcohol-based rubs in case of
patients infected with C. Difficile or non-enveloped viral infections (Rotaviral or
Noroviral Diarrhea)
Prefer hand wash if chlorhexidine-based hand rubs are not available in above
situations.
PPE Wear gloves and gowns upon entering the patient room
A surgical mask or protective eyewear must be worn if there is potential for the
generation of splashes or sprays of blood and body fluids into the face and eyes.
Remove and discard the gloves and gown before leaving the area.
PatientCare Use patient-dedicated equipment or single-use disposable equipment wherever
Equipment possible.
If dedicated equipment is not possible, clean it and allow it to dry before using it on
another patient.
Patient A single-patient room is recommended.
Placement Keep patient's notes and bedside charts outside the room
Keep doors closed
Disinfect hands upon leaving the room and after writing the chart
If single room is not available:
1. Avoid placing these patients with other patients with increased susceptibility of
infection
2. Change protective attire and perform hand hygiene between contacts with
patients in the same room.
Transfer of Avoid transfer of patients so far as possible
Patients If transfer is necessary, ensure that the infected or colonized areas of patients are
covered and contained.
Wear PPE while handling the patients at the destination

4.9.2 Droplet Precautions:

These precautions are to be applied while offering care to patients infected with organisms that are
transmitted through respiratory droplets (>5μm) generated by patients during coughing, sneezing or
talking. As these droplets can travel only short distances (<1 meter), precautions are required when
close contact with the infected patient is expected.
Following diseases/infectious agents warrants droplet precautions:
 Diphtheria: pharyngeal
 Influenza virus: Seasonal
 Invasive disease: H. influenzae type b, N. meningitidis, Streptococcus group A
 Mumps
 Parvovirus B19: erythema infectiosum
 Pertussis (whooping cough)
 Plague: pneumonic
 Pneumonia: Adenovirus, H. influenzae type b (infants and children), Mycoplasma
 Rhinovirus, Respiratory syncytial virus
 Rubella
 Streptococcus group A disease: pharyngitis and scarlet fever (infants and young children)
 Viral hemorrhagic fevers due to Lassa, Ebola, Marburg, Crimean- Congo fever viruses
Droplet transmission occurs through large respiratory droplets >5 microns in size.
Transmission occurs when infectious respiratory droplets are expelled by coughing, sneezing or talking,
and come into contact with another person’s mucosa (eyes, nose or mouth), either directly or via
contaminated hands. Since these microorganisms do not travel over long distances, special air handling
and ventilation are not required.
Droplet precautions include:
 Patient placement: keep a minimum of 1–2 meter inter-bed distance.

 Cough etiquette:Explain the importance of respiratory hygiene and cough etiquette to patients.
 Personal protective equipment: wear a triple-layered surgical mask within 1–2 meters of the
patient. For practical purposes, it is advisable to use the mask when entering the patient's room.
For aerosol-generating procedures, N95 masks should be used.
 Patient transport: the patient should wear a triple-layered surgical mask.
4.9.3 Airborne precautions

These precautions are applied while dealing with patients having respiratory infections by pathogens
which are transmissible through droplet nuclei ≤5 μm. These particles remain suspended in the air for
longer duration and can travel longer distances (>1 meter).

 Airborne route of infection occurs through droplet nuclei of 1–5 micron that are disseminated
through the air.
 These droplet nuclei can remain suspended in the air for varying periods of time and can travel
long distances (>1 meter) and from room to room.
 Droplet nuclei arise from drying suspended droplets carrying the infectious agent.
 Diseases that spread by the airborne route include Pulmonary or laryngeal tuberculosis,
measles, chicken pox, pulmonary plague and viral hemorrhagic fever with pneumonia.
 Transmission of droplet nuclei at a short range may occur with SARS-CoV, human influenza, and
other viral respiratory infections, during performance of aerosol-generating procedures.
Indications
 Influenza A: Avian H7N9, Asian H5N1

 Measles
 MERS-Corona virus: Middle East Acute Respiratory Syndrome
 Mycobacterium tuberculosis: Laryngeal and pulmonary disease, extra-pulmonary draining lesion
 Smallpox
 Varicella-zoster: Disseminated disease, localized disease in immune-compromisedpatients.
Persons caring for patients with airborne infections should take the following precautions:
 Respiratory protection: Persons entering the airborne infection isolation room should wear a
particulate respirator, e.g. an N95 mask with a proper fit.
 Restricted entry: Susceptible healthcare personnel should be restricted from entering the room
of patients known or suspected to have airborne infections.
 Immunize susceptible persons: Susceptible persons should be immunized as soon as possible
following unprotected contact with vaccine-preventable infections.
 Protection during aerosol-generating procedures:Appropriate PPE should be used in an airborne
infection isolation room for aerosol-generating procedures associated with pathogen
transmission. N95 masks should be worn by persons performing aerosol-generating procedures
(such as endotracheal suction and bronchoscopy) on patients with respiratory infections.
PPE Wear a P2 respirator or N95 mask when entering the patient’s room.
Surgical masks do not offer protection but may be given to coughing patients to limit
the spread of aerosols and droplets at the point of generation.
Gloves and gowns are to be worn as per standard precaution.
Patient A single-patient room preferably having negative pressure ventilation is
Placement recommended
Door of the room should remain closed
Ask patients to wear surgical mask if he is with other patients in the same room.
Only staff or visitors immune to the infectious agent should be allowed to enter the
room if possible.
Transfer of the Ask the patients to wear a correctly fitted mask while they are being transferred and
Patients follow respiratory hygiene and cough etiquette.
Limit transfer as much as possible.
Any associated skin lesions with the condition should be covered.

Table no.4.1: Application for Transmission-based Precautions
Activity Contact Transmission Droplet Transmission Airborne Transmission

Isolation Room Single Room and Minimize Single Room, Minimize Single Room with Negative
Time Outside Time Outside when Pressure Ventilation,
Patient may Wear Minimize Time Outside when
Mask Patient may Wear Mask
Exclude Non-Essential
Susceptible People
Hand hygiene Yes Yes Yes
Gloves Wear gloves on entering When likely to touch When likely to touch blood
room to provide patient blood body fluids and body fluids and contaminated
care and when likely to contaminated items items
touch blood, body fluids
and contaminated items
Apron/Gown Wear it on entering room If soiling likely, i.e. If soiling likely, i.e. during
if clothing will have during procedures procedures likely to generate
substantial contact with likely to generate contamination from blood
the patient, environmental contamination from and body fluids.
surfaces or items in the blood and body fluids.
patient’s room
Mask Wear regular mask during Wear regular mask Wear high efficiency filtration
procedures likely to during procedures mask (FFP3 or N95) on
generate contamination likely to generate entering the room.
with aerosols. contamination with
aerosols.
Equipment Yes Yes Yes
decontamination
Miscellaneous Remove gloves and gown, Provide at least 1 Advise patient to cover nose
wash hands before leaving meter of separation and mouth when coughing or
patient’s room between patients in sneezing
cohort

CHAPTER
Control of Environment for Infection
Prevention
Introduction
This chapter deals with standard practices for cleaning and disinfection of health care facilities, general
principles of Cleaning and sanitation, and frequencylevel of cleaning and disinfection followed in various
areas of health care facilities. Further, this chapter includes blood and body substance spill
management, level of cleaning, and disinfection of commonly used items. It also includes terminal
disinfection by fogging of patient care areas after the patients are discharged. Lastly, this chapter
explains the procedure for cleaning, disinfection, and sterilization of patient care articles based on risk of
infection (like non-critical patient care items, semi-critical items, and critical items). Cleaning and
sanitation protocols of environments like ceilings, walls, floors, and doors are also included here. This
chapter is detailed under the following headings;
1. Cleaning, disinfection, frequency, and level of disinfection to be followed in various areas of the
hospital
2. Blood and body substance spill management
3. Types of disinfection
4. Reprocessing of commonly used equipment in the hospital
5. Procedures for cleaning, disinfection, and sterilization based on infection risk
6. Procedure for cleaning and sanitation of the environment
Keywords-
Cleaning: Removal of visible soil (e.g., organic and inorganic material) from objects and surfaces is
normally accomplished manually or mechanically using water with detergents or enzymatic products.
Disinfection: A process that eliminates many or all pathogenic microorganisms, except bacterial spores,
on inanimate objects.
Sterilization: A process that destroys or eliminates all forms of microbial life and is carried out in health-
care facilities by physical or chemical methods.
Decontamination: Refers to the use of physical or chemical means to remove, inactivate, or destroy all
pathogens on a surface or item to the point where they are no longer capable of transmitting infectious
particles and the surface or item is rendered safe for handling, use, or disposal.
5.1. Cleaning and Sanitation

Dry conditions favor the persistence of gram-positive cocci (e.g., coagulase-negativeStaphylococcus spp.)
in dust and on surfaces. In contrast, moist, soiled environments favor the growth and persistence of
gram-negative bacilli. Fungal spores are present in dust and can proliferate in moist, fibrous material.
Pathogenic organisms that survive in the environment can cause infection in patients admitted to the
5. Control of Environment for Infection Prevention Page 57

hospital. Therefore, it is important to clean the environment thoroughly regularly. This will reduce the
bacterial load, get rid of soil, and make the environment unsuitable for the growth of microorganisms.
Hospitals need to practice and maintain the highest hygiene standardsto create an environment
conducive to speedy patient recovery.
Cleaning-
After an instrument has been used, it should be washed to remove any gross soiling. At this stage,
detergent and water are appropriate agents of cleaning. If available, it is preferable to use multi-
enzymatic cleaning solutions for this purpose.
Organic matter, if not removed properly, may prevent the disinfectant or sterilant from having contact
with the instrument/equipment and may also bind and inactivate the chemical activity of the
disinfectant.
Methods of cleaning-
1. Manual cleaning-
 All surfaces of the instrument/equipment must be cleaned, taking care to reach all channels and
bores of the instrument.
 Remove any gross soiling on the instrument by rinsing it in tepid water (150C–180C).
 Open the instrument apart fully and immerse all parts in warm water with a biodegradable, non-
corrosive, non-abrasive, low foaming, and free rinsing detergent or use an enzymatic cleaner if
necessary.
 Dry the instrument in either a drying cabinet or hand dry with a clean towel.
2. Enzymatic cleaning-
Used for fiberoptic instruments, accessories, and other items that are difficult to clean. These
products are hazardous, and due care should be taken when dealing with them. Follow the
manufacturer’s recommendations for their use.
Disinfection-
Disinfection isthe process of destroying all pathogenic microorganisms. It can refer to the action of
antiseptics as well as disinfectants. Disinfection can be;-
1. Concurrent disinfection
2. Terminal disinfection
3. Pre-current (prophylactic) disinfection
Disinfection is required in the following situations: -
 Before use of contaminated equipment/devices for any patient.

 Before sending contaminated equipment for further processing in the CSSD.
 Before sending used & and contaminated needles and syringes for disposal.

 For the inanimate environment,which is likely to be infected and could be a potential source of
HAI?
 Before any item is subjected to disinfection /sterilization, thorough cleaning is mandatory to
remove organic material that may interfere with these processes.
Methods of disinfection-
1. Thermal disinfection
 This may be used for an instrument that can withstand the process of heat and moisture
and is not required to be sterile.
 The level of disinfection depends on the water temperature and the duration the
instrument is exposed to that temperature.
2. Chemical disinfection
 The performance of chemical disinfectants depends on several factors including
temperature, contact time, concentration, pH, presence of organic or inorganic matter, and
the numbers and resistance of the initial bio-burden on a surface.
 Examples- Glutaraldehyde 2%, hydrogen peroxide, ethyl alcohol and sodium hypochlorite
The most common causes associated with transmission of infection related to devices are:
1. Inadequate manual cleaning.

2. Inadequate rinsing and drying.
3. Inadequate exposure of surfaces to the disinfectant.
4. The use of automated endoscope re-processors.
5.1.1 General principles of cleaning and sanitation-

Regardless of the agent used for cleaning, the following protocol must be followed:
 Health Care Worker (HCW) should be properly trained in the practices of cleaning and
decontamination of surfaces.
 The HCW should wear appropriate Protective gear before the start of work.
 A log of all cleaning procedures must be maintained.
 Housekeeping surfaces can be divided into two groups – those with minimal hand contact (e.g.,
floors and ceilings) and those with frequent hand contact or “high touch surfaces” (e.g.,
doorknobs, bedrails, light switches, wall areas around the toilet in the patient’s room, and the
edges of privacy curtains).
 All spillovers and housekeeping surfaces (floors/ table tops/ counters) visibly soiled should be
thoroughly cleaned with either simple hot water or with a neutral detergent disinfectant.
 Housekeeping surfaces should be cleaned with a detergent/ disinfectant solution three times a
day or more frequently,and when there are suspected spills of blood/body fluids in High-risk
areas ICUs, transplant units, isolation rooms, burns wards, OTs, emergency rooms, and in areas
that have patients with known transmissible infectious diseases.

5.1.2 Cleaning strategy
• Proceed From Cleaner To Dirtier

• low-touch surfaces>high-touch surfaces
1. • pt. zones>pt. toilets
• From High To Low: Top To Bottom

• cleaning bed rails> surfaces> floors
2.
• Methodical, Systematic Manner
• Avoid missing areas
• E.g., Lt. to Rt. or clockwise, multi-bed area: starting at the foot of the bed &
3. moving clockwise.
Figure 5.1: Example of a cleaning strategy from cleaner to dirtier areas& moving in a systematic
manner around the patient care area

Figure 5.2: Direction of cleaning in patient care areas like Ward & OTs.
The following cleaning frequency and disinfection levels should be used for various areas in the hospital
based on the risk classification:
Table 5.1: Cleaning and disinfection frequency and level be followed in various areas of the hospital as
per AIIMS Bhopal Disinfectant Policy; 2015 (A-Z list)
Location Risk Routine cleaning Additional Disinfection level

Classification frequency cleaning required
All ICUs High risk At least thrice a day Yes High
at fixed times
Burn ward Medium risk At least twice a day at As High
fixed times required
Casualty treatment area High risk At least twice a day at Yes High
fixed times
CSSD Medium risk At least twice a day at As High
Echocardiography (No Low risk At least twice a day at As Only cleaning / low
patients with respiratory fixed times required level disinfection
infection)
General public areas Low risk At least twice a day at As Only cleaning / low
fixed times required level disinfection
General ward Medium risk At least twice a day at As High
Hemodialysis unit High risk At times twice a day Yes High
at fixed times

Laboratory Medium risk At least twice a day at As High

Labour room High risk At times twice a day Yes High
at fixed times
Offices Low risk At least twice a day at As Only cleaning low
Operation theatre High risk Start of the day Yes High
Between cases
End of the list
Deep Cleaning
Patient rooms (Patient Low risk At least twice a day at As Low
not on isolation fixed times required
precautions)
Patient rooms (Patient Medium risk At least twice a day at Yes High
on isolation precautions) fixed times
Pharmacy Low risk At least twice a day at As Low
Physiotherapy Low risk At least twice a day at As Low
Procedure rooms High risk At least twice a day at Yes High
fixed times
Radiology Low risk At least twice a day at As Only cleaning / low
Reception area Low risk At least twice a day at As Only cleaning / low
Respiratory therapy High risk At least twice a day at Yes High
room / area fixed times
Soiled linen collection Medium risk At least twice a day at As High
area fixed times required
 All horizontal surfaces and all toilet areas including washbasins and commodes should be
cleaned at least three times in a day, besides when there is visible soiling.
 Administrative and office areas with no patient contact require normal domestic cleaning, (at
least once in a day).
 Fresh detergent/ disinfectant solutions must be prepared every day according to manufacturer’s
instructions’ 24-hour old solutions must be replaced with fresh solutions.
 Diluted disinfectant solutions may become contaminated with resistant pathogens. Therefore,
after the day’s use, remaining solutions must be discarded and containers must be cleaned with
detergent before being dried.
 High-touch surfaces must be cleaned and disinfected more frequently than minimal-touch
surfaces.
 The methods of cleaning floors include vacuum cleaning with filters attached followed by wet
mopping. Use of brooms generate dust aerosols & therefore not allowed in patient care area.

 Horizontal surfaces must be wet mopped with a cloth moistened with a detergent solution
follow by disinfectant solution.
 Contamination of cleaning solutions and mops must be minimized. For wet mopping, a three-
bucket method should be used. Used cleaning solutions must be discarded in the sluice. The
buckets should be cleaned with detergent and kept inverted to assist drying.
 Mop heads must be discarded after cleaning blood/body fluid spills.
 Mop heads and cleaning cloths must be decontaminated regularly with 0.5% hypochlorite
solution.
 Walls, blinds and window curtains must be cleaned when visibly soiled or contaminated.
 Disinfectant fogging is not recommended for routine patient care areas.
 Bacteriological testing of the environment is not recommended as a routine unless seeking a
potential source of an outbreak.
Figure 5.3: High Touched surfaces (source- CDC)
5.2 Blood and body substance spill management-
Introduction:
Spillage of blood and body fluids in the workplace constitutes a bio-safety hazard for healthcare workers
and patients present in the affected area because of the potential risk of transmission of pathogens
from the spilled material. Proper containment of the spill by trained persons can significantly mitigate
such risk.
Spill Kit
It is logistically convenient to assemble all the items required for the execution of this protocol in a self-
contained kit so that they can be made available at the site of requirement with minimal waste of time.
The location of the spill kit must be well-known to every healthcare worker in the area.

The contents of the spill kit are as follows:
1. Autoclavable Bio-hazard Bags (of different sizes)(should be Red; as per Bio-Medical Waste
Guidelines 2016)
2. 5 % Sodium Hypochlorite
3. PPE: 2 sets (Each set having an apron, 2 pairs of Gloves, Mask, Goggles, and Boots)
4. Tissue Roll
5. Towels & Cotton Roll
6. Forceps (Big)
7. Plastic Broom
8. Dustpan
9. Mop
10. Chalk
11. Rubber Bands
12. Plastic Broom
13. Water-proof copy of SOP
14. Spill alert signage
Procedure
1. Alert co-workers in the immediate area of the spill. Depending on the nature of the risk,
everybody should be asked to leave the area till the spill is contained.
2. Contaminated clothing like PPE, if any, should be immediately discarded.
3. The Spill Kit is brought to the area.
4. The “Spill Alert” signage should be put up to prevent access to the area.
5. Persons executing this protocol should put on PPE. Two persons are required to clean up the
spill.
6. Splashes of body fluids on walls and surfaces can be cleaned by using a high-level disinfectant.
7. The spill area is established and demarcated with chalk. A roll of tissue paper may also be torn
and placed outside the chalk marking.
8. Broken pieces of sharp items, if present in the spill area, are carefully removed with a pair of
forceps.
9. For decontamination of small spills (<10 ml), if sodium hypochlorite solution is selected, use a
1:100 dilution (0.05% of 5% Sodium hypochlorite) (525–615 ppm of available chlorine).
10. If spills involve larger amounts of blood or involve a spill of microbiology cultures in the
laboratory, a 1:10 dilution of 5 % sodium hypochlorite (0.5% of 5% Sodium hypochlorite)
solution for the first application (before cleaning) reduces the risk of infection during cleaning.
I. The disinfectant is allowed to act for at least 10 minutes.
II. The spill area is wiped outside inwards, starting at the edges and working towards the center,
with the help of a plastic broom. The plastic broom is put inside a Biohazard bag.

III. The towel, along with the absorbed spillage, is picked up with a dustpan and put inside the
Biohazard bag. The dustpan and the outer pair of gloves are also put in the Biohazard bag, which
is then tied with a rubber band.
IV. The spill area is again mopped with freshly prepared Sodium hypochlorite solution as described
under point no.9. The mop is put in a Biohazard bag, which is then tied with a rubber band.
V. The PPE (with an inner pair of gloves) is removed and put in a Biohazard bag, which is then tied
with a rubber band.
VI. Use PPE (gloves, face masks, and fluid-resistant gowns) for cleaning blood spills. Wear protective
shoe covers/ boots when cleaning large spills.
Reporting and follow-up:
The details of the incident should be entered into a controlled document and reported to a designated
authority. The following needs to be recorded:
i. Date;
ii. Time;
iii. Persons involved;
iv. Nature of spillage;
v. Injury, if any
vi. Actions taken.
The persons exposed in the incident should be followed up for potential transmission of any pathogen,
depending on the nature of the spillage
Steps of Blood and body substance spill management are:-
Inform co-workers about spill & isolate the area.
Contaminated clothing should be discarded in the area of

spill.
Spill kit to be brought to the area of spillage & wore PPE.
Broken pieces of sharps to be picked with forceps & discarded

in to puncture proof Blue container.
use freshly prepared (5000PPM) Hypochlorite solution over

spill allow acting for 10 minutes.
Housekeeping staff discards the waste in BMW bins liners&

tie proeprly.
Incident reporting

5.3 Cleaning agents and disinfectants for environmental useand types of disinfectants
A neutral detergent and warm water solution should be used for all routine and general cleaning. When
a disinfectant is required for surface cleaning, e.g., after spillage or contamination with blood or body
fluids, or in special areas such as the surgical unit, dialysis unit, and ICU, the manufacturer’s
recommendations for use and occupational health and safety instructions should be followed. Below
lists the disinfectants used for the environment, their recommended use, and precautions.
Based on efficacy i.e. killing power of pathogens, the disinfectants are divided into three categories.
I. High-level disinfectants:2% Glutaraldehyde, stabilized hydrogen peroxide and 1%

sodium hypochlorite solution (10,000 ppm of Chlorine) will destroy all
microorganisms, including vegetative bacteria, most bacterial spores, fungi,
viruses including entero-viruses, and Mycobacterium tuberculosis, except some
bacterial spores.
II. Intermediate-level disinfectants: 0.1% sodium hypochlorite solution (1,000 ppm of
Chlorine), ethyl or isopropyl alcohol (70%), iodophors, and phenol solution will destroy
vegetative bacteria, Mycobacterium tuberculosis, most viruses, and fungi but not
bacterial spores.
III. Low-level disinfectants: Quaternary ammonium compounds, e.g., Benzalkonium
chloride, destroy most vegetative bacteria, fungi, and enveloped viruses e.g., HIV, but
they will not kill bacterial spores, mycobacterium, and non-enveloped virus like
enteroviruses.
Classification of patient care items
The risk of transferring infection from patient care items is dependent on the following factors:
 The presence of microorganisms, the number, and virulence of these organisms.

 The type of procedure that will be performed (invasive or non-invasive).
 The body site where the instrument/and or equipment will be used (penetrating the mucosal or
skin tissue or used on intact skin).
Spaulding’s classification:
The risk of infection to the patients determines the method of choice for disinfection/sterilization:
1. Critical medical and surgical devices/instruments (e.g., devices and surgical instruments) that
enter sterile tissue or the vascular system or through which a sterile body fluid flows are to be
sterilized before being used on any patient.
2. Semi-critical patient care equipment that comes in contact with mucous membrane (e.g.,
gastroenterological endoscopes, anesthesia breathing circuits and respiratory therapy
equipment) or non-intact skin, requires a high-level disinfection.

3. Non-critical patient care surfaces (e.g., bedrails, over bed table etc.) and equipment that touch
intact skin (e.g., blood pressure cuffs), require intermediate or low-level disinfection.
5.4 Terminal disinfection of an area:

A terminal clean is defined as a procedure required to ensure that an area has been
cleaned/decontaminated following discharge of a patient with an infection or communicable disease to
ensure a safe environment for the next patient.
Terminal cleaning should be carried out after a patient with an alert organism or communicable disease
has been discharged (or transferred), to ensure a safe environment for the next patient. Bed screens,
curtains and bedding should be removed before the room/area is decontaminated. When the
environment is potentially contaminated, disinfectants such as sodium hypochlorite must be used. The
decontaminated surface must be free from organic soil for disinfectants to work effectively. A neutral
detergent solution should be used to clean the environment before disinfection, or a combined
detergent /disinfectant may be used.
5.4.1 Procedures for terminal cleaning-

 Every item in the room must be cleaned with an appropriate hospital germicidal solution.
 Linen should be stripped from the bed gently to avoid shaking. Linen should be folded away
from the person and folded inward into a bundle, then removed with minimal agitation.
 When applicable, all reusable receptacles, such as drainage bottles, urinals, bedpans, etc. should
be emptied and rinsed with 1% sodium hypochlorite solution.
 All equipment that is not to be discarded, such as IV, stand ventilators, and suction machines,
should be cleaned thoroughly with 1% sodium hypochlorite solution.
 When applicable, mattresses and pillows covered with durable plastic covers should be washed
/cleaned with 1% sodium hypochlorite solution.
 Beds and furniture should be 1% sodium hypochlorite solution.
 Wastebaskets should be thoroughly washed with soap water and disinfected with 1% sodium
hypochlorite solution after removing trash.
 Walls and ceilings need not be washed entirely, but areas that are obviously soiled should be
washed (&and disinfected) with 1% sodium hypochlorite solution.

Table 5.2- Dilution chart for liquid sodium hypochlorite (if Minimum 5% & 10% concentration
available in original solution)
Original Dilution Dilution in water for preparing 1 lt solution Chlorine in ppm

Concentration (Prepared v/v)
Minimum 5% None None 50,000 ppm
1:5(20%) 200ml 5%sodium hypochlorite +800ml water = 10,000 ppm
1% sodium hypochlorite
1:10(10%) 100ml 5 sodium hypochlorite+900ml water = 5000 ppm
0.5% sodium hypochlorite
1:100(1%) 10ml 5%sodium hypochlorite+990ml water= 500 ppm
1:200(0.5%) 5ml 5%sodium hypochlorite +995ml water = 250 ppm
Minimum 10% None None 1,00,000 ppm
1:10(10%) 100ml 10%sodium hypochlorite +900ml water = 10,000 ppm
1% sodium hypochlorite
1:20(5%) 50ml 10% sodium hypochlorite +950ml water = 5000 ppm
1:200(0.5%) 5 ml 10%sodium hypochlorite+995ml water = 500 ppm
1:400(0.25%) 2.5 ml 10%sodium hypochlorite+997.5 ml 250 ppm
water=0.025% sodium hypochlorite
5.4.2 Fogging
Fogging is being done by fogger by this fogger machine; the solution is sprayed in the area as an aerosol.
The small particles of disinfectant solution are suspended in the air for a long time, killing all the
airborne bacteria, fungi, and spores. This is also a very effective method to control microbial
contamination in controlled areas.
Methodology
A combination of Hydrogen peroxide (11% W/V) with silver nitrate (0.01% W/V) is a non-toxic
environment friendly disinfectant for critical area fogging and surface disinfectant.
Eco shield®/Baccishield® are a non-toxic, environment friendly disinfectant for criticalarea fogging and
surface disinfection. It is a complex formulation of stabilizedHydrogen Peroxide (11% w/v) and Silver
Nitrate solution (0.01% w/v), (Silvernitrate's role is to stabilize the H 2O2)
Indication
 Commissioning of new critical areas such as OTs and ICUs.

 After annual maintenance in the above-mentioned areas.
 Fogging of OTs may be done based on microbiology surveillance reports and/or clinical
procedures in the operating areas. Routine fogging are not recommended.

 Any civil or engineering work should invite fogging of OTs.

 Airborne diseases like Tuberculosis, Influenza, Ebola, etc. (After the patient’s discharge/death in
the facility)
 Any known fungal infection in the facility (e.g., Aspergillus) When routine environmental
surveillance reveals C.tetani or any pathogenic spore former.
Instructions to be followed
 Use Personal Protective Equipment.

 Use a cap, face mask, and gloves for protection.
 Surface cleaning/Terminal disinfection.
 Visibly contaminated areas are to be cleaned with a damp duster, water, or soap; then, an Eco
shield-soaked duster is used to clean the surface areas.
 For disinfection, make 10% solution with Eco shield/Baccishield.
 Example: For making 10% solution (v/v 01:09 ratio) i.e., 10 ml Eco shield + 90 ml water.
 Pour reconstituted 10% solution into a container.
 Take a clean duster dip it into the 10% solution, and squeeze.
 Use this wet duster to clean all surfaces and underneath metallic surfaces of equipment, OT
tables, ICU beds, side lockers, lights, instrument tables, mattresses, walls, etc.
 When the duster is relatively dry, dip it again in 10% solution and squeeze to continue the
above-mentioned procedure until all the surfaces are mopped clean.
Calculation of t he disinfectant to be used for fogging
To undertake Terminal Disinfection before fogging

Calculate the area to be fogged in cubic feet i.e., Length x Breadth x Height
Example:
A room has Length (L)= 10 ft, width (W)=10 ft & Height (H)=10 ft
Then volume of room in cu. Ft is = L X W X H=1000 cu. ft.
Then volume of room in cu. Ft is = 10 X 10 X 10=1000 cu. ft.
Make a 20% solution with Eco shield /Baccishield in distilled water for fogging.
Table 5.3: Requirement&Dilution of fogging solution (Hydrogen peroxide 11% stabilized with silver
nitrate 0.01%) according to the volume of patient care areas in cubic feet
Dilution
Space in cubic feet Fogging solution (Hydrogen peroxide 11% A timer of the fogger
LXWXH stabilized with silver nitrate 0.01% ) + tobe set at
Water
1000 cu ft 200 ml + 800 ml=1 L 1L
2000 cu ft 400 ml + 1600 ml= 2 L 2L
2500 cu ft 500 ml + 2000 ml=2.5 L 2.5 L

 As per the room size and example above, make Eco shield solution and pour it into the fogger
tank.
 Before starting the fogging, cover electronic equipment with sterile drapes.
 Take the fogger and place it at least 2 feet above the floor surface, in one corner of the room. Its
nozzle head should be kept at an angle of 45 degree facing the corner diagonal to it. If two
foggers are used, place them in opposite directions as shown below.
Fogger Fogger
Image 5.4: Placement of foggers in room
In case of window AC/ split AC:
 Switch on air conditioning for 10 minutes once fogging starts in case of window or split
AC.
 Set the timer as per the volume of solution in the tank and switch on the fogger.
 Switch off the air conditioning after 10 minutes of fogging in case of window or split AC.
 After completion of fogging i.e., when fogger gets switched off, allow 45 minutes for the
mist to settle down.
 In case you find any wet area, wipe it off with a clean duster.
In case of central air conditioning:
 Close the AC vent once fogging starts.

 Set the timer as per the volume of solution in the tank and switch on the fogger.
 After completion of fogging i.e., when fogger gets switched off, allow 45 minutes for the mist to
settle down.
 In case you find any wet area, wipe it off with clean duster.
 Now fogged area can be opened for use after switching on the air conditioning.
Microbiological Surveillance after Fogging
 Recommended only in case of fogging done after new construction/ renovation/ repair work or
after procedures done on septic cases.

 Not indicated in case of fogging being done as a part of terminal cleaning. In such case the
area/room can be used immediately after fogging.
 Surveillance cultures in the form of air sampling by open plate cultures (settle plates) and swabs
for isolation of aerobic and anaerobic bacteria should be taken by infection control nurse.
 Information regarding the same should be provided to infection control team prior to fogging.
 The area/room where fogging was performed should not be used until the microbiological
surveillance cultures are reported as negative.
Action Plan in Case of Positive Microbiological Surveillance Report
 In case of a positive microbiological sampling report, the area/ site should be cleaned and
scrubbed thoroughly with soap/ detergent and water, followed by cleaning with disinfectant
(phenolic agents/ hypochlorite). This should be followed by repeat fogging wherever necessary
and repeat microbiological testing.
 OT/ room/ area can be used only after microbiological surveillance cultures are reported as
negative.
There is “No substitute” for vigorous scrubbing, washing of surfaces, and removing the organic matter.
5.5 Procedures for cleaning and sanitation of the environment

Procedures for cleaning and sanitation of various areas/ items in the hospital
Table no 5.4: List of Cleaning and sanitation of environment (A-Z list)

Area/Items Process Item/ Method/ procedure
equipment
Air-vents and Vacuum cleaner Cleaning • Vents are vacuumed to remove any dust and wiped out
filters Duster with a cloth and detergent.
Detergent Solution • Some vents require removal to wash the back and
entrance of the ducting.
• Metal vents and filters are washed
under running water and dried with
a lint-free cloth to remove stubborn soil age. It should be
done in collaboration with the engineering department.
All clinical areas/ Hypochlorite 1:100 Blood and • Wear non-sterile gloves.
Laboratories (1%) body fluid • Cover the spill with hypochlorite
Rag piece spill (1:100).
Absorbent paper care • For large spills, cover with rag piece/
Unsterile gloves Absorbent papers for 10–20 minutes contact time.
Spill care kit • Clean up spill and discard into infectious waste bin, and
Mop mop area. With soap and hot water.
Hot water • Clean the mop and mop area with
1% hypochlorite.
• Wash mop with detergent and hot
Water and allow it to dry.
Bathroom Warm water Cleaning • Thoroughly scrub the basin/ tiles with
showers Detergent powder warm water and detergent inside and

Nylon Scrubber Outside.

Hypochlorite 1:100 • Special attention to soap runs under the basin.
dilution • Tap fittings to be washed and dried.
Note: Do not use powder cleanser dry as it can scratch the
chrome on the taps. If required, disinfection to be done.
Bedpans, urinals Detergent water Cleaning and • After washing with soap and water immerse in 1:500
kidney Brush scrubber disinfection i.e.>100 ppm of 5%hypochlorite for 20 minutes.
trays(plastic), Hypochlorite (1:50) • Keep it for air-dry in a stand so that water will drain
sputum mugs, downward.
urine measuring
jugs
Bed tables, Warm water and Cleaning • Wipe down over the bed, table. Wipe top and underneath
bedside lockers detergent base and stand, using warm water and detergent. Dry on
Wiper completion.
Duster • Wipe down the bedside. Remove marks from fronts of
draws and sides. Wash the top using warm water and
detergent to remove any sticky marks and dust.
Book case, Damp duster Damp • Damp dust with warm water anddetergent.
files, lockers, Warm water dusting
tables, cupboard, Detergent
wardrobes, Dry duster
benches, shelves
and cots
Ceiling and walls Sweeping tool Damp • Damp dusting with a long handled
Duster dusting tool for the walls and for ceiling damp dusting done with
Bowl/ small bucket very little moisture, just enough to collect the dust.
of soap solution • Damp dusting should be done in straight lines that overlap
Plain water one another.
• Change the mop head/ cover when soiled.
Chairs (Vinyl) Warm water and Cleaning • Wipe down with warm water and detergent. Remove any
Detergent marks under the arms and seat. Check for damage to
stoppers, if the stopper requires replacement, report to the
maintenance department.
Cots, railings and Detergent/ Daily dusting • Damp dust with warm water anddetergent followed by
lockers Sanitizer–hot water disinfectionwith hypochlorite or as per disinfection
Three small policy.
buckets/ or big
bowls
One with plain
water
One with solution
One for
hypochlorite 1:100
dilution
Curtains, blinds Vacuum cleaner Cleaning • Curtains blinds should be vacuumed,
and drapes Soft clothes then wiped down with moist, soft cloth.
Water • Always start at the top and work
Mild soap solution down
• Solution for cleaning blinds should not contain strong
detergents. Cloth should not be wet or these conditions
could stain the blind.

• Always use fresh cleaning solution and replace if it

becomes soiled.
• Rinse cleaning cloth regularly.
Desks Damp cloth Dusting • Wipe top sides and draw handles with a damp cloth.
Furniture polish Wooden desks should be cleaned with furniture polish and
buffed to clear glows. Pen holder etc. to be cleaned or
dusted.
Fabric chairs Vacuum cleaner Cleaning Vacuum the cloth area of the chair and wipe down
Warm water and remainder of the chair with warm water and detergent.
detergent Remove stains from fabric with stain remover.
Stain remover
Floors Scrubbers Thorough • Scrub floors with the hot water anddetergent with using
Hot water washing minimal water.(Do not pour the water.)
Detergent • Clean with plain water
Mop • Mop area, and allow to dry
• Hypochlorite 1:100 mopping can be done.
Floors (clinical Mopping with Cleaning • Prepare cleaning solution using cleaning agent with warm
areas) – daily Three buckets Daily water (detergent/ sanitizer).
mopping (one with plain mopping • Use the three-bucket technique for mopping the floor, one
water and one with bucket with plain water and one with the detergent
solution; solution.
one bucket for • First, mop the area with warm water and detergent
hypochlorite (1:50 solution.
dilution) • After mopping clean the mop in plain water and squeeze .
• Repeat this procedure for the remaining area.
• Mop area again using hypochlorite1:50 dilution after
drying the area.
• In between mopping if the solution orWater is dirty
changing it frequently.
• Mop the floor starting at the farCorner of the room and
work towards the door.
• Clean articles between cleaning.
Note: Mopping should be done thrice aday, in each shift
Furniture and Warm water and Dusting With a damp cloth, using warm water and detergent, clean
fittings detergent furniture and fittings, including chairs, sofas, stools, beds,
Rag piece tables, cupboards, wardrobes, lockers, trolleys, benches,
shelves and storage racks, waste/ bins, fire extinguishers,
oxygen cylinders, televisions, window sills and dry properly.
General clinical Dust mops Sweeping Sweep with the dust mop or damp mop to remove surface
areas Mop dust. Sweep under the furniture and remove dust from
(No broom will be corners.
used for sweeping) Gathered dust must be removed using a hearth brush and
shovel.
The sweep tool should be cleaned or replaced after use.
Isolation room Detergent/ Terminal • Before cleaning an isolation room,liaise with the infection
Sanitizer–warm cleaning control team fordetails of any special requirements.
water Staff will be instructed on specificcleaning procedures
Three buckets required withreference to --
(one with plain – Safety uniform to be worn.
water and one – Chemicals or disinfectants to beused.
with solution); – Also, if the bed screen and showerscreen are to be cleaned

separate bucket for orchanged, refer to cleaning inisolation rooms.

hypochlorite (1:50
dilution)
Light switches Damp cloth (never Cleaning • Light switches to be cleaned of dust, spots and finger
and wet) marks. Clean with a damp cloth (never wet) and detergent.
over-bed lights Detergent • Over-bed lighting to be damp dusted.
Warm water Light housing to be wiped down with warm water and
detergent.
Mirrors and Warm water Cleaning • Using warm water and a small
Glass Detergent water/ quantity of detergent and using a
cleaning solution damp cloth, wipe over the mirror and
Damp cloth surround, then using a dry lint-free
Wiper cloth, buff the mirror and glass to a clean dry finish.
Mop Care of mop Hot water • Clean with hot water and deterrent
Detergent Solution, disinfect it with hypochlorite and keep for drying
Hypochlorite upside down.
1:1000
Pantry Furniture Duster Dusting • Damp cloth using warm water and detergent.
Screens and Damp Dusting • Screen rails should be damp-dusted using warm water and
Screen rails detergent.
This includes rail supports.
• Screens to be replaced on a set rotation basis or as soon as
they are visibly soiled.
Taps and fittings Warm water Cleaning • Wipe over taps and fittings with a damp cloth and
Detergent powder detergent.
Nylon scrubber • If heavily soiled, sprinkle a little powder cleanser onto a
wet cloth, fold cloth over and rub into a paste and polish.
Note: Do not use powder cleanser dry as it can scratch the
chrome on the taps.
• Care should be taken to clean the underside of taps and
fittings.
• Taps should be dried after cleaning
Telephone Warm water General • Damp dust with warm water and detergent.
detergent solution cleaning • Paying special attention to the ear and mouth piece and
Duster dry it properly.
Walls and doors, Damp cloth or Thorough • The walls and doors are to bewashed with a brush, using
door knobs Sponge squeeze washing detergent and water once a week (usually on Sundays);
mop gently applycloth to soiled area, taking care
Detergent not to remove paint, then wipe the wallwith warm water to
remove excess cleaning agent.
• Door knobs and other frequentlytouched surfaces should
be cleaned daily.
The formula for preparing disinfectant solutions:
For the preparation of disinfectant solution, the following formula may be used as guide:
𝐷
A= 𝐻 × 𝑄

A = Amount of disinfectant
D = Desired strength
H = Strength in hand
Q = Quantity
For example: - For preparation of one liter of 1% hypochlorite solution from 10% hypochlorite solution:
• D =1%
• H =10%
• Q =1000 ml
Water required (1000 -100) = 900 ml
900 water + 100 ml one liter Sodium Hypochlorite solution makes 1% Sodium Hypochlorite solution
General guidelines:
1. Disinfectant solutions should be re-constituted and changed according to in-use life span – As
per manufacturer's recommendations.
2. Label the container with the name of the solution/date/time of preparation/date of expiry.
3. Always use PPE while handling the chemicals (gloves, mask, apron).
5.6 Bio Medical Waste Management

Appropriate management and disposal of hospital waste is one of the important ways of reducing
hospital acquired infection. The bio medical waste management policy followed at AIIMS Bhopal
complies with the latest Bio medical management rules, framed by the ministry of Environment and
Climate Change, Government of India.
The biomedical waste, as defined by the BMW Rules, 2016, is any waste that is generated during the
activities of diagnosis, treatment and immunization of human beings or animals or any research
activities pertaining thereto or in the production or testing of biological or health camps.
The biomedical waste disposal at AIIMS Bhopal has been outsourced to a common biomedical waste
management facility, duly authorized by the Madhya Pradesh Pollution Control Board and has been
selected through an institutional tendering process. Bio-medical Waste Management rules apply to all
persons who generate, collect, receive, store, transport, treat, dispose, or handle bio-medical waste in
any form.
5.6.1 Categorization of biomedical waste:

Biomedical Waste Management Rules 2016, four color-coded categories, including their disposal
methods, have been defined.

TABLE 5.5: Biomedical waste categories and their segregation, collection, treatment,
processing, and disposal options.
Type of bag or
Treatment and
Category Type of waste container to be
disposable options
used
1 2 3 4
(a) Human Anatomical Waste: Human tissues,
organs, body parts and fetus below the viability
period (as per the Medical Termination of
Pregnancy Act 1971, amended from time to Incineration through
Yellow colored
time). Common Biomedical
non-chlorinated
Waste Treatment
b)Animal Anatomical Waste : Experimental plastic bags
Facility Operator
animal carcasses, body parts, organs, tissues,
including the waste generated from animals used
in experiments or testing in veterinary hospitals
or colleges or animal houses.
YELLOW
c) Soiled Waste: Items contaminated with blood,
Yellow colored Incineration through
body fluids like dressings, plaster casts, cotton
non-chlorinated Common Biomedical
swabs and bags containing residual or discarded
plastic bags or Waste Treatment
blood and blood components.
containers Facility Operator
Expired cytotoxic drugs

(d) Expired or Discarded Medicines: and items
Pharmaceutical waste like antibiotics, cytotoxic Yellow colored contaminated with
drugs including all items contaminated with non-chlorinated cytotoxic drugs to be
cytotoxic drugs along with glass or plastic plastic bags or handed over to
ampoules, vials etc. containers common bio-medical
waste treatment facility
for incineration
Yellow colored Incineration through

(e) Chemical Waste: Chemicals used in
containers or Common Biomedical
production of biological and used or discarded
non-chlorinated Waste Treatment
disinfectants
plastic bags Facility Operator
(f) Chemical Liquid Waste: Liquid waste

generated due to use of chemicals in production Separate After resource
YELLOW
of biological and used or discarded disinfectants, collection recovery, the chemical
Silver X-ray film developing liquid, discarded system leading liquid waste shall be
Formalin, infected secretions, aspirated body to effluent pre-treated before
fluids, liquid from laboratories and floor treatment mixing with other
washings, cleaning, house-keeping and system wastewater.
disinfecting activities etc.

Incineration through
Non-chlorinated
(g) Discarded linen, mattresses, beddings Common Biomedical
yellow plastic
contaminated with blood or body fluid. Waste Treatment
bags
Facility Operator
(h) Microbiology, Biotechnology and other
Disinfection at site
clinical laboratory waste: Blood bags, Laboratory
Autoclave safe followed by
cultures, stocks or specimens of microorganisms,
Non-chlorinated Incineration through
live or attenuated vaccines, human and animal
plastic bags or Common Biomedical
cell cultures used in research, industrial
containers Waste Treatment
laboratories, production of biological, residual
Facility Operator
toxins, dishes and devices used for cultures.
Contaminated Waste (Recyclable) (a) Wastes
Microwaving followed
generated from disposable items such as tubing, Red colored
by handing over to
bottles, intravenous tubes and sets, catheters, non-chlorinated
RED Common Biomedical
urine bags, syringes (without needles and fixed plastic bags or
Waste Treatment
needle syringes), and vacutainers with their containers
Facility Operator
needles cut) and gloves.
Waste sharps including Metals: Needles, syringes Disinfection at site
with fixed needles, needles from needle tip Puncture proof, followed by handing
cutters or burner, scalpels, blades, or any other Leak proof, over to Common
WHITE
contaminated sharp object that may cause tamper proof Biomedical Waste
(TRANSLUC
puncture and cuts. This includes both used, containers Treatment Facility
ENT)
discarded and contaminated metal sharps Operator
(a) Glassware: Broken or discarded and

Puncture proof,
contaminated glass, including medicine vials and Handing over to
Leak proof;
ampoules, except those contaminated with Common Biomedical
BLUE tamper proof
cytotoxic wastes. Waste Treatment
containers with
Facility Operator
blue marking.
(b) Metallic Body Implants
5.6.2 The process flow of biomedical waste management in AIIMS Bhopal
Generation
Bio-medical Waste is generated from different areas in the hospital, medical college, animal house, etc.
Most part of biomedical waste is, however, produced in the laboratories, OTs and inpatient areas during
dressings and other procedures. On an average approximately 1000 Kg of biomedical waste is generated
monthly. Designated nursing staff maintains a daily checklist to ensure proper segregation of biomedical
waste in all the hospital's generation points.
Segregation
This step is vital to a good biomedical waste management system. It may be defined as separating
various categories of bio-medical waste, at the point of generation, into color-coded bins lined with
plastic bags of appropriate cooler as recommended in the guidelines. Posters are displayed at the point
of waste generation to guide the proper segregation of the generated biomedical waste in appropriate
color coded bins.

Figure 5.5 Biomedical Waste Segregation Bins in ward
Figure 5.6 Posters of BMW displayed at site of segregation

Collection
The biomedical waste generated in different areas is collected by trained personnel employed by an
outsourced agency selected by the institute. The waste is collected on a daily basis (once/twice daily)
depending on the pre-planned collection schedule from various collection points. No waste is allowed to
be kept in the institute premises for more than 24 hours. The waste is collected in the color coded bags,
loaded on to the dedicated and covered trolleys and transported to the temporary storage area.
Figure 5.7 BMW Collection Trolley& collection of waste from patient care areas by waste handlers.
Temporary storage
The biomedical wastes collected from different areas are brought in to a common point where they are
stored temporarily till it is handed over to the authorized common biomedical waste treatment facility
selected by the institute. The temporary storage area in the hospital is located behind the Medical
College building near animal house.

Figure 5.8 BMW Collection Trolley& collection of waste from patient care areas by waste handlers,
pre-treatment of waste by Microwave Machines Bio-Hazardous Waste Bags with Bar code & Racks.
Final disposal
The biomedical waste collected is finally disposed of in covered vehicles of the designated common
biomedical waste treatment facility operator selected by the institute. Before handing over, barcode
labels are generated by logging in to the website of the common biomedical waste treatment facility
operator. These barcode labels are stuck on the bags and weight of the bags is taken. The barcode label
is scanned by logging into the mobile app designed by the common biomedical waste treatment facility
operator. The record of the number of bags generated and the weight of the individual bags is
maintained in the proper registers and finally the bags are transported in the covered vehicle of the
common biomedical waste treatment facility operator.
Figure 5.9: Bio-Medical Waste Transportation Trolley of CBWTF
Instructions for Biomedical waste handlers

 All HCWs involved in the handling of biomedical waste are immunized against Hepatitis B and
Tetanus.
 Occupational safety of all handlers of bio-medical waste is ensured by providing appropriate and
adequate PPE.
 Health check-up of all HCWs involved in handling biomedical waste is conducted at the time of
induction and at least once a year.
Maintenance of records
 A register is maintained for daily recording of the category-wise quantity of biomedical waste
generated and handed over from the institute.
 Records related to the generation, collection, reception, storage, transportation, treatment,
disposal, or any other form of handling of biomedical waste must be maintained for a period of
5 years.
 All records must be available for inspection and verification by the prescribed authority or the
Ministry of Environment, Forest and Climate Change at any time.
 The annual report of Bio-medical waste is uploaded to the institute website in the prescribed
format.

Reporting of accidents
Any major accident at any institution or facility or any other site while handling biomedical waste must
be intimated immediately to the prescribed authority and a report forwarded within 24 hours in writing
regarding the remedial steps taken in Form I of the Biomedical Waste Management Rules 2016.
The annual report shall provide information on all other accidents and remedial steps.

CHAPTER
IPC in Special Units or Situations
6.1 IPC in surgical units OTs:
6.1.1 Aseptic protocols

 Personnel Hand/ forearmantisepsis for surgical team members is crucial.
 Nails should be kept short, and all jewelry, artificial nails, or nail polish should be removed
before surgical hand preparation.
 Hands should be washed, and debris should be removed from underneath finger nails using a
nail cleaner (no brushes), preferably under running water. Sinks should be designed to reduce
the risk of splashes.
 Surgical hand antisepsis should be performed using either a suitable antimicrobial soap or ABHR
before donning sterile gloves.
 A preoperative surgical hand scrub should be done for at least 5 minutes using an appropriate
antiseptic scrub. Hands and forearms should be cleaned up to the elbows.
 After performing the surgical hand scrub, hands should be kept up and away from the body
(elbows in flexed position) so that water runs from the tips of the fingers toward the elbows and
not vice versa (Hands and elbow should be kept above the waist).
 If running water is unavailable, clean stored water can be used. Water should be stored in a
bucket with a tap on one side to dispense water. If such a bucket is unavailable, clean water can
be poured on the hands with the help of a container with a long handle. Another person should
pour the water.
 If the OT does not assure water quality, surgical hand antisepsis using ABHR is recommended. A
sufficient amount of ABHR should be applied to dry hands and forearms for the length of time
recommended by the manufacturer, typically 1.5 minutes, and hands and forearms should be
allowed to dry before donning sterile gloves.
6.1.2 Scrubs
Microorganisms are constantly shed from the hair and skin of persons and also from their clothes.
Microorganisms are also expelled through respiratory secretions while breathing, talking, coughing, and
laughing.
“Scrubs” refers to the sanitary clothing worn by the OT staff, usually comprising a short-sleeve, V-neck
shirt and loose-fitting, drawstring pants. The design of scrubs minimizes places where contaminants can
hide, and they are easy to launder. They should be changed after likely contamination and should always
be cleaned in a healthcare laundering facility.
6.1.3 Surgical attire

The surgical attire includes gloves, gowns, caps, masks, eye protection, waterproof aprons, and
footwear. It protects the patient from the risk of infection from the surgical team's hair, skin, clothes,
6. IPC in Special Units or Situations Page 80

and respiratory secretions. The surgical attire also protects the surgical team from the risk of exposure
to the patient’s blood and tissues during the operation.
Function of the various items of surgical attire
Gloves: Protect the patient from organisms on the surgeon’s hand and also protect the surgeon from
contact with the blood and tissues of the patient.
Gown and waterproof apron: Protects the patient from organisms on the surgical team's body surface
and clothes and protects the surgeon's clothes and body surface of the surgeon from the blood and
tissues of the patient.
Mask: Protects the patient against microorganisms expelled during breathing, talking, laughing, and
coughing. It also protects the surgeon (the mouth and nose) from splashes of blood and secretions.
Eye protection, or visors, protect the eyes of the surgeon from splashes of blood andsecretions.
Cap: Protects the patient from organisms shed from the hair and skin of the surgeon; should cover all
the hair.
Footwear: These should be made of sturdy, washable material with closed toes to protect the feet from
splashes and injury due to falling instruments.
(Refer to Chapter 4 for surgical scrub)
6.1.4 Wearing the gown

The sterile gown is worn after the surgical scrub. The gown should ideally be made of waterproof
material. If a water proof gown is unavailable, a waterproof apron must be worn under the gown.
 An assistant opens the sterile pack containing the sterile gown (the sterile gown is folded inside
out.
 Lift the folded gown from the pack; stepping away from the table, locate the neck band and grasp
the front of the gown below the neck band.
 Allow the gown to unfold, keeping the inside of the gown towards the body.
Note: Do not touch the outside of the gown with bare hands. The outside of the gown is the sterile
surface.
 With hands at shoulder level, slip both arms into arm holes simultaneously.
 The assistant brings the gown over the shoulders by touching the inside of the gown at the arm
seams.

Figure 6.1: Wearing the gown
Step 1: Dry Hands and pick up the gown.

Step 2: Let the gown unfold.
Step 3: Open the gown to locate sleeve/ Arm holes and slip arms into sleeves.
Step 4: Hold your arm out and slightly up.
Step 5: The assistant pulls the gown on.
Step 6: Assistant ties the gown.

Figure 6.2: Removing the gown
6.1.5 Gloving
After wearing the sterile gown, the sterile gloves are worn. Sterile surgical gloves should be worn in the
following way.
1. The assistant opens the outer package of gloves without touching the inner wrapper.
2. Open the inner glove wrapper exposing the cuffed gloves with palm up.
3. Pickup one glove by the cuff touching only the inner portion of the cuff.
4. While holding the cuff in second hand with the fingers pointing downwards, slip the other hand
into the glove. Pickup these glove by sliding the fingers of the gloved hand under the cuff of the
second glove.
5. Do not contaminate the gloved hand with the ungloved hand as the second glove is being put
on. Keep hands at waist level in front of the body with fingers clasped.

Figure 6.3: Donning of sterile gloves

Figure 6.4: Removing sterile gloves

Important: After the surgical procedure the first thing to do is to remove the gloves. Do not allow the
outside of the used glove to touch your skin.
 The gloves should be removed before touching anything.

 Rinse gloved hands in a disinfectant solution to remove blood and body fluids.
 Partly pull off one of the gloves by grasping it near the cuff.
 Keeping the first glove partly on, remove the second glove partly to avoid touching the outer
surface of either glove.
 Both gloves are now turned partially inside out and can together be removed completely while
avoiding touching the outside of the glove with bare hands.
 Wash hands after removing gloves, since gloves may contain nicks and tears which could allow
blood and body fluids to contaminate the hands with wearing of mask which should cover
mouth and nose both.

6.1.6 The sterile field

It is important to maintain a sterile field to prevent contamination of surgical incision.
 A sterile field is the area prepared around the surgical procedure site and where the sterile
instruments and other items needed during the operation are placed.
 It is created by placing sterile towels or sterile drapes on the prepared procedure site on the
patient and includes a stand nearby.
 Only sterile objects and persons in surgical attire (scrubbed team) are allowed within this field.
 Areas above the chest and below the waist of the scrubbed team are considered non-sterile.
Items outside and below the draped area are considered non-sterile.
 The field is considered non-sterile if a non-sterile object or non-scrubbed person comes within
the sterile field.
Cleaning and disinfection
A clean operating environment is essential to prevent SSI. The OT is cleaned and disinfected to prevent
microbial contamination. Exogenous sources of infection in the OT are people, anesthesia equipment,
surfaces such as walls, floors and furniture, air and dust, instruments supplies, and medications.
Maintenance of the sterile field
 Place only sterile items within the sterile field.

 Open, transfer, and dispense items without contaminating them.
 The outer cover of sterile items is considered unsterile and should not be placed within the
sterile field.
 Scrubbed persons should not touch non-sterile objects.
 Non-sterile items or personnel should not enter the sterile field.
 Never touch a sterile item with bare hands.
 If a sterile barrier has been made wet, cut, or torn, it is considered non-sterile.
 If there is a doubt whether the sterile field has been breached, consider it non-sterile.
There should be no dust in the OT; dust settling on the sterile field can carry microorganisms,
particularly in operations of long duration. Dust may be acquired from the outside environment due to
defective filtration of air. Lint-containing textiles can be a source of dust and floor mops. Dust particles
can be reduced by good laundry practices to reduce the formation of lint and by using a wet vacuum on
the floor.
General principles
 Surfaces must be routinely cleaned first with detergent to remove any foreign and organic
matter. Disinfection should follow cleaning. Do not apply disinfectant without cleaning as
organic matter such as pus, blood urine, amniotic fluid, etc., inhibits the action of the
disinfectant by protecting microorganisms. A detergent disinfectant combination solution if
available can be used for convenience.

 Spills must be cleaned immediately. Apply a higher disinfectant concentration to the spill, then
clean with detergent.
 Disposable or freshly laundered washable cloths or mops should be used with a freshly prepared
solution for each task.
 OTs must be cleaned daily. This includes furniture, lights, equipment, windowsills, ledges, scrub
rooms, and sinks. Thorough cleaning of the entire OT should be done once a week.
 Wet vacuuming is the preferred method to clean the floors; wet mopping can be done if the wet
vacuum is unavailable.
 Collections of water should be dried immediately. Leaking faucets and sinks should be fixed as
wet areas encourage microbial growth and can be a source of infection.
6.1.7 Cleaning of operation theatre

Daily cleaning procedure
Before the start of the first case, at least one hour before:
 Damp dust with detergent–disinfectant all equipment, furniture, and lights.

 Wipe the surgical light reflector again with 70% alcohol to remove the film left by the detergent.
Between cases:
 Place soiled towels, drapes, and gowns in a clean laundry bag and send them to the laundry. Wet
linen should be placed in a plastic containers that bacteria do not pass through the moist
material.
 Soiled instruments must be placed in disinfectant (1% sodium hypochlorite solution for 30 mins)
and then sent to the cleaning area; this prevents occupational hazards to the cleaner. Wipe all
used equipment, furniture, and lights.
 Move the operating table to one side and wet vacuum or wet mop a 3–4 feet area around the
operating site.
 Empty the suction bottle and wash the suction bottle and tubing with detergent–disinfectant.
The best is a disposable suction bottle.
Terminal daily cleaning after scheduled cases are over:
 Remove all portable equipment from the room.

 Wipe window sills, overhead lights, equipment, furniture, and waste containers with a cloth
soaked in a detergent disinfectant solution.
 Wet vacuum or wet mop the entire floor area.
 Clean and disinfect the wheels/castors.
 Restock unsterile supplies.
 Check level send dates of all sterile supplies and restock.
 Clean the air-conditioning grills.
 Clean scrub sinks.

 Empty all shelves, wipe them with detergent–disinfectant and dry them before replacing the
supplies.
The Weekly general cleaning procedure
 Remove all portable equipment. Clean lights and fixtures with detergent disinfectant solution
and cloth.
 Clean doors, hinges, and facings and rinse with solution.
 Wipe down the walls with a mop soaked in detergent disinfectant solution.
 Scrub the floor with a floor cleaning machine and use a wet vacuum to pick up the fluid
depending on availability.
 Replace clean portable equipment, clean wheels, and cast or by rolling them across a towel
saturated with detergent disinfectant.
 Wash and dry all furniture and equipment, including:-
 Operating room table
 Suction holders
 Foot and sitting stools
 IV stands and all other stands
 X-ray view boxes
 Tubing to oxygen tanks
 Waste containers and buckets
Note: Thorough washing and cleaning are essential. Fumigation and fogging have no role in the modern
operation room. Fumigation with formalin is hazardous to persons and should not be done. It can also
harm sensitive equipment.
6.1.8 Infrastructure of OTs

Location
To ensure a clean and uncontaminated environment, the OT should be located away from patient care
areas and patient traffic. For this reason, the OT is located at a higher level, preferably on the top floor.
Components of the OT
The OT is a multifunctional area. In this area, patients are received and prepared for surgery, the
operation team prepares for surgery, and the actual surgical procedures are carried out. In many
hospitals in the developing world that do not have a CSSD, the OT may also include equipment cleaning,
processing, and sterilization areas. In addition, there are areas for administrative functions, sluicing, and
waste disposal. The OT areas are distributed into zones depending on the level of sterility and
cleanliness required.
Zones
Concept of zoning (Zone 1, 2, 3 & 4)

The features of the different zones in order of their cleanliness are:
 Zone 3 is the cleanest or ultra-clean zone. It is also called the aseptic zone and includes the OT
and areas where the operation team and patient are prepared for surgery. The areas for
packaging and sterilizing surgical instruments are also included in this zone. The different areas
in this zone are physically separated from each other. Within this zone, the cleanest is the OT,
where the patient’s tissues are exposed during surgery.
 Zone 2 is the restricted zone where entry is restricted. It is the transitional area between the
outer zone and the aseptic zone. Persons entering this zone mustwear protective clothing and
footwear to prevent contamination of the surroundings.
 Zone 1 is also called the outer zone and has a similar level of cleanliness as other patient-care
areas in the hospital. It is the zone where patients are received, and administrative functions are
carried out. Toilets are located in this zone.
 Zone 4, or disposal zone, is a relatively dirty zone. Staff working in this area need to wear special
protective wear for their protection. There should be no movement of staff or equipment from
this zone to cleaner zones of the OT. This zone is connected by a separate corridor (also called a
“dirty corridor”) leading out of the OT.
6.1.9 Surgical antimicrobial prophylaxis

 Surgical antimicrobial prophylaxis (SAP) should be administered before the surgical incision
when indicated (depending on the type of operation). This should be based on the hospital
antibiotic policy.
 The intravenous route should administer the initial dose of a prophylactic antimicrobial agent,
timed such that a bactericidal concentration of the drug is established in serum and tissues
when the incision is made.
 Administration of SAP should be within 60 minutes of incision while considering the half-life of
the antibiotic.
 Clinicians should consider the half-life and protein binding as the most important
pharmacokinetic parameters of any single SAP agent to ensure adequate serum and tissue
concentration at the time of incision and during the entire surgical procedure.
 SAP should not be prolonged after the operation’s completion and is not recommended in the
presence of a wound drain to prevent SSI.
To reduce the stay in the hospital, patients are discharged before the incision has healed. The patient
should be educated as to how to take care of the incision site, personal hygiene, signs and symptoms of
infection, and whom to contact if infection occurs
6.2 IPC in ICUs:

Intensive care units (ICUs) house patients who are particularly vulnerable and at five- to ten times at
higher risk of HAI. With defenses compromised due to various invasive devices such as peripheral and
central lines, urinary catheters, and mechanical ventilators, they are particularly prone to device-related
infections. Intrinsic factors such as immune suppression and co-morbidities compound their

vulnerabilities. Patients in the ICU are also exposed to broad-spectrum antibiotics and are susceptible to
multidrug-resistant organisms such as Acinetobacter spp. and Pseudomonas spp. It is estimated that:
 In high-income countries, approximately 30% of patients in ICU are affected by at least one HAI.
 In Low and Middle-Income Countries (LMICs), the frequency of ICU-acquired infection is at least
2–3 fold higher than that in high-income countries; device-associated infection densities are up
to 13 times higher than those in the USA. Similarly, newborns admitted in NICUs are at higher
risk of acquiring HAI in developing countries, with infection rates 3 to 20 times higher than those
in high-income countries.
6.2.1 Patients at Risk of HAI

Patient, therapy, and environment-related risk factors for the development of HAI are:
 Age >70 years

 Shock, major trauma, acute renal failure, coma
 Prior antibiotics
 Mechanical ventilation
 Indwelling catheters
 Immuno-compromised patients on steroids or chemotherapy
 Prolonged ICU stay (>3 days)
6.2.2 IPC practices

Standard precautions should be applied for all patients in the ICU. In addition, transmission-based
precautions should be applied to standard precautions to prevent infections where the transmission
route is known (see also Chapter 4).
Skin preparation and use of antiseptic agents
 Gross contamination at the incision site should be removed before the antiseptic skin
preparation.
 Antiseptic skin preparation should be applied in concentric circles moving away from the
proposed incision site to the periphery, allowing sufficient prepared area to be included.
ICU footwear
 Special well-fitting footwear with impervious soles should be worn in the ICU. Shoes should be
preferred over slippers.
 Footwear should be regularly cleaned to remove splashes of blood and body fluids.
 The ICU footwear must not be taken out of the ICU to other hospital areas.
6.2.3 Care of Devices

General Guidelines to be followed for all procedures:
1. Hand hygiene is mandatory before, after, and in between procedures and patients.

2. Each healthcare worker should adhere to the Standard precautions required for each procedure.
3. Waste segregation and disposal as per the latest BMW guidelines after each procedure.
1. Vascular Care
A. Peripheral Catheters Insertion
 Establish the vein before disinfection.

 Perform procedural hand wash with antimicrobial soap or alternatively use hand rub before
insertion of the line.
 Wear sterile gloves.
 Apply antiseptics over the selected site with 70% isopropyl alcohol and 0.5-2% w/v chlorhexidine
and wait till it dries. Begin at the center of the insertion site, use a circular motion, and move
outward. If using 10% povidone Iodine, it should have a contact time of at least 30 seconds
before catheter insertion.
 Use a sterile dressing.
 Strict aseptic techniques should be maintained when manipulating intravascular catheter
systems.
 Examples of such manipulations include the following: Placing a heparin lock. Starting and
stopping an infusion,changing an intravascular catheter site dressing, Changing an intravascular
administration set, etc.
 Flushing: should be done after blood sampling, after administering fluids/medications, or every
8 hours when the device is not in continuous use. Flushing is to be done with a minimum of 5ml
sterile normal saline using positive pressure. Heparin is not needed.
 Monitor peripheral IV insertion date and change peripheral line every 96 hours or earlier if signs
of infection/thrombophlebitis. (If required, a new peripheral IV catheter may be inserted at a
new site.
 In the case of pediatric patients, burn patients, patients receiving chemotherapy and radiation
do not change routinely unless any signs of phlebitis.
B. Central venous catheter (CVC) insertion
 Train the staff in catheter insertion, maintenance, and infection control measures
 Regularly assess compliance and knowledge about infection control practices
 Insertion [USG guided insertion method is preferable, and femoral line should be avoided]
 Optimal number of lumens to be preferred while insertion based on clinical judgment.
 Practice surgical hand washing/Surgical Hand Rub before procedure
 Appropriate skin preparation must be done:
 2% w/v chlorhexidine (CHG) for patients ≥ 60 days old unless there is a documented
contraindication to CHG
 Povidone iodine (10%)and 70% Isopropyl alcohol are specified for children < 60 days old.
 Skin prep agent should completely dry before insertion

 Use maximum barrier precautions (all 5)

 Sterile gloves
 Sterile gown
 Cap
 Mask
 Sterile full-body drape (for patient)
 Use either plain sterile gauze with opaque or transparent dressing (Do not use povidone-iodine,
mupirocin, or any other antibiotic ointment).
Maintenance and Dressing Change
i. The morning shift nurse is responsible for communicating with the treating physician whether
the central line was reviewed for necessity and filling out the bundle compliance form.
ii. The on-duty nurse is responsible for checking whether the dressing for the central line is soiled,
damped, or loosened.
iii. Designate one port exclusively for TPN if a multi-lumen catheter is used.
iv. The in-charge nurse should ensure that strict aseptic techniques (Hand Hygiene & Sterile gloves)
are maintained when manipulating central venous vascular catheter systems.
v. Scrub the hub: The in-charge nurse should ensure that an appropriate antiseptic (2% w/v
CHG/70% Isopropyl alcohol) is used to scrub the access port of the central line each time before
use. (Both during the day shift and night shift). Rub for 10 to 15 seconds (unless directed
otherwise by the manufacturer’s instructions), generating friction by scrubbing in a twisting
motion as juicing an orange. Ensure you scrub the hub’s top well, not just the sides.
vi. Regular central line dressingmust be performed every 2 days for gauze andevery 7 days for
transparent dressings.
vii. Change dressing when it is damp, loosened, or soiled.
viii. Ensure strict hand hygiene with sterile gloves before dressing change
ix. Inspect for purulence or any evidence of catheter site infection
x. Affix the date label after the change of dressing.
Removal of CVC:
a. Remove when no longer necessary.

b. Do not routinely culture vascular line tips on removal unless indicated.
c. Send appropriate Culture: About 8-10 ml blood is to be drawn in separate blood culture bottles
through the Central line and Peripheral vein simultaneously if CLABSI (central line-associated
bloodstream infection) is suspected, preferably in automated blood culture bottles.
C. Arterial catheters
a) The same principles for insertion, maintenance, and removal as for CVC apply

b) Preferably use disposable transducers. Use sterile reusable transducers per the manufacturer’s
instructions if disposable transducers are unavailable.
c) Replace transducers at 72 hours intervals along with other components of the system, including
the tubing, the flush solution, and the continuous flush device.
d) Keep all components of the pressure monitoring system sterile.
e) Minimize manipulations and ensure a closed-flush system
f) If the pressure monitoring system is accessed through a diaphragm, wipe the diaphragm with
70% alcohol before access.
g) Do not use any parenteral fluids or dextrose-containing fluids throughout the system.
D. Administration of IV fluids, IV medication
a) Replace administration sets with add-on devices (like tubing, stopcocks, needleless devices)
every 72 hours.
b) Replace sets used to administer blood, blood products, and lipid emulsions every 24 hours.
c) Replace the tubing used to administer propofol every 6-11 hours.
d) Complete infusions of lipids within 11 hours of initiation (max 24 hours), and blood products
within 4 hours of initiation.
e) Use collapsible bags for IV fluids whenever possible (avoid using needles for air inlets).
f) Preferably use single-dose vials.
g) If multi-dose vials are used, refrigerate after every use and wipe the access surface with 70%
alcohol before inserting the needle.
h) Line filters are not routinely required.
2. Respiratory Care
1. Care of mechanically ventilated patients
a) Elevate the head of the bed to 30–450 in patients without contraindications

b) Interrupt sedation once a day (spontaneous awakening trials) for patients without
contraindications in consultation with a critical care physician.
c) Assess readiness to extubate once a day (spontaneous breathing trials) in patients without
contraindications
d) Provide endotracheal tubes with subglottic secretion drainage ports for patients requiring more
than 48 or 72 hours of intubation.
e) Perform oral care with chlorhexidine
f) Change the ventilator circuit only if visibly soiled or malfunctioning
g) Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators.
h) Breathing circuits, humidifiers, and heat and moisture exchangers (HMEs)
 Do not change routinely, based onthe duration of use, the breathing circuit (i.e.,
ventilator tubing and exhalation valve and the attached humidifier) that is in use on an
individual patient. Change the circuit when it is visibly soiled or mechanically
malfunctioning.

 Breathing-circuit-tubing condensate- Periodically drain and discard any condensate that

collects in the tubing of a mechanical ventilator, taking precautions not to allow
condensate to drain toward the patient by wearing gloves.
 Change the HME filter every 48 hours or earlier if it is malfunctioning, mechanically
soiled, or blocked. Use sterile water to fill the humidifier
Care of patients with tracheotomy

a. Aseptic technique to be used to care for fresh tracheotomies and patients in critical care. A
clean technique will be used to care for non-established and established tracheotomies using
sterile supplies.
b. Tracheotomy stoma should be cleaned with sterile normal saline.
c. Securing of Tracheotomy tube:
 Fresh Tracheotomy Stoma: A tracheotomy securement device (twill tape or Velcro tube holder)
will be used to secure fresh tracheotomy tubes for the first 24 hours postoperatively and should
not be changed or adjusted without physicians’ order and supervision.
 Established Stomas: Tracheotomy securement devices should be changed daily
(neonates/pediatrics) or once a week (adults).
Tracheotomy Tube changes:
a. The initial tracheotomy tube change should be performed preferably by the surgeon who
performed the tracheotomy.
b. Tracheotomy tubes with inner cannula should be changed every thirty (30) days
c. Tracheotomy tubes without inner cannula should be changed weekly to monthly, as per
physician order and/or patient need.
Suctioning
a. The wall suction is to be set no higher than 120 mm Hg for adults and between 60 and 80 mm
Hg for children.
b. Perform Hand Hygiene before and after suctioning.
c. Wear sterile gloves and a mask
d. Use a catheter with a blunt tip.
e. Attach the suction catheter to the suction tubing.
f. Insert the catheter gently through the inner cannula until resistance is met. Do not apply suction
during insertion.
g. Withdraw the catheter approximately 1 cm and institute suctioning.
h. Carefully withdraw the catheter, rotating it gently between the thumb and forefinger, applying
intermittent suctioning.
i. When suctioning is completed, clear the catheter and tubing of mucous and debris with sterile
water or saline.
j. Discard the catheter, water container, and gloves appropriately and wash hands

k. The tubing and suction canister are to be changed every 24 hours. The canister is labeled with
the date and time when they are changed. If debris adheres to the side of the tubing or the
canister, either or both are changed. The tubing is secured between suctioning periods so that it
will not fall to the bed, floor, etc.
Care of other respiratory equipment
Small-volume medication nebulizers like in-line and hand-held nebulizers care:
a. Between treatments on the same patient, disinfect, rinse with sterile water, or air-dry small-
volume in-line or hand-held medication nebulizers (IB).
b. Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically
c. Whenever possible, use aerosolized medications in single-dose vials. If multi-dose medication
vials are used, follow manufacturers ‘instructions for handling, storing, and dispensing the
medications.
d. AMBU bags must be subjected to high-level disinfection between multiple uses or on different
patients.
3. Care of indwelling urinary catheter:

Urinary Catheter Insertion Method:
1. Perform hand washing.

2. Use sterile gloves, drape & sponges
3. Clean the peri-urethral with sterile water followed by an antiseptic (10% Povidone Iodine) and a
single-use packet of lubricant jelly should be used for insertion.
Techniques for Urinary Catheter Maintenance
1. Maintain a closed drainage system

2. Keep the catheter and collecting tube free from kinking.
3. Keep the collecting bag below the level of the bladder at all times by hanging it at the bedside.
Do not rest the bag on the floor.
4. Empty the collecting bag regularly using a separate, clean collecting container for each patient;
avoid splashing and prevent contact of the drainage spigot with the nonsterile collecting
container.
5. Routine hygiene (e.g., cleansing of the metal surface with sterile water) is advisable. Do not
clean the peri-urethral area with antiseptics to prevent CAUTI while the catheter is in place.
6. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended.
Rather, it is suggested to change catheters and drainage bags based on clinical indications such
as infection, obstruction, or when the patency of the system is compromised.
7. If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), aspirate
the urine from the needleless sampling port with a sterile syringe/cannula adapter after
cleansing the port with a disinfectant

4. Wound Care:
Surgical wounds
a. Surgical wounds after an elective surgery are inspected on the third post-operative day or
earlier if wound infection is suspected.
b. All personnel doing dressings should wash their hands before the procedure. Ideally, a two-
member technique is followed. One to open the wound and one to do the dressing.
c. If two health care workers are unavailable, remove the dressing and wash hands again before
applying a new dressing.
d. A clean, dry wound may be left open without any dressing after inspection.
e. If there is any evidence of wound infection or purulent discharge, then dressings are done daily,
using povidone-iodine to clean the wound and applying dry absorbent dressings.
Collection of wound swabs:
The superficial wound site:

a. Wound site should be gently washed with sterile saline. This process helps to removing the
colonizers from the wound.
b. Sampling should be done from the margin and floor of the wound to maximize the
microbiological yield.
c. Paired wound swab (one for gram staining and another for culture) should be sent
In deep wound site with pus discharge/ooze:

a. Wound site should be gently washed with sterile saline. This process helps removing the
colonizers from the wound.
b. The pus/discharge should be actively expressed and collected on the cotton swab.
c. Paired wound swab (one for gram staining and another for culture) should be sent.
d. All specimens should be sent immediately with the laboratory request clearly mentioning of
wound site, body side (in case of limbs/face), diagnosis, and surgical procedure (if any)
undertaken.
6.3 IPC in Maternal and Neonatal Units
6.3.1 Maternal and neonatal infections

Maternal “peripartum infection” includes:
 Intrapartum (intra-amniotic infection occurring before birth, i.e. during labor and delivery), and
 Postpartum (or puerperal) bacterial infections following childbirth/delivery
The clinical presentations of maternal infections are:
Surgical Site Infection (SSI): Infection of the surgical site after CS may be superficial, deep, or in organ
space. Postpartum SSI, wound infection, and endometritis are major causes of prolonged hospital stay
and burden the healthcare system.

Endometritis: The term refers to infection of the endometrium (lining of the uterus), which may extend
to the myometrium (smooth muscle of the uterus). It presents as fever, pain in the abdomen, uterine
tenderness, and sub-involution of uterus foul smelling vaginal discharge, and signs of peritonitis in
women who had caesarean section. Caesarean Section (CS) is the most important risk factor
forpostpartum endometritis. The risk of infection is 5-20 times higher in cesarean section deliveries than
in Vaginal Deliveries (VD).
Septic pelvic thrombophlebitis: Thrombosis of the deep pelvic veins due to inflammation and infection
may occur in the background of the hypercoagulable state of pregnancy. Thehigh-risk conditions for
septic thrombophlebitis are prolonged labor, Premature Rupture of Membranes (PROM), and difficult
labor requiring manipulation or intervention.
Infected episiotomy: This is an infection in the surgical cut that is made in the perineum to facilitate
delivery
HealthCare-associated UTIs: Usually occur after cesarean deliveryeg: CAUTI
Intra-amniotic infection syndrome also referred to as amnionitis or chorioamnionitis. This is an acute

infection of the uterus and its contents (foetus, placenta and amniotic fluid) during pregnancy. It occurs
after prolonged rupture of membranes and is an ascending infection due to organisms present in the
cervix and vagina.
6.3.2 Prevention of newborn and maternal infections during delivery

Prevention of maternal and neonatal infections during Vaginal Delivery (VD)
Vaginal deliveries do not require sterile conditions of the OT, but cleanliness is of utmost importance.
Particular attention should be given to having clean hands, a clean perineal area, a clean umbilicus,
clean sheets, sterile drapes during procedures, and cleaning of labor beds/tables and other surfaces in
the area.
Factors that increase the risk of infection during Vaginal Delivery:
 Prolonged rupture of membranes (>24 hours)

 Trauma to the birth canal: lacerations of the vagina or perineum or urethral tear
 Retained placenta, necessitating Manual Removal of Placenta (MRP) or placental fragments
 Episiotomy
 Forceps delivery
 Multiple vaginal examinations (particularly by medical and nursing students)
 Prolonged labor
 Intermittent urinary catheterization in labor
Prevention of infection during vaginal examination:

 Digital vaginal examination at intervals of four hours is recommended for routine assessment of
active first stage of labour in low-risk women.
 Clean pair of gloves should be used for each examination. Sterile gloves,thoughnot necessary,
are desirable.
 The tip of the examining finger should not enter the cervical os unless the decision has been
made to induce labor. Student training should be limited to cases that are in active labor.
Prevention of infection before delivery:
 Use clean examination gloves, wash the perineal area (vulva, perineum, and anal region) with
soap and clean water.
 Use downward and backward motion while cleaning so that faecal organisms are not introduced
into the vagina.
 The anal area should be cleaned last, and the wash towel should be discarded in a yellow-coded
container. Disinfect gloved hands by immersing them in 0.5% chlorine solution, wash gloved
hands, and remove gloves by inverting and discarding them in the yellow-coded container.
 Perineal/ pubic/ head hair should not be shaved; hairclippers should be used if required. WHO
does not recommend routine shaving. Shaving has been shown to increase the risk of infection
after delivery.
 Routine vaginal cleansing with chlorhexidine(0.25-0.50%) at vaginal examinations during active
laborto prevents infection is not recommended. However, in low-resource settings, a decision
regarding this may be taken based on available resources e.g., in case of non-availability of
parenteralantibiotics.
Prevention of infection during delivery/ in the second stage of labor:
 Hand hygiene by ABHR or washing with antiseptic soap and water meticulously up to the elbows
and adhering to the seven steps of hand hygiene
 PPE: High exposure to blood and body fluid as splashes of blood and blood-tinged amniotic fluid
is expected
 Gloves
 Sterile surgical gloves
 To provide protection up to the elbow, normal-length gloves can be augmented by sterile
surgical sleeves that come up to the elbow (these sleeves can be made by cutting off the fingers
of a pair of sterile gloves with a sterile scissors). The sterile sleeve can be worn on each forearm
before wearing the sterile surgical glove. Clean examination gloves for washing the perineum.
 Sterile water-resistant gown, rubber/ plastic apron
 Mask with eye shield
 Boots
 Cap
 Instruments used during delivery (scissors, cord clamp, needle holder, forceps, tissue
forceps, urinary catheter, sutures, etc.) should be sterile or high level disinfected.

 Perineal support must be given at the appropriate time to prevent perineal trauma and
tears
 The HCW receiving the baby should clean their hands by performing handhygiene and
wear clean examination gloves. Baby should be received in a clean towel.
 If resuscitation of the baby is required, it should be done by mechanical suction. A trap
should be placed in the line if mouth suction is done.
 If manual removal of placenta is required, a fresh pair of sterile gloves should be worn,
augmented by a sterile sleeve up to the elbow to avoid contaminating the forearm with
blood.
 Routine antibiotic prophylaxis is not recommended during uncomplicated vaginal
delivery with or without episiotomy, but it should be administered in high-risk women
and in women with Group B Streptococcus colonization. A decision regarding the same
may also be taken based on overall patient condition and setting.
 Antibiotic prophylaxis with IV antibiotics must be given in case of MRP, uterine curettage,
and 3rd or 4thdegree perinea tear
Prevention of infection after delivery
 Before removing gloves, put the placenta in a clean basin and place all bloodstained waste in the
appropriate yellow-color-coded container with lid.
 Place suture needles after use in the puncture-proof sharps container.
 Immerse both gloved hands in 0.5% chlorine solution, rinse with water, and remove gloves by
inverting. Wash hands with soap and water after removing gloves.
Prevention of infection durin g Caesarean Section (CS)
The WHO surgical safety checklist to prevent surgical complications MUSTbe applied.
Similar to implementing surgical bundles to prevent SSI in non-obstetric patients, creating patient care
bundles comprising evidence-based elements in patients who undergo CS may decrease the incidence of
SSI. It is recommended that the unit creates its own CS surgical bundle suited to the setting.
Procedures to prevent infection in patients undergoing CS include:
 The abdomen should not be shaved before surgery. If required, a hair clipper should be used
instead.
 The surgeon and assistant should wear a cap, face shield or mask, goggles, gown, and a plastic
or rubber apron over the scrub-suit since splashing with blood and blood-tinged amniotic fluid is
expected.
 If there has been a prolonged rupture of membranes or the CS is non-elective, then a single shot
of first-generation cephalosporin or penicillin is given intravenously, preferably just before
incision (15-30 minutes prior) rather than after the cord is clamped.

 The HCW receiving the infant should clean their hands by hand hygiene and wear clean
examination gloves before handling the baby.
 The baby should be placed in a clean towel.
 Avoid manual removal of placenta during CS after delivery of the baby. Spontaneous separation
of placenta is preferable unless specific situation necessitates its manual removal.
 If there is prolonged rupture of membranes or chorioamnionitis is present:
1. Avoid spillage of amniotic fluid into the abdominal cavity.
2. Place sterile, moistened surgical mops in the paracolic gutters to absorb as much of the amniotic
fluid as possible. Keep a strict count of the mops placed; the same must be checked at removal
before closure of the abdomen.
3. If there are large amounts of amniotic fluid spill into the abdominal cavity, lavage the cavity with
sterile isotonic saline solution.
4. Avoid exteriorizing the uterus unless absolutely necessary and only after closing the uterine
incision.
 In elective cesarean section, if the cervix is closed and membranes are not ruptured, then dilate
the cervix through the vagina to allow the outflow of blood and fluid from within the uterus
after delivering the baby and removing the placenta. Dilate the cervix with a gloved finger only
once. When dilatation is completed, change the gloves and wear a new pair of sterile surgical
gloves.
6.3.3 Postpartum care of the mother

 Gloves should be worn when handling perineal pads, touching vaginal discharge or touching the
episiotomy.
 Check whether the mother is voiding urine without difficulty.
 The mother should be taught to wash the perineal area with boiled water (cooled to a tolerable
warm temperature) after changing the pad or passing stool.
 If the mother is breastfeeding, she should be taught how to care for her breasts and nipples to
avoid mastitis.
 If delivery was by cesarean section, care should be taken to avoid pulmonary problems during
the postoperative period.
 Patient should be encouraged to move about frequently in bed and encouraged to walk within
12 hours.
 If the indwelling urinary catheter is inserted, precautions to prevent urinary infection should be
followed. Remove the catheter as soon as possible.
6.3.4 Postnatal care of the neonate

 Gloves and plastic/ rubber aprons should be worn while handling the neonateuntil blood,
meconium or amniotic fluid has been removed from the neonate’s skin.
 The removal of blood and body fluids from neonate’s skin should be done carefully using cotton
swabs/ soft cotton soaked in boiled warm water, followed by drying the skin to avoid infection.
 Hand hygiene (hand washing or ABHR) should be performed before handling the neonate.

 Bathing or washing the neonate should be done once the temperature of the neonate has
stabilized (usually by 6 hours of birth). The perineal area and buttocks should be kept clean, by
washing with soft cloth, cotton swabs soaked in warm water after every diaper change. Using
fresh swabs and separate bowl for each wash occasion. Perform hand hygiene before and after
diaper change.
Cord care:
 Perform hand hygiene before and after cord care

 Keep cord stump clean and dry
 Do not cover the cord stump with dressing or bandage
 Educate the mother to examine the stump for redness or presence of pus/ blood and to report
to the clinic as soon as possible if this happens
6.3.5 Prevention of infection during procedures in neonatal unit

Preparation of intravenous fluids:
 Intravenous (IV) administration of fluids and drugs is a potent source of infection for the
vulnerable neonate. Outbreaks of sepsis have often implicated IV fluids as either the source or
vehicles of transmission between neonates. Strict attention to aseptic technique is essential in
preparing and administering IV fluids.
 As far as possible, procure base solutions such as IV glucose and saline solutions in pediatric
packings/ small amounts rather than use adult packaging and transfer them into smaller
aliquots. Avoid procurement of multi-dose vials as far as possible; single-use ampoules/ vials are
preferred.
 Have a designated area to prepare IV infusions. Clean the area with a disinfectant before a
procedure.
 Gather the necessary materials (IV fluids, drugs, syringes, needles, swabs, 70% alcohol, etc.).
 Examine the IV fluid containers, ampoules, and vials for expiry date, cracks, leaks, cloudy
consistency, flakes, etc.
 Perform hand hygiene either by hand washing using medicated soap followed by drying with a
single-use towel or ABHR (it is important that hands are dry before starting the procedure).
 Disinfect the port of IV bottles/ bags with 70% alcohol immediately before removing/ adding
fluids.
 Wear sterile gloves.
 Use a sterile needle/ syringe for each IV fluid bottle and ampoule/vial using the no-touch
technique while mixing IV fluids and medications.
 Never enter IV fluids and bottles with a needle except through a designated port.
 Label the prepared bottle with the patient’s name, registration number, date, and preparation
time.
 If need to be stored in fridge, do not refrigerate for more than 24 hours. Discard after 24 hours
in fridge and after 8 hours at room temperature.

 The improper use of multi-dose vials can be a cause and source of infection in the neonate.
 Strict aseptic technique to be followed during administration of IV fluids, and closed system to
be maintained at all times.
Intravenous (IV) therapy and Umbilical Catheter care
Umbilical vessel catheters are frequently used in the initial management of the sick neonate. There is
increased potential for bacterial colonization as this site is non-sterile, and devitalized cord tissue is
present. Percutaneous peripheral or central venous catheters should replace umbilical catheters in
neonates requiring long-term access.
 Umbilical catheters should be inserted using sterile techniques.

 Umbilical catheters should only be replaced if catheter site is infected or catheter malfunctions.
 Do not replace umbilical catheter if there are signs of CRBSI or thrombosis. In addition, for the
umbilical artery catheter, do not replace if there are signs of vascular insufficiency.
 Clean umbilical site before insertion with appropriate disinfectant avoiding tincture of iodine
due to its potential effect on neonatal thyroid. Povidone-iodine can be used.
 Do not use topical antibiotic or creams due to potential for fungal infection and AMR.
 Low-dose heparin can be added to the fluid infused through umbilical arterial catheter.
 Umbilical arterial catheters should be removed immediately and not left in place for more than
5 days. Remove the catheter if there are signs of vascular insufficiency in the lower limbs.
 Umbilical venous catheters should be removed immediately and left in place for not more than
14 days.
6.4 IPC in Outpatient and Emergency care
6.4.1 Outpatient department

Registration desk
The first point of contact for an ill patient seeking hospital care is the outpatient department's (OPD)
registration desk. Recognition of transmissible illness and moving the infectious patients to the
appropriate examination room as quickly as possible is important. Frontline staff at the registration desk
should be trained to recognize patients showing signs and symptoms of transmissible diseases. At the
entrance, visual alerts and posters indicating the signs and symptoms of transmissible diseases should
be displayed. If required, a short (3–5 questions) and simple questionnaire can be given to patients at
registration to facilitate rapid identification and isolation. This is particular important in epidemic/
pandemic situations.
Pandemic preparedness
Time and again, emerging and re-emerging diseases have caused epidemic and pandemic situations. The
major international outbreaks in the last decade have been: Swine Flu in 2009, MERS in 2012, Ebola in
2014 and Zika in 2016, Nipah in India (2018), and most recently the COVID-19 pandemic. In outbreaks of
public health importance, the first point of contact in an HCF is the OPD or the emergency department.

Staff at the frontline must be prepared to identify and transfer cases safely without disease
transmission. Preparation for all diseases should include screening and isolating potentially infectious
persons, PPE use, cleaning and disinfection and drill exercises.
 Individuals who meet criteria for highly communicable diseases requiring isolation such as novel
influenza or other emerging infections, must be placed in a private examination room as soon as
possible
 PPE kits should be available. Staff should be trained on the correct steps and techniques to wear
and remove PPE. PPE assessment includes competency validation to ensure that participants are
using PPE correctly.
 To maintain the level of competency and awareness, staff should participate in drills. PPE skill
maintenance can be included in annual competency training.
6.4.2 IPC in emergency care

The emergency department is a busy place subject to rapid patient turnover and overcrowding; half of
all admissions to the hospital are from the emergency. The emergency department, such as the OPD, is
also the frontline in response to public health emergencies and disasters. Patients admitted through the
emergency are sicker than those who report to the OPD.
Infection prevention is a major challenge in the emergency department due to the following:
 High volume of patients, many needing rapid intervention.

 Patients present with undifferentiated illnesses of various types, and the condition ranges from
the otherwise healthy to the critically ill.
 Acutely ill and injured patients undergoing evaluation and treatment in the emergency
department have the potential to spread communicable infectious diseases to HCWs and other
patients.
 Risk recognition and decision-making are often based on limited and changing data
 Patients await diagnosis, intervention, and decisions about further management or discharge in
close proximity to one another
IPC in emergency care has two aspects:
Preventing the transmission of infectious diseases from ill patients to HCWs and other patients and
reducing the risk of infection associated with receiving emergency care.
The basics of standard precautions including hand hygiene PPE, etc. should be strictly adhered to.
6.5 IPC in the dialysis unit

Patients undergoing haemodialysis are at increased risk of HAIs. Therefore, the
IPC programme is essential for HD units. It includes multiple interventions which are designed to reduce
the risk of infection.

A doctor or a senior nurse working in the unit should be given responsibilities of IPC activities. The role
of this link person includes
 Monitoring of IPC practices

 Training of new staff and ongoing training of all staff
 Periodic surveillance to assess risk
 Implementation of preventive bundles
It is important that this link person communicates and networks with the facility IPC team and all
members of the HD team, including nurses, technicians, physicians, housekeeping staff, and the patient/
family. It is important that all members of the HD team understand their role and are held accountable
for compliance with IPC practices.
6.5.1 Measures to reduce risk of infection in HD patients

In the hemodialysis setting, contact transmission plays a major role in transmitting blood-borne
pathogens. Transmission occurs via the hands of HCWs contaminated with infected blood directly or
indirectly from contaminated surfaces and equipment.
 Standard precautions are to be used routinely on all patients and include use of gloves,
disposable plastic aprons or gowns, and masks (whenever needed), to prevent contact of HCWs
with blood, secretions, excretions, or contaminated items.
 Respiratory etiquette should be observed routinely.
 Patients identified with an airborne illness should be masked immediately and separated from
other patients in a single room, which is preferably under negative pressure.
 Patients and staff should be vaccinated as per the recommendations of the national
immunization program.
 The patient and nurse must wear a mask when a catheter (not fistula or graft) is connected or
disconnected from the bloodlines during dialysis.
6.5.2 IPC for patients with blood-borne infections

Besides standard precautions, the following points should be kept in mind.
 HBsAg-positive patients should undergo dialysis in a separate room using separate machines,
equipment, instruments, and supplies.
 Dialyzersare discarded in biomedical waste after treatment and should notbe reprocessed or
reused.This should apply to HCV and HIV-infected patients as well.
 Staff caring for HBV patients should be HBV-immune, and should not care for HBV-positive and
negative patients at the same time.
• Care of patients with HCV and HIV requires strict adherence to environmental IPC
practices including equipment disinfection.
Why are Dialysis Patients at Risk for Infection?
 Patients who undergo hemodialysis have a higher risk of infection, due to the following factors:

o Frequent use of catheters or insertion of needles to access the bloodstream.

o Weakened immune systems.
o Frequent hospital stays and surgery.
6.5.3 Infections in Dialysis Patients

Dialysis patients are at risk of getting hepatitis B and C infections and bloodstream infections. Hepatitis
B and Hepatitis C are blood-borne viral infections that can cause chronic
(life-long) disease involving inflammation (swelling) of the liver.Hepatitis B and C viruses can live on
surfaces and be spread without visible blood.
A serious bloodstream infection can occur when bacteria or other germs get into the blood.Bacteria can
enter the bloodstream through a vascular access (catheter, fistula, or graft). Bloodstream infections are
a dangerous complication of dialysis1 in 4 patients who get a bloodstream infection caused by
S. aureus (staph) bacteria can face complications such as:endocarditis (infected heart valve),
osteomyelitis (infected bone)etc Bloodstream infections can cause sepsis (a potentially deadly
condition).Up to 1 in 5 patients with an infection die within 12 weeks.
6.5.4 Measures to prevent the Spread of Infections

Standard Precautions:
Standard Precautions for all Healthcare Workers in All Healthcare Settings

 perform hand hygiene
 use personal protective equipment (PPE)
 follow safe injection practices
Perform Hand Hygiene
 Before you touch a patient.

 Before you inject or infuse a medication.
 Before you cannulate a fistula/graft or access a catheter.
 After you touch a patient.
 After you touch blood, body fluids, mucous membranes, wound dressings, or dialysis fluids.
(e.g., spent dialysate).
 After you touch medical equipment or other items at the dialysis station.
 After you remove gloves.
Use Personal Protective Equipment (PPE) Correctly:
 Wear gloves, a gown, and/or face protection when you think you may come into contact with
blood or other potentially infectious materials.
 Change gloves during patient care if the hands will move from a contaminated body-site to a
clean body-site.

 Remove gloves after contact with a patient and/or the surrounding environment. (including
medical equipment)
 Do not wear the same pair of gloves for the care of more than one patient.
Safe Injection Practices-Importance:
 Medications are injected directly or indirectly into the patient’s bloodstream.

 Any germs that have entered the medication vial or syringe can cause serious infections in the
patient.
 Germs also can be introduced at the time of injection (e.g. contaminated port of vascular
catheter).
Specific Infection Control Precautions for Hemodialysis Healthcare Workers
 Wear gloves and other personal protective equipment (PPE) for all patient care.
 Promote vascular access safety.
 Separate clean areas from contaminated areas.
 Use medication vials safely.
 Clean and disinfect the dialysis station between patients.
 Perform safe handling of dialyzers.
Basic Steps in Fistula/Graft Care
Cannulation Procedure:
 Wear proper face protection

 Wash the site.
 Perform hand hygiene.
 Put on a new, clean pair of gloves.
 Apply skin antiseptic and allow it to dry.
 Insert needle using aseptic technique.
 Remove gloves and perform hand hygiene.
Aseptic technique means taking great care to not contaminate the fistula or graft site before or during
the cannulation or decannulation procedure.
Decannulation Procedure:
 Wear proper face protection.

 Remove needles using aseptic technique.
 Apply clean gauze/bandage to site.
 Compress the site with clean gloves.

Basic Steps in Catheter Care
Catheter Connection Procedure:

 Apply antiseptic to catheter hub and allow it to dry.
 Connect the catheter to blood lines using aseptic technique.
 Unclamp the catheter.
Catheter Disconnection Procedure:

 Disconnect the catheter from blood lines using aseptic technique.
 Apply antiseptic to catheter hub and allow it to dry.
 Replace caps using aseptic technique.
 Make sure the catheter remains clamped.
Catheter Exit Site Care:

 Wear a face mask if required.
 Apply antiseptic to catheter exit site and allow it to dry.
 Apply antimicrobial ointment.
 Apply clean dressing to exit site.
Separate Clean Areas from Contaminated Areas:
Clean areas should be used for the preparation, handling and storage of medications and unused
supplies and equipment
Your center should have clean medication and clean supply areas.
Contaminated areas are where used supplies and equipment are handled.
Do not handle or store medications or clean supplies in the same area as where used equipment or
blood samples are handled.

Disinfecting the Dialysis Station:
 All equipment and surfaces are considered to be contaminated after a dialysis session and
therefore must be disinfected.
 After the patient leaves the station, disinfect the dialysis station (including chairs, trays,
countertops, and machines) after each patient treatment.
 Wipe all surfaces.
 Surfaces should be wet with disinfectant and allowed to air dry.
 Give special attention to cleaning control panels on the dialysis machines and other commonly
touched surfaces.
 Empty and disinfect all surfaces of prime waste containers.
Safe Handling of Dialyzers and Blood Tubing:
 Before removing or transporting used dialyzers and blood tubing, cap dialyzer ports and clamp
tubing.
 Place all used dialyzers and tubing in leak-proof containers for transport from station to
reprocessing or disposal area.
 If dialyzers are reused, follow published reprocessing methods (e.g., AAMI standards).
6.6 IPC in Clinical Laboratory

The clinical laboratory is a workplace where many potential pathogens are encountered daily. However,
the laboratory can be a safe workplace if possible risks are identified and safety and infection control
protocols are followed.
 Laboratory workers can minimize the risks associated with work involving these infectious
agents through the application of appropriate bio safety and containment principles and
practices.
 While safe practices in the laboratory are primarily intended to prevent morbidity due to
infections in laboratory workers, laboratory-associated infections may impact public health,
leading to secondary cases in the community.
 For example, household transmission of pathogens (e.g. influenza A) is well documented.
 Therefore, prevention of laboratory-associated infections has an individual as well public health
impact.
6.6.1 Good personal habits:

 Wear proper attire and protective clothing as described above.
 Wash hands after entering and before leaving the laboratory.
 Never eat, smoke, drink, chew gum, apply cosmetics, or adjust contact lenses while in the
laboratory.
 Mouth pipetting is prohibited, instead use pipetting bulbs.
 Keep hands away from the mouth, nose, and eyes to prevent self-inoculation with infectious
agents.

 Do not put objects in mouth (such as pens, pencils or pipettes).

 Wear gloves when working with biological specimens. Change gloves when contaminated.
 In preparing specimens, prevent aerosols and the resultant possible spread of infectious agents
by;
 Capping all tubes to be centrifuged prior to centrifugation;
 Never open the lids of centrifuges until the centrifuge has come to complete stop; and only
open specimen tubes by gently twisting the stoppers and lifting them (sometimes holding a lint-
free tissue over the stopper may prevent aerosolization).
 Keep test request forms, registers and other paper work separate from specimen containers
since the outer surface of specimen containers may be contaminated.
 Wipe outer surface of containers with suitable disinfectant before handling.
 Keep smear preparation area separate from other laboratory activities.
 Open containers carefully to minimize production of aerosols.
 Keep the container open only long enough to remove a portion for direct smear preparation if
not processing for culture.
6.6.2 Infection prevention and control in clinical laboratory

Clinical laboratory is a workplace where many potential pathogens are encountered on a daily basis.
However, the laboratory can be a safe workplace if possible risks are identified and safety and infection
control protocols are followed. Laboratory workers can minimize the risks associated with work
involving these infectious agents through the application of appropriate bio safety and containment
principles and practices.
While safe practices in the laboratory are primarily intended to prevent morbidity due to infections in
laboratory workers, laboratory-associated infections may impact public health, leading to secondary
cases in the community.
For example, household transmission of pathogens (e.g., influenza A) is well documented. Therefore,
prevention of laboratory-associated infections has an individual and public health impact.
6.6.3 Laboratory Design features for biosafety

 There should be a designated area for collecting blood and other clinical samples, physically
separated from the patient waiting room and specimen processing area.
 Hand-washing basins, with running water if possible, should be provided in each laboratory
room, preferably near the exit door.
 Ample space must be provided for the safe conduct of laboratory work and for cleaning and
maintenance.
 Walls, ceilings and floors should be coved and slip-resistant, which allow easy cleaning,
impermeable to liquids and resistant to the chemicals and disinfectants normally used in the
laboratory.
 Floors should be slip-resistant.

 Bench tops should be impervious to water and resistant to disinfectants, acids, alkalis, organic
solvents and moderate heat.
 Illumination should be adequate for all activities. Undesirable reflections and glare should be
avoided.
 Laboratory furniture should be sturdy open spaces between and under benches, cabinets and
equipment should be accessible for cleaning.
 Storage space must be adequate to hold supplies for immediate use and thus prevent clutter on
bench tops and in aisles. Additional long-term storage space, conveniently located outside the
laboratory working areas, should also be provided.
 Space and facilities should be provided for safe handling and storage of solvents, radioactive
materials, and compressed and liquefied gases.
 Facilities for storing outer garments and personal items should be provided outside the
laboratory working area.
 Facilities for eating and drinking and for rest should be provided outside the laboratory working
area.
 Doors should have vision panels, appropriate fire ratings, and preferably be self-closing.
 At bio safety level 2, an autoclave or other means of decontamination should be available in
appropriate proximity to the laboratory.
 Safety systems should cover fire, electrical emergencies, and emergency shower and eyewash
facilities.
 First-aid areas or rooms suitably equipped and readily accessible should be available.
6.6.4 Biosafety levels

Laboratory facilities are designated as Biosafety levels 1 to 4 based on a composite of design features,
construction, containment facilities, equipment, practices, and operational procedures required for
working with agents from various risk groups.
The principal hazardous characteristics of an agent are: its capability to infect and cause disease in a
susceptible human or animal host, its virulence as measured by the severity of disease, and the
availability of preventive measures and effective treatments for the disease.
Bio safety level 1 (BSL-1) is the basic level of protection and is appropriate for agents that are not known
to cause disease in normal, healthy humans.
Bio safety level 2 (BSL-2) is appropriate for handling moderate-risk agents that cause human disease of
varying severity by ingestion or through percutaneous or mucous membrane exposure.
Bio safety level 3 (BSL-3) is appropriate for agents with a known potential for aerosol transmission, for
agents that may cause serious and potentially lethal infections and that are indigenous or exotic in
origin.

Exotic agents that pose a high individual risk of life-threatening disease by infectious aerosols, and for
which no treatment is available, are restricted to high containment laboratories that meet bio safety
level 4 (BSL-4) standards
6.6.5 Safety equipment

 Bio safety cabinets or safety centrifuge cups must be used to minimize aerosol hazards.
 Bio safety cabinets these are to be used when performing procedures with high potential for
producing infectious aerosols. These include:
 Open-fronted Class I and Class II bio safety cabinets are primary barriers that offer significant
levels of protection to laboratory personnel and to the environment when used with good
microbiological techniques.
 The Class II biological safety cabinet also provides protection from external contamination of the
materials (e.g. cell cultures, microbiological stocks) being manipulated inside the cabinet.
 The gas-tight Class III biological safety cabinet provides the highest attainable level of protection
to personnel and the environment.
 Biological safety cabinets must be validated with appropriate methods before being taken into
use.
 Recertification should take place at regular intervals, at least once a year or more frequently
when required.
6.6.6 Decontamination
Steam autoclaving is the preferred method for all decontamination processes. Materials for
decontamination and disposal should be placed in containers, e.g. autoclavable plastic bags that are
color-coded according to the Biomedical Waste Management Rules.
6.6.7 Handling laboratory waste

A well-managed and monitored biomedical waste management system must be in place in the
laboratory in accordance with the Biomedical Waste Management Rules.
Good laboratory practices (GLP)
 Use appropriate PPE.

 Do not operate new or unfamiliar equipment until proper training and authorization have been
given.
The international biohazard warning symbol and sign must be displayed on the doors of the rooms
where microorganisms of risk Group 2 or higher risk groups are handled.
 All persons entering the laboratory must have approval of laboratory in-charge.
 Minimize use of sharps. Sharps should be discarded in biohazard sharps containers that are
tamper-proof, puncture-proof and leak-proof, labelled and color-coded appropriately.

 Stocks and other cultures must be stored in a leak-proof container when work is complete. A
sealed, leak-proof container, labelled with a biohazard symbol, must be used to transport stocks
and cultures from one room to another.
 Cultures should be disinfected/ inactivated prior to disposal, either by chemical disinfection or
autoclaving.
 Broken glass must be handled using forceps/ tongs, not to be picked up by laboratory personnel
by hand. Broken glass must be disposed of in appropriately color-coded puncture-proof boxes
with the biohazard symbol.
 Staff must be aware of the location of eyewash stations and showers and must be trained on bio
safety including spill management.
6.6.8 Procedures for taking blood specimens

All blood should be considered potentially infectious. The following precautions are needed when taking
specimens:
Blood specimens from all patients should be collected in a separate area. Blood should not be taken in
any room normally used as a laboratory or office; and PPE should be worn, which include a clean
laboratory coat or gown and gloves.
Handling specimens submitted to the laboratory
 All specimens are to be received in a closed container labelled with appropriate patient
information along with duly filled specimen referral form.
 Test tube racks or trays must be used to transport specimens in the laboratory.
 Review, revise and modify the assessment – particularly if the nature of the work changes or if
developments suggest that it may no longer be valid.
In evaluating the risks, the key points to consider are the following:
 Listing of risk groups for microbiological agents that are involved

 pathogenicity of the agent and infectious dose;
 potential outcome of exposure;
 natural route of infection;
 other routes of infection, resulting from laboratory manipulations (parenteral, airborne,
ingestion);
 stability of the agent in the environment;
 concentration of the agent and volume of concentrated material to be manipulated;
 prevalence of particular infections in the local community;
 information available from animal studies and reports of laboratory-acquired infections or
clinical reports;
 Laboratory activity planned (sonication, aerosolization, centrifugation, etc.);
 likelihood of infection occurring (including during normal work and in the event of an accident);
 risks to laboratory staff and others such as visitors, cleaners, maintenance staff, contractors;

 competency of laboratory staff in handling the pathogen, whether the staff is trained to handle
the pathogen/ procedure in a safe manner; and
 Local availability of effective prophylaxis or therapeutic interventions.
Risks must be assessed at all sites where diagnostic testing is carried out, including hospital wards,
clinics, health centre and surgeries. If the assessments show that risks cannot be adequately controlled,
either appropriate arrangement must be made or the specimens may be sent elsewhere for processing.
SOPs must be in place in the laboratory for any anticipated accidents or contamination. Laboratory must
also keep a record of occurrence of any accidents in the laboratory, staff exposures, action taken and
procedures put in place to prevent future occurrences.

7
Preventing Infection among Health CHAPTER
Care Workers
7. Introduction
Healthcare workers (HCWs) perform various activities in varying environments that can put their health
and well-being at risk of harm. The administration of Healthcare facilities (HCF) is responsible for its
employees' safety and health. At the same time, HCWs are also responsible for adopting safe work
practices and taking necessary precautions to mitigate the risk during the course of their work.
Workers at risk in the healthcare environment-
 Hospital staff
 Medical staff
 Cleaning staff
 Laboratory technicians
 Employees of healthcare services
 Cleaning services
 Property management
 Environmental hygiene services: collection and disposal of healthcare waste
Hazards in the healthcare environment-
 Physical: e.g. injuries while lifting and shifting of patients

 Chemical: e.g. exposure to toxic chemicals such as disinfectants
 Biological: e.g. infections transmitted in the healthcare environment
 Radiation: e.g. radiation in X-ray and radiotherapy units
 Psychological: e.g. stress due to understaffing, night shifts
 Ergonomic: e.g. backache or neck ache or eye strain due to poorly designed seats, computer
workstations
 Accidents/ falls due to lack of patient safety arrangements.
7.1. Biological hazards

These hazards refer to organisms or organic material produced that harm human health. These include
parasites, viruses, bacteria, fungi and proteins.
Major biological hazards are:
 Blood-borne infections: HBV, HCV, HIV

 Respiratory infections: influenza, TB
 Others: viral hemorrhagic fevers (VHFs) such as Ebola virus disease (EVD)
7. Preventing Infection among Health Care Workers Page 115

The infections can be transmitted by:
 Percutaneous and mucocutaneous route

 Contact with body fluids or contaminated objects
 Respiratory route
Adherence to standard precautions and transmission-based precautions helps in protecting HCWs as

well as patients from transmission of infection in HCFs. Safe work practices help in preventing exposure
to hazards in the workplace.
7.2. Sharps management, sharp injuries/ occupational exposure and post-

exposureprophylaxis-
7.2.1. Sharp Management

Safe handling and disposal of sharps is a vital component of the Standard Precautions approach to
reduce the risk of transmission of blood-borneviruses.
Good practice involves
 Correct assembly of the sharps container with proper size opening.

 Label the container upon assembly as “SHARP CONTAINER” with a Biohazard symbol and
department name.
 Sharps container should not be more than three-fourths full.
 Sharps containers should be properly sealed before being it for final segregation.
 Being aware of the first aid treatment following a needle-stick injury.
 Being aware of the follow-up treatment after a used needle-stick injury.
Disposal of Sharps
 An adequate number of sharps containers are located and conveniently placed in clinical areas.
 Ensure that the sharps containers have been assembled correctly.
 Make sure the department’s name is identified on the sharps bin.
 Sharps (needles, scalpel blades, razor blades, glass ampoules etc.) should be placed directly into
a container.
 Whenever possible, take a sharps bin to the point of use.
 Needles must not be recapped, bent, or broken.
 If it is necessary to disassemble a needle and syringe, such as before transferring blood from a
syringe to a pathological specimen bottle, the needles are placed in the sharps container before
transferring the blood.
 Sharps containers should be sealed when three fourth (¾) full.
 Sharps containers, when carried, are to be held away from the body.
 Use needle safety devices with clear indications that they will provide a safer working system.
 It is the responsibility of the person using the sharp to dispose of it safely.

7.2.2. Occupational exposure &Sharp injuries-

Occupational exposure refers to exposure to potential blood-borne infections (HIV, HBV, and HCV) that
may occur in healthcare settings during the performance of duties. An exposure that might placeHealth
Care Workers at risk for HBV, HCV, or HIV infection is defined as:
 Sharp Injury- A percutaneous injury {e.g. - a needle stick injury (NSI) or cut with a sharp object}.
 Blood and body fluid exposure (BBF)-Contact of mucous membrane or non-intact skin {e.g.,-
exposed skin that is chapped, abraded or affected with dermatitis}, contact with blood, tissue,
or other body fluids that are potentially infectious.
 Contamination from an infected known case or highly suspicious person to another. The risks
are:
 Hepatitis B virus 1:3
 Hepatitis C virus 1:30
 Human Immunodeficiency Virus 1:300
*It has been estimated that the risk of acquiring HIV through mucous membrane exposure splashed with
contaminated body fluids is much less (probably 1 per 1000 injuries) - 0.1%.
Main Risks from Needle-
In stick injury and blood contamination, the main concern is the transmission of blood-borne viruses, i.e.
• Hepatitis B (HBV)
• Hepatitis C (HCV)
• Human Immunodeficiency Virus (HIV)
Body Fluids Likely to Be Infectious- There are more incidences of occupational exposure in the health
care situation; in these circumstances; the highest risk of transmission is from exposure to blood. The
risk is lower for other body fluids or body tissues from an infected patient.
Those which represent a lower risk are:-
 Cerebrospinal Fluid
 Peritoneal Fluid, Pleural Fluid, Pericardial Fluid, Synovial Fluid, Amniotic Fluid
 Semen
 Vaginal Secretions
 Breast Milk
 Any other body fluid containing visible blood, e.g., saliva
 Bleeding gums in association with bites
 Unfixed tissues and organs, i.e., those not preserved in formalin.

Risks from Injuries
The risk of transmission is higher (particularly for HIV) when there is: -
 A deep injury, i.e., when the injury is deeper than a superficial scratch drawing blood.
 Visible blood on the device that caused the injury (including teeth).
 Injury with a needle that had come from the source patient’s artery or vein.
 Terminal HIV-related illness in the source patient.
When may NSI (Needle stick injury) occur?
 Recapping needles (most important)

 Performing activities involving needles and sharps in a hurry
 Handling and passing needles or sharp after use
 Failing to dispose off used needles properly in puncture-resistant sharps containers
 Poor healthcare waste management practices
 Ignoring Universal Work Precautions.
Table No. 7.1: Infections transmitted by NSI / BBF
Blastomycosis Brucellosis Diphtheria Ebola fever

Hepatitis B Hepatitis C Herpes Scrub typhus
Malaria Mycobacteriosis Mycoplasmosis HIV
S. aureus S.pyogenes Syphilis Toxoplasmosis
Rocky mountain fever HIV Leptospirosis Tuberculosis Gonorrhea
7.2.3Management of the exposed site

First Aid-
For Skin (if the skin is broken after a needle stick or sharp instrument):
 Immediately wash the wound & surrounding skin with water & soap, and rinse.
 Do not scrub.
 Do not use antiseptics or skin scrub (bleach, chlorine, alcohol, betadine)
After a splash of blood or body fluid to unbroken skin:

 Wash the area immediately
 Do not use antiseptics.
For the Eye:

• Irrigate the exposed eye immediately with water or normal saline.
• Sit in a chair, tilt your head back, and gently ask a colleague to pour water or normal saline over
the eye.

• If wearing contact lenses, leave them in place while irrigating, as they form a barrier over the
eye and will help to protect it. Once the eyes are cleaned, remove the contact lenses and clean
them normally.
• Do not use soap or disinfectant on the eye.
For Mouth:
• Spit fluid out immediately
• Rinse the mouth thoroughly, using water or saline, and split again. Repeat this process several
times.
• Do not use soap or disinfectant in the mouth.
Table 7.2: Do’s &Don’t after NSI
Do’s Don’t
Remove gloves, if appropriate. Do not panic.
Wash the exposed site thoroughly with running Do not put the pricked finger in the mouth.
water.
Irrigate with water or saline if eyes or mouth Do not squeeze the wound to bleed it.
have been exposed.
Wash the skin with soap and water. Do not use bleach, chlorine, alcohol, betadine,
iodine or any antiseptic or detergent.
Figure 7.1:- Information Displayed on prevention and management of occupational hazards
NOTE:-Do consult the designated physician immediately as per institutional guidelines for management
of the occupational exposure. Report all needle stick injuries to the unit head/casualty medical officer.
Fill out the requisite Performa and send the blood sample to the microbiology laboratory for HIV, HBsAg
& HCV testing after pre-test counseling and consent of both patient and health care worker.

7.2.4 Post-Exposure Prophylaxis (PEP)

Post exposure prophylaxis" (PEP) refers to the comprehensive management given to minimize the risk of
infection following potential exposure to blood-borne pathogens (HIV, HBV,HCV). This includes:
1. First aid
2. Counseling
3. Risk assessment
4. Relevant laboratory investigations based on informed consent of the source and exposed
person.
5. Depending on the risk assessment, the provision of short term (4 weeks) of antiretroviral drugs.
6. Follow up and support
"Exposure" which may place an HCP at risk of blood-borne infection is defined as:
1. Percutaneous injury (e.g. needle-stick or cut with a sharp instrument),
2. Contact with the mucous membranes of the eye or mouth,
3. Contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or
afflicted with dermatitis), or
4. Contact with intact skin when the duration of contact is prolonged (e.g. several minutes or
more) with blood or other potentially infectious body fluids.
Table No. 7.3:Potentially infectious body fluids
Exposure to body fluids considered ‘at risk’ Exposure to body fluids considered ‘not at risk’
Blood
Tears
Semen
Vaginal Secretions
Sweat
Cerebrospinal fluid
Unless these secretions
Synovial, pleural, peritoneal fluid contain visible blood
Urine and feces
Amniotic fluid
Other body fluids contaminated with visible
Saliva
blood
Table No. 7.4:HIV transmission risk of different routes
Exposure route Risk of HIV

Blood transfusion 90-95%
Perinatal 20-40%
Sexual Intercourse 0.1-10%
Vaginal 0.05-0.1%
Anal 0.065-0.5%
Oral 0.005-0.01%
Injecting drugs use 067%
Needle stick exposure 0.3%
Mucous membrane splash to eye, oro-nasal 0.09%
Note: needle stick exposure for HBV is 9-30% and for HCV is 1-10%

Steps for managing occupational Exposure

0 hr 0 min As soon as possible Ideally within 2 hrs, but 6 months
certainly within 72 hrs
Timeline
Step 1: Step 2: Step 3: Step 4: Step 5: Step 6:

Manage Establish Counsel for Prescribe Laboratory Follow up
Exposure site Eligibility for PEP PEP Evaluation and Monitor
PEP adherence
Wash wound Provide Assess source Provide HIV
and surrounding Exposure within information on patient’s ARV pretest Record keeping
skin with water 72 hours HIV and PEP status Counseling
and soap Follow up visits
OR Obtain consent Check for Check for clinical
Assess exposed
Irrigate exposed for PEP pregnancy if immunization assessment at
individual
eye immediately exposed status for 2 weeks and
with water or Offer special female HCP hepatitis B hepatitis B
Assess exposure
normal saline vaccination if
source leave from
OR work Explain side- Offer HIV,HBV needed
Rinse the mouth effects of ARVs and HCV tset
thoroughly, Assess type of
exposure HIV test at 3 and
using water or Explain post- Draw blood to 6 months
saline and spit exposure include CBC,
again Determine risk of
transmission measures LFT, Pregnancy
against HBV & test if
Refer to HCV applicable
physician Determine
eligibility of
PEP Provide HIC post-
test counseling
Step 1: Management of exposure site - First Aid

For skin- If the skin is broken after a needle-stick or sharp instrument: Immediately wash the wound and
surrounding skin with water and soap, and rinse. Do not scrub. Do not use antiseptics or skin washes
(bleach, chlorine, alcohol, betadine).
After a splash of blood or body fluids:
To unbroken skin:
 Wash the area immediately

 Do not use antiseptics
For the eye:
 Irrigate exposed eye immediately with water or normal saline.

 Sit in a chair, tilt head back and ask a colleague to gently pour water or normal saline over the
eye.

 If wearing contact lens, leave them in place while irrigating, as they form a barrier over the eye
and will help protect it.
 Once the eye is cleaned, remove the contact lens and clean them in the normal manner. This
will make them safe to wear again.
 Do not use soap or disinfectant on the eye.
For mouth:
 Spit fluid out immediately.

 Rinse the mouth thoroughly, using water or saline and spit again. Repeat this process several
times.
 Do not use soap or disinfectant in the mouth.
 Consult the designated physician of the institution for management of the exposure
immediately.
Table No. 7.5: Summary of do’s and don’t
Do Do not
Remove gloves, if appropriate Do not panic

Wash the exposed site thoroughly with running
Do notput the pricked finger in mouth
water.
Irrigate with water or saline if eyes or mouth have
Do notsqueeze the wound to bleed it
been exposed
Do notuse bleach, chlorine,alcohol,betadine,iodine or
Wash the skin with soap and water
other antiseptic/detergents on the wound
** Do- Consult the designated physician immediately as per institutional guidelines for management of the
occupational.
Step 2: Establish eligibility for PEP
The HIV sero-conversion rate of 0.3% after an AEB (for percutaneous exposure) is an average rate. The
real risk of transmission depends on the amount of HIVtransmitted (= amount of contaminated fluid and
the viral load).
A designated person/trained doctor must assess the risk of HIV and HBV transmission following an AEB.
This evaluation must be made rapidly, so as to start any treatment as soon as possible after the accident
(Ideally within 2 hours but certainly within 72 hours). This assessment must be made thoroughly
(because not every AEB requires prophylactic treatment).
The first dose of PEP should be administered within the first 72 hours of exposure and the risk
evaluated as soon as possible. If the risk is insignificant, PEP could be discontinued, if already
commenced. Two main factors determine the risk of infection:

 The nature of exposure and

 The status of the source patient
2.1 Assessing the nature of exposure and risk of transmission:
Three categories of exposure can be described based on the amount of blood/fluid involved and the
entry port. These categories are intended to help in assessing the severity of the exposure but may not
cover all possibilities.
1. Determination of the Exposure Code (EC)

• Exposure code can be defined as per the flow chart given below:
Is source material blood, bloody fluid , semen/vaginal fluid or other potentially infected
material or an instrument contaminated with one of these substances.
No PEP required
YES NO
What type of exposure occurred?
Mucous membrane or skin Percutaneous

integrity compromised Intact skin
exposure
Severity
Volume No PEP required
Large: Major Less severe: solid Major severe: large

Small few Drops
splash/long duration Needle , scratch bore hollow needle ,
deep puncture
EC 1 EC 2 EC 2 EC 3

2.2 Assessing the HIV status of the source of exposure:
 PEP needs to be started as soon as possible after the exposure and within 72 hours. In animal
studies, initiating PEP within 12, 24 or 36 hours of exposure was more effective than initiating
PEP 48 hours or 72hours following exposure
 PEP is not effective when given more than 72 hours after exposure. A baseline rapid HIV testing
should be done before starting PEP
 Initiation of PEP where indicated should not be delayed while waiting for the results of HIV
testing of the source of exposure
 Informed consent should be obtained before testing of the source as per national HIV testing
guideline.
Determination of status code by NACO
HIV Exposure Source
HIV Negative HIV Positive Status/Source

Unknown
No PEP Required HIV SC unknown

Low titer exposure, High titer Exposure
Asymptomatic , Advanced disease,
High CD4 Low CD4
HIV SC 1 HIV SC 2
2.3 Assessment of the exposed individual:
 The exposed individual should have confidential counseling and assessment by an experience
physician.

 The exposed individual should be assessed for pre-existing HIV infection intended for people
who are HIV negative at the time of their potential exposure to HIV.
 Exposed individuals who are known or discovered to be HIV positive should not receive PEP.
They should be offered counseling and information on prevention of transmission and referred
to clinical and laboratory assessment to determine eligibility for antiretroviral therapy (ART). •
 Besides the medical assessment, counseling exposed HCP is essential to allay fear and start PEP
(if required) at the earliest.
Step 3: Counselingfor PEP
 Exposed persons (clients) should receive appropriate information about what PEP is about and
the risk and benefits of PEP in order to provide informed consent.
 It should be clear that PEP is not mandatory.
 Informed Consent.
 Psychological support: Many people will feel anxious after exposure. Every exposed person
needs to be informed about the risks and the measures that can be taken. This will help to
relieve part of the anxiety, but some may require further specialized psychological support.
 Documentation on record is essential. Special leave from work should be considered for a period
of time eg. 2 weeks (initially) then, as required based on assessment of the exposed person’s
mental state, side effects and requirements.
Step 4: Prescribe PEP
Step 4.1: Deciding on PEP regimen
Table No. 7.6: PEP Recommendation

Exposure code * HIV Source Code** PEP Recommendation Duration
1 1 Not warranted
1 2 Recommend PEP 28 days
2 1
2 2
3 1 or 2
2/3 Unknown Consider PEP, if HIV prevalence is high in
the given population and risk
categorization
In case of sexual assault- PEP should be provided to exposed person in case of sexual assault as apart of
overall package of post sexual assault care.
4.2 Initiate HIV Chemoprophylaxis
 Because post-exposure prophylaxis (PEP) has its greatest effect if begun within 2 hours of
exposure, it is essential to act immediately. There is little benefit if >72 hours later. The
prophylaxis needs to be continued for 4 weeks.

 Report exposure immediately to appropriate authority.

 Never delay start of therapy due to debate over regimen. Begin with basic 2-drug regimen, and
once expert advice is obtained, change as required.
 The 3rd drug can be added after consultation with an expert
4.3 Selection of the PEP regimen when the source patient is known to be on ART:
The physician should consider the comparative risk represented by the exposure and
information about the exposure source, including history of and response to antiretroviral
therapy based on clinical response, CD4cell counts, viral load measurements (if available), and
current disease stage (WHO clinical staging and history). When the source person's virus is
known or suspected to be resistant to one or more of the drugs considered for the PEP regimen,
the selection of drugs to which the source person's virus is unlikely to be resistant is
recommended.
4.4 PEP regimen

a. Wherever PEP is indicated and source is ART naïve or unknown: recommended regimen
is Tenofovir 300 mg + Lamivudine 300mg + Efavirenz 600 mg once daily for 28 days.
Wherever available, single pill containing these formulations should be used. Dual drug
Regimen should not be used any longer in any situation for PEP.
b. The first dose of PEP regular should be administered as soon as possible, preferably
with in 2 hours of exposure and the subsequently dose should be given at bed time with
clear instruction to take it 2-3 hours after dinner and to avoid fatty food in dinner.
c. In case of intolerance to Efavirenz, regimen containing Tenofovir + Lamivudine + PI
(ATV/r or LPV/r) can be used after expert consultation by an experienced physician.
d. In case of exposure where source is on ART, Tenofovir 300 mg + Lamivudine 300mg +
Efavirenz 600 mg should be start immediately and an expert opinion should be sought
urgently by phone/email from CoE / ART plus centre.
e. Appropriate and adequate counselling must be provided regarding possible side effects
and adherence & follow up protocol
4.5 Antiretroviral drugs during pregnancy
If the exposed person is pregnant, the evaluation of risk of infection and need for PEP should be
approached as with any other person who has had an HIV exposure. However, the decision to use any
antiretroviral drug during pregnancy should involve discussion between the woman and her health-care
provider (s) regarding the potential benefits and risks to her and her fetus. Data regarding the potential
effects of antiretroviral drugs on the developing fetus or neonate are limited. There is a clear
contraindication for Efavirenz (first 3 months of pregnancy) and Indinavir (pre natal). In conclusion, for a
female HCP considering PEP, a pregnancy test is recommended if there is any chance that she may be
pregnant. Pregnant HCP are recommended to begin the basic 2-drug regimen, and if a third drug is
needed, Nelfinavir is the drug of choice.

4.6 Side-effects and adherence of PEP
Studies of HCP taking PEP have reported more side effects than PLHAs taking ART, most commonly
nausea and fatigue. Possible side-effects occur mainly at the beginning of the treatment and include
nausea, diarrhea, muscular pain and headache. The person taking the treatment should be informed
that these may occur and should be dissuaded from stopping the treatment as most side-effects are
mild and transient, though possibly uncomfortable. Anemia and/or leucopenia and/or
thrombocytopenia may occur during the month of treatment. A complete blood count and liver function
tests (transaminases) may be performed at the beginning of treatment (as baseline) and after 4 weeks.
In practice and from HCP studies, many HCP did not complete the full course of PEP because of side
effects. Side effects can be reduced by prescribing regimens that do not include a protease inhibitor (PI),
by giving medications to reduce nausea and gastritis and by educating clients about how to reduce side
effects eg. taking PEP medications with food. It is important that side effects should be explained before
initiating PEP so that the symptoms are not confused with symptoms of sero conversion to HIV.
Adherence information is essential with psychological support. More than 95% adherence is important
in order to maximize the efficacy of the medication in PEP.
4.7 Amount of medication to dispense of PEP
 All clients starting on PEP must take 4 weeks (28 days) of medication.
 In all cases, the first dose of PEP should be offered as soon as possible, once the decision to give
PEP is made.
 HIV testing or results of the source HIV test can come later.
 As usage of PEP drugs is not frequent and the shelf life is 1 to 1.5 years, it is proposed that
starter packs for 7 days can be put in the emergency department with instructions to go to a
designated clinic/officer within 1-3 days for a complete risk assessment, HIV counseling and
testing and dispensing of the rest of the medications and management.
 At least 3 such kits are provided in the casualty department.
Step 5: Laboratory evaluation
The reason for HIV testing soon after an occupational exposure is to establish a "baseline" against which
to compare future test results.
 If the HCP is HIV-negative at the baseline test, it is in principle possible to prove that subsequent
infection identified by follow-up testing is related to the occupational exposure (Depending on
the timing of infection and consideration of other risks or exposures).
 When offered HIV testing, the exposed person should receive standard pre-test counseling
according to the national HIV testing and counseling guidelines, and should give informed
consent for testing.
 Confidentiality of the test result must be ensured. There are different reasons for possibly
delaying HIV testing: the HCP may be unable to give informed consent immediately after the

exposure due to anxiety, the exposure occurs outside working hours or in settings where HIV
testing is not readily available.
 The HIV test may be done up to several days after the exposure, based on informed consent and
with pre- and post-test counseling and ensuring confidentiality.
 Do not delay PEP if "IV testing is not available.
Step 6: Follow-up of an Exposed Person
6.1 Clinical follow-up
 In addition, in the weeks following an AEB, the exposed person must be monitored for the
eventual appearance of signs indicating an HIV seroconversion: acute fever, generalized
lymphadenopathy, cutaneous eruption, pharyngitis, non-specific flu symptoms and ulcers of the
mouth or genital area.
 These symptoms appear in 50%-70% of individuals with an HIV primary (acute) infection and
almost always within 3 to 6 weeks after exposure. When a primary (acute) infection is
suspected, referral to an ART centre or for expert opinion should be arranged rapidly.
 An exposed person should be advised to use precautions (e.g., avoid blood or tissue donations,
breastfeeding, unprotected sexual relations or pregnancy) to prevent secondary transmission,
especially during the first 6-12 weeks following exposure. Condom use is essential.
 Adherence and side effect counseling should be provided and reinforced at every follow-up visit.
Psychological support and mental health counseling is often required.
6.2 Laboratory follow-up
 Follow-up HIV testing: exposed persons should have post-PEP HIV tests. Testing at the
completion of PEP may give an initial indication of sero-conversion outcome if the available
antibody test is very sensitive.
 However, testing at 4-6 weeks may not be enough as use of PEP may prolong the time to
seroconversion; and there is not enough time to diagnose all persons who seroconvert.
 Therefore, testing at 3 months and again at 6 months is recommended.
 Very few cases of sera conversion after 6 months have been reported. Hence, no further testing
is recommended if the HIV test at 6 months is negative.

Table No. 7.7 : Flow chart for Management of Sharps-Rel ated Accidents
S.no. Activity Person responsible

1. Wash the area with plenty of soap and water immediately and The injured person with
rinse. Do not squeeze or suck the area. Do not use antiseptics or the assistance of a
skin washes (bleach, chlorine, alcohol, betadine). colleague
2. Report to the nearest Nursing In-charge/On-duty Nurse(in The injured person with
emergency hours) the assistance of a
colleague
3. The Nursing In-charge/On-duty Nurse administers Inj.Tetanus Nursing In-charge/On-
Toxoid 0.5ml IM to the exposed person if he has not taken it in the duty Nurse
past 10 years.
4. The Nursing In-charge/On-duty Nurse should report to the Nurse in Nursing In-charge/On-
charge of BMW Management who would fill up the specified form duty Nurse
for documenting the details of exposure, severity of exposure,
seropositivity status of source of exposure, vaccination status of the
exposed individual, etc,
5. The Nursing in-charge/On-duty Nurse should also send source Nursing In-charge/On-
blood samples for testing HBV/HCV/HIV to the Microbiology Lab if duty Nurse
the source infection status is unknown.
6. The Nurse in charge of BMW Management counsels the exposed Nurse In-charge of BMW
healthcare worker to submit blood samples for HBV, HCV&HIV Management
testing.
7. The Nurse In-charge of BMW Management guides the exposed Nurse In-charge of BMW
HCW through the appropriate line of post-exposure prophylaxis and Management
refers him to the designated physician.
8. The Nurse in charge of BMW Management Nurse In- charge of BMW

Documents the result of follow-up investigations at 3 & 6 Management
Months in the designated form.

SOURCE STATUS STEPS IN POST-EXPOSURE PROPHYLAXIS

HIV/HBV/HCV status  Check exposed for HIV/HBs Ag /HCV/Anti HBs Ag level.
unknown  If exposure is partially immunized or unimmunized for HBV, start HBV
vaccination.
 If the chances of a needle belonging to HIV patient are high, start on a
basic regime with a starter pack.
 The exposed HCW is counseled to meet the designated physician
within 24hours of exposure for risk assessment and continuation of
anti-retroviral treatment.
 Follow-up of HIV/HBs Ag & HCV at 3 & 6 months.
HBV Positive Exposed person is Exposed person is Exposed person is

unvaccinated Incompletely Fully vaccinated
vaccinated
 HBIG0.06  Anti-HBs titer  Anti-HBs titer
ml/kg  HBIG if Anti-HBs  If Anti-HBs titer is
 Vaccinate titer >10mU/ml, no
for HBV is<10mU/ml further action
 Continue the required
vaccination  HBIG if Anti-HBs titer
schedule. is <10mU/ml
Repeat HBs Ag at 3 & 6months.
HCV Positive  Test the exposed for Anti-HCV and baseline LFT.
 Refer to the designated physician.
HIV Positive  Pregnancy status of the HCW is to be ascertained.

 Start post-exposure prophylaxis.
 Refer patient to physician immediately or definitely within the next 24
hours for counseling & further management.
 Test HIV status of exposed by ELISA at 3 and 6months.
Prevention of Needle stick Injury
1. Avoid recapping the needles; If unavoidable, use single hand scoop technique.
2. Never break or bend the needles
3. Never pass the sharps directly in your hands (use trays).
4. Never place used sharps on tables, beds, or furniture.
5. Always dispose of sharps at the point of use.
6. Use needle cutters/burners/sharp boxes for disposal of sharps

7.3 Immunization of healthcare workers
Healthcare Workers / Healthcare Personnel (HCP) are the persons who provide healthcare to patients or
to those who work in an institution that provides healthcare. Healthcare Personnel (HCP) refers to all
people working in healthcare setting who have the potential for exposure to patients and/or to
infectious materials, including body substances, contaminated medical supplies and equipment,
contaminated environmental surfaces, or contaminated air. HCP include physicians, nurses, nursing
assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists,
laboratory personnel, autopsy personnel, students, trainees, contractual staff and people (e.g., clerical,
dietary, housekeeping, laundry, security, maintenance, billing, administrators and volunteers) not
directly involved in patient care but potentially exposed to infectious agents that can be transmitted to
and from HCP and patients. Healthcare workers (HCW) are at risk for exposure to a number of diseases,
of which some are serious (because of high risk of complication), and may sometimes be deadly.
7.3.1 Measures adopted to minimize the risk of disease among HCW-

❖ Adherence to standard precaution
❖ Isolation of patient with known communicable disease
❖ Proper use of Personal Protective Equipment
❖ Appropriate immunization of HCP
❖ Post-exposure prophylaxis
Benefits of immunization:
Cost-effective in comparison to treatment gives indirect protection to other staff, family members of
HCW, patients and visitors.
7.3.2 Immunization of HCW

1. Active—Pre-exposure and Post-exposure
2. Passive—Post-exposure
Vaccines recommended for HCW (as per CDC guidelines)

 Hepatitis B*
 Influenza
 Measles
 Mumps
 Rubella
 Tetanus, diphtheria, and acellular pertussis (Tdap)
 Varicella
* For HCW potentially at risk to blood or body fluids
Biomedical waste management and handling rules (2016) of India mentions about Hepatitis B and
Tetanus toxoidvaccination.

Table 7.7 Dosage &Schedule of Vaccines

Vaccine Dose Schedule Amount Route Effectiveness
Hepatitis B Three 0,1m,6m or 0,1m,2m* 1ml IM 90% in < 40 yrs
doses *Booster after 1yr
Influenza One dose Inactivated 0.5ml IM Variable
annually
Live attenuated 0.5ml Intranasal 0.25
ml per nostril
MMR Two doses 4wks apart 0.5m SC 99% measles
-Measles and rubella
-Mumps 75-95% mumps
One dose
-Rubella
Varicella Two doses 4-8wks apart 0.5ml SC 80%
**
Tdap* One dose 0.5ml IM 92%
* Booster dose of Td every 10yr revaccination during each pregnancy with one dose of Tdap
** Persons who have previously been infected with Chickenpox are immune to reinfection and do not
require vaccination.
7.3.3. Pre and post-exposure prophylaxis using various vaccines

Hepatitis B Vaccine (Pre-Exposure Prophylaxis)
Dosage schedule: Three doses-1ml IM at 0,1month &6month or 0,1month &2month (with booster after
1yr)
Testing for immunity after vaccination:
 Newly vaccinated HCWsshould be tested for immunity 1–2 months after completing the 3-dose
series.
 Anti-HBs >10mlU/ml no action
 Anti-HBs <10mlU/ml revaccinate
o 3 doses followed by testing (1-2 months after the third dose)
o Anti-HBs<10mlU/ml after revaccination test for HBs Ag
 HBsAg positive provides appropriate management
 HBsAg negativeNon-responder –susceptible to HBV infection
o Counsel: precautions to prevent HBV infection (PEP,etc)
o HBIG post-exposure prophylaxis for parenteral exposure to HBsAg-positive blood
Non-responders for Hepatitis B

 10%-15% fail to respond to the primary series of vaccine
 30%-50% chance of responding to a second 3-dose series.
 Risk of non-response

o Smoking
o Obesity
o Genetic factors
o Immune suppression
o Age >40yrs
o Chronic illness
o Female sex
HCWs who have been previously immunized with Hepatitis B
Measure Anti-HBs
a. Anti- HBs>10mlU/ml – No action
b. Anti- HBs <10mlU/ml
Measure Anti HBs After 1month*
 Anti-HBs >10mlU/ml- no action
 Anti- HBs <10mlU/ml
 Administer two more dose (1 & 6 month) and measure Anti HBs.
 Anti-HBs <10mlU/m--Evaluate for each exposure
 Anti-HBs>10mlU/ml—No action
*If it is not feasible to measure antibody titer after one month, one can go for 2nd 3-dose series of
vaccine.
Table 7.8: Post Exposure Prophylaxis for Hepatitis B (HB)
Vaccination and Treatment
antibody response
Source HBsAg positive Source HBsAg negative Source unknown or not
status of exposed
available for testing
worker*
Unvaccinated HBIG X 1 and initiate HB Initiate HB vaccine Initiate HB vaccine
vaccine series series series
Previously vaccinated No treatment No treatment No treatment
known responder
Know non- responder HBIG X 1 and initiate No treatment If known high risk
revaccination*** or source, treat as if
HBIG X 2**** source were HBsAg
positive
Antibody response Test exposed person No treatment Test exposed person

unknown for anti-HBs for anti-HBs
1. If adequate, no 1. If adequate, no
treatment is necessary treatment is necessary
2. If inadequate, 2. If inadequate,
administer HBIG X 1 administer vaccine
and vaccine booster booster and recheck
titer in 1-2 months

* Persons who have previously been infected with Hepatitis B are immune to reinfection and do not
require post-exposure prophylaxis.
**Hepatitis B Immunoglobulin (HBIG).
***Persons exposed to HBsAg-positive blood or body fluids and not responded to a primary vaccine
series
A single dose of HBIG and restart the hepatitis B vaccine series
or should receive two doses of HBIG, one dose as soon as possible after exposure, and the second dose
1 month later.
****For persons who previously completed a second vaccine series but failed to respond
two doses of HBIG are preferred
Influenza Vaccine
 Live Attenuated Influenza Vaccines (LAIV): One dose vial (with 0.5 ml diluent) and five dose vials
(with 2.5 ml diluent) are available.
 A dose of 0.5 ml is administered as 0.25 ml per nostril using 0.5 ml or 1 ml syringe and spray
device. (One dose annually)
 HCWs, who work with patientshoused in protected environments like stem cell transplant units,
should avoid working for 7 days after receiving the vaccine.
 Inactivated Vaccine—
 0.5ml IM (One dose annually)
 If age>50 yrs-Inactivated vaccine
 If egg allergy-Inactivated vaccine
 (if, only hives one can give LAIV)
MMR Vaccine
 0.5ml SC (2 doses 4 weeks apart for protection against mumps and measles; one dose gives
protection against rubella)
 Avoid pregnancy for one month after vaccination
Exposure to Measles
 If exposed to measles without evidence of immunity–offer the first dose of MMR vaccine or
Immunoglobulin and exclude from work from day 5–21 following exposure (under observation)
 If immune globulin is administered, observations should continue for signs and symptoms of
measles for 28 days after exposure (immune globulin might prolong the incubation period)
Tetanus Vaccine
 Pre-exposure —3 doses (0,1m, 1yr)—0.5 ml-IM(if not immunized during childhood)

 Post-exposure (for clean minor wounds)—
 Previously immunized—
o Last dose within 5 yr—No vaccine
o Last dose within 5–10yr—One dose of TT

o Last dose within >10yr—One dose of TT*

o Not immunized—Complete course—3 doses*(0,1m,1yr)
*If an unclean wound (wound contaminated with saliva, deep puncture wound, etc—add ATS/Human Ig
in the above two categories)
Special Circumstances
Vaccine for HCW (Laboratory Personnel) in Special Situation

 The following vaccines may be required based on the risk of exposure to the mentioned
organisms/ infections.
 Anthrax
 Hepatitis A
 Meningococcal*
 Pneumococcal
 Polio
 Rabies
 Typhoid
 Vaccinia
 Zoster
*Those who are routinely exposed to isolates of N. meningitidis should get one dose of Men ACWY and
Men B (two vaccines can be given simultaneously but in two different anatomical sites)
Active immunization and post-exposure prophylaxis
 TT/Tdap
 Hepatitis B
 Measles-within 3 days of exposure
 Varicella-within 3-5 days of exposure
Passive immunization and post-exposure prophylaxis
 Hepatitis B-HBIg 0.06ml/kg IM within 7days

 Varicella-VariZIg-12.5unit/kg(max 625U)-IM within 10 days(Pregnant and immunocompromised)
 Hepatitis A-Ig-0.02ml/kg-IM within 14days (>40 yrs)
 Measles-Ig-0.25ml/kg(max 15ml)-IM within 6 days
 Tetanus-ATS(1500) or Human IG (250 units)-IM
7.3.4 Information related to vaccination

Immunization in Special Groups
 Pregnancy:-Avoid live vaccine
 Immune-compromised
 Live vaccine contraindicated

 Extra vaccines required -H.influenzae, pneumococcal ,meningococcal

 Higher dosesof routine vaccinesin some cases
Some Basic Principles of Immunization
 Two live parenteral vaccines—either give simultaneously or keep 4wks interval
 MMR-avoid pregnancy for one month
 Live Attenuated Influenza Vaccine (LAIV)-avoid working with pregnant and immune-
compromised persons for 7 days
Information to be kept while Giving Vaccination
 Name
 Age
 Date of immunization
 Potential contraindication
 Vaccine provided
 Name of manufacturer
 Lot number
 Site and route immunization
 Date for next dose/additional vaccine
 Complications(if any)
Contraindications for Vaccination
 Permanent—Severe allergic reaction to any component of vaccine—gelatin, neomycin, yeast,
egg protein etc.
 Temporary (For live vaccine)
o Pregnancy
o Immunodeficiency
Precautions for Vaccination
 Moderate or severe acute illness (all vaccines)
 Recent receipt of an antibody containing blood product (MMR and varicella only).
 Tuberculin test in 4 weeks (MMR)
No Contraindications to Vaccination
 Mild illness
 Antimicrobial therapy*
 Disease exposure or convalescence
 Pregnant or immuno-suppressed person in the household **
 Breastfeeding
 Preterm birth
 Allergy to products not present in vaccine or allergy that is not anaphylactic
 Family history of adverse events
 Tuberculin skin test
* Except for oral typhoid and live attenuated influenza vaccine

**Except live attenuated influenza vaccine
A contraindication is a condition that makes a particular treatment or procedure, such as vaccination
with a particular vaccine, inadvisable.

Precautions are not contraindications but are events or conditions to be considered in determining if the
vaccine’s benefits outweigh the risks.
Staff records-
Healthcare management should maintain records of screening results and immunizations provided,
including the history of vaccine-preventable disease, serology date and results, and vaccine refusal
records. Date of giving the vaccine and batch number, type, and brand name of the vaccine. Records
need to be secure and maintained following confidentiality.
7.4 Human factors:
7.4.1. What are human factors and why is it important to patient safety?
The meaning of the terms “human factors” and “ergonomics”. The terms human factors and ergonomics
(as it is sometimes called) are used to describe interactions between three interrelated aspects:
individuals at work, the task at hand and the workplace itself.
Or
Human factor is the study of the interrelationship between humans, the tools and equipment they use
in the workplace, and the environment in which they work.
7.4.2. The relationship between human factors and patient safety

It is important for all healthcare workers to be mindful of situations that increase the likelihood of error
for human beings in any situation. This is especially important for medical staff and other inexperienced
junior staff to be aware of.
The two factors with the most impact are fatigue and stress. There is strong scientific evidence linking
fatigue and performance decrement making it a known risk factor in patient safety. Prolonged work has
been shown to produce the same deterioration in performance as a person with a blood alcohol level of
0.05 mmol/l, which would make it illegal to drive a car in many countries.
The relationship between stress levels and performance has also been confirmed through research.
While high stress is something that everyone can relate to, it is important to recognize that low levels of
stress are also counterproductive, as this can lead to boredom and failure to attend to a task with
appropriate vigilance. Example -The acronym IM SAFE (illness, medication, stress, alcohol, fatigue,
emotion) that was developed in the aviation industry is useful as a self-assessment technique to
determine when entering the workplace each day whether a person is safe for work.
7.4.3 What needs to be done to limit the potential errors caused by human factors
1. Avoid reliance on memory- Success in examinations requires students to remember lots of facts
and information. This is fine for exams, but when it comes to treating patients, relying solely on
memory is dangerous, particularly when the result may be a patient receiving thewrong dosage
or drug.
2. Staff should look for pictures and diagrams of the steps involved in a treatment process or
procedure. Checking one’s actions against a picture diagram can reduce the load on the working
memory. This frees the staff to focus on the tasks in real-time, such as taking a history or
ordering the drugs from the hospital pharmacy.

3. Make things visible- A good example of making the right thing to do more visible is using
pictorial reminders to staff and patients about hand washing—this has proven effective in
improving hand washing compliance and technique.
4. Review and simplify processes- Simple is better. This statement applies to all walks of life,
including health care. Some healthcare tasks have become so complicated that they are a recipe
for errors—examples include hand-off (or hand-over) and discharge processes. Making handoff
simpler by implementing communication strategies that are fewer in number but more clear in
purpose will reduce errors. Staff can help simplify communication processes by repeating back
instructions and ensuring they understand any protocols being instituted. If there is no protocol
for handoffs
5. Standardize common processes and procedures- Even though staff will be working in one place
(clinic or hospital), they may observe that each department or ward does common things
differently. This means that they have to relearn how things are done when moving to each new
area. Hospitals that have standardized the way they do things (where appropriate) help staff by
reducing their reliance on memory—this also improves efficiency and saves time. Drug order
forms, discharge forms, prescribing conventions and types of equipment can all be standardized
within a hospital.
6. Routinely use checklists- Checklists have been successfully applied in many areas of human
endeavor— studying for exams, traveling, shopping, and in health care. Checklists are now
routine in surgery. Staff should use checklists in their practice, particularly when there is an
evidence-based way of implementing a treatment.
7. Decrease reliance on vigilance- Humans quickly become distracted and bored if not much is
happening. Students should be alert to possible errors when they are involved in lengthy,
repetitive activities. In such situations, most of us will have decreased attention to the task at
hand, particularly if we become tired. Our efforts to stay focused will fail at some point.
7.4.4. Risk assessment –

Human beings are not machines; machines, when maintained, are, on the whole, very predictable and
reliable. In fact, compared to machines, humans are unpredictable and unreliable, and our ability to
process information is limited due to the capacity of our (working) memory. However, human beings are
very creative, self-aware, imaginative, and flexible in their thinking.
Human beings are also distractible, which is both a strength and a weakness. Distractibility helps us
notice when something unusual is happening. We are very good at recognizing and responding to
situations rapidly and adapting to new situations and new information. However, our ability to be
distracted also predisposes us to error because by being distracted, we may ignore the most important
aspects of a task or situation. Consider a medical student taking blood from a patient. As the student is
in the process of cleaning up after taking the blood, a patient in a neighboring bed calls out for
assistance. The student stops what she is doing, goes to help, and forgets that the blood tubes are not
labelled, which the student forgets when she returns to collect the tubes. Or consider a nurse taking a
medication order over the telephone and being interrupted by a colleague asking a question; the nurse

may mishear or fail to check the medication or dosage due to the distraction. Our brain can also play
“tricks” on us by misperceiving the situation, contributing to errors.
7.4.5. Point of risk care assessment (PCRA)

The PCRA is a routine practice that should be conducted before every patient/client/resident (hereafter
patient) interaction by health care workers (HCW) to assess the likelihood of exposing themselves
and/or others to infectious agents. This assessment informs the selection of appropriate action and
Personal Protective Equipment (PPE) to minimize the risk of exposure. This is the general tool. The
questions and actions may need to be adapted for specific healthcare settings and role.
Figure 7.2 : Point of care risk assessment
Example- COVID-19 point of care risk assessment tool by CDC
A. Before each patient interaction, a healthcareworkermust assess the following-

The patient
 What are the patient’s symptoms (e.g., frequent coughing or sneezing)?

 Does the patient require additional precautions(droplet, contact, airborne) for infectious
agents?
 What is the patient’s health status (e.g., immune-compromised)?
 Is the patient able to practice respiratory etiquette and perform hand hygiene?
The Task
 What type of task am I carrying out(e.g., providing direct face-to-face care, performing an
aerosol-generating medical procedure(AGMP), coming into contact with body fluids, personal
care, and non-clinical interaction)?
 Am I trained, equipped & ready for the task?
The Environment
 Where am I doing my task?

 Is there triage or screening?
 Is the patient in an isolation room? Is the bathroom shared?
 Can physical distancing be maintained?
 Is there Cleaning & disinfection?
B. Choose appropriate actions and PPE including the following:
 Hand Hygiene (e.g., before and after task, before and after PPE use, before and after contact
with the patient).
 Respiratory etiquette (e.g., support the patient to cover their coughs with a tissue or their
elbow)
 Patient placement (e.g., prioritize a patient with risks for infectious agents a single room where
possible).
 Physical distancing (e.g., encourage the patient to maintain a two-meter physical distance if
direct care is not involved).
 Environmental & equipment cleaning &disinfection (e.g., clean re-usable equipment between
each use).
 Implement additional precautions if required (e.g., droplet and contact precautions for COVID-
19)
 Select appropriate pieces of PPE, as outlined below.

Selecting PPE
Wear mask as per the provincial mask use in health care setting policy.
Wear eye protection if entering the patient/exam room or bed space or when within 2 meters of a patient. If
additional precautions (i.e. droplet , contact, airborne) are in place, put on all required PPE.
Could my hands Could my eyes or Could my clothing or skin Is there a risk of airborne
be exposed to face be slashed with come into contact with transmission (e.g. tuberculosis ,
blood or body blood or body fluids blood or body fluids, performing AGMP on the
fluids including splashes/sprays patient at COVID-19 risk?
Yes Yes Yes Yes
Wear Gloves Wear mask and eye Wear gown Wear N95 respirator
protection or equivalent
7.5 Occupational health programme:

An occupational health programme is essential for an effective IPC programme and has implications for
patient safety. The components of such a programme are:
 Evaluation ofthe general health of employees including infectious diseases at entry, periodically
as required
 Screening for vaccination for childhood communicable diseases (measles, rubella, chickenpox,
diphtheria, pertussis, tetanus)
 Hepatitis B status and immunization
 Influenza vaccine, TST status
 Screening for tuberculosis
 Surveillance and management of exposure risk: hazard identification, risk assessment and
control, post-exposure management
 Education and training.

8
CSSD Work Protocol CHAPTER
8.1 Introduction
The central sterile supply department (CSSD) is one of the critical features of the hospital. It aims to
centralize the activities of receipt, cleaning, assembly, sterilization, storage, and distribution of sterilized
materials from a central department where it is microbiologically safe.
It is imperative that the Hospital must provide adequate facilities for cleaning, sterilization, and storage
of equipment and instruments to ensure the care and safety of patients and the safety of staff, at all
times. The sterilization process may be carried out entirely or partially on-site, the latter relying on an
external supply source to regularly restocks the hospital sterile goods store/s.
8.2 Functional Areas

The Central Sterile Supply Unit will include the following functional areas or zones:
 Receiving Area where soiled articles for recycling are received on trolleys from Units throughout
the facility
 Decontamination Area where all articles are sorted, rinsed, ultrasonically cleaned or
mechanically washed, then mechanically dried; this area may also include cleaning of the
delivery trolleys
 Packing Area (Clean Workroom) where the clean instruments, equipment, and other articles are
sorted, counted, and packaged for sterilizing
 Sterilizing and Cooling Area where sterilizers are loaded, set into operation, and unloaded
following completion of the sterilizing cycle
 Dispatch Area where sterile stock is held before dispatch to Units in the facility; distribution
trolleys may also be located in this area
A unidirectional flow ‘dirty’ area to the ‘clean’ area should be maintained for optimum functioning.
There should be a changing area for a worker, including toilet facilities and lockers in proximity to the
decontamination area.
Figure 8.1: Functional area of CSSD
8. CSSD Work Protocol Page 142

8.3 Collection and Distribution of Items

All items should be collected and distributed twice a day and, if necessary, whenever required. CSSD
items should be transported to the wards in a manner that ensures that the sterility of the items is
maintained. When the items are collected back from the patient care areas, the quantity of each
collected item is recorded in a book. These items are transported to CSSD. Depending on the
requirement, another set of personnel transports sterile items to the various wards. Items which have
crossed the expiry date should be returned and new ones obtained.
8.4 Monitoring Sterilization

Sterilization procedures should be monitored using biological, mechanical, and chemical indicators.
Biological indicators, or spore tests, are the most accepted means of monitoring sterilization because
they assess the sterilization process directly by killing known highly resistant microorganisms (e.g.,
Geobacillus or Bacillus species). However, because spore tests are only done weekly and the results are
usually not obtained immediately, mechanical and chemical monitoring should also be done.
Mechanical and chemical indicators do not guarantee sterilization; however, they help detect
procedural errors (e.g., overloaded sterilizer, incorrect packaging) and equipment malfunctions.
Mechanical and chemical monitoring should be done for every sterilizer load.
a. Mechanical monitoring involves checking the sterilizer gauges, computer displays, or printouts
and documenting in your sterilization records that pressure, temperature, and exposure time
have reached the levels recommended by the sterilizer manufacturer. Since these parameters
can be observed during the sterilization cycle, this might be the first indication of a problem.
b. Chemical monitoring uses sensitive chemicals that change color when exposed to high
temperatures or combinations of time and temperature. Examples include chemical indicator
tapes, strips, or tabs and special markings on packaging materials. Chemical indicator results are
obtained immediately following the sterilization cycle and therefore can provide more timely
information about the sterilization cycle than a spore test. A chemical indicator should be used
inside every package to verify that the sterilizing agent has penetrated the package and reached
the instruments inside. An external indicator should also be used if the internal chemical
indicator is not visible outside the package. Chemical indicators help to differentiate between
processed and unprocessed items, eliminating the possibility of using instruments that have not
been sterilized.
c. Biological monitoring A spore test should be used on each sterilizer at least weekly. Users should
follow the manufacturer’s directions for how to place the biological indicator in the sterilizer. A
spore test should also be used for every load with an implantable device. Ideally, implantable
items should not be used until they test negative.
Do not use instrument packages if mechanical or chemical indicators indicate inadequate

processing. Chemical indicators should be inspected immediately when removing packages from the
sterilizer; if the appropriate color change did not occur, do not use the instruments.

8.4.1. Moist Heat Sterilization

 This is used for steel instruments, latex rubber tubes, gloves, dressing packs, cotton, and gauze.
 CSSD has electric autoclaves, gravity type of autoclaves, and a high pressure autoclave. The high-
pressure autoclaves operate using a central steam supply.
Guidelines for All Types of Steam Sterilizers
Device Preparation
Devices should be prepared for sterilization in the following manner:
a. Clean, and remove excess water.
b. Jointed instruments should be in the open or unlocked position.
c. Multi-piece or sliding pieces should be disassembled unless otherwise indicated by the device
manufacturer.
d. Devices with concave surfaces that retain water should be placed so that condensate does not
collect.
e. Instruments with lumens should be moistened with distilled water immediately before
sterilization.
f. f. Heavy items should be arranged not to damage lighter, more delicate items.
g. Sharp instruments should have tips protected.
Packaging:
Packaging materials for steam sterilization should:

a. Be validated for steam sterilization.
b. Contain no toxic ingredients or dyes.
c. Be capable of withstanding high temperatures.
d. Allow air removal from packages and contents.
e. Permit sterile contact with the package contents.
f. Permit drying of the package and contents.
g. Prevent the entry of microbes, dust, and moisture during storage and handling.
h. Have a proven and tamper-proof seal.
i. Withstand normal handling and resist tearing or puncturing.
Unloading
Upon completion of the cycle, the operator responsible for unloading the sterilizer should
Review the sterilizer printout for the following:
a. Correct sterilization parameters.
b. Cycle time and date.
c. Cycle number matches the lot control label for the load.
d. Verify and initial that the correct cycle parameters have been met.
Examine the load items for:

 Any visible signs of moisture.

 Any signs of compromised packaging integrity.
 Printed records of each cycle parameter (temperature, time) should be retained.
Load Cool-Down
Upon removal of the sterilized load, the operator should:

 Visually verify the results of the external chemical indicators.
 Allow the load to cool to room temperature (the amount of time for cooling depends on the
devices that have been sterilized).
 Ensure cool down occurs in a traffic-free area without strong warm or cool air currents.
Validation and communication
 Procedures being carried out in the CSSD should be continuously validated.

 This should include all activities, including wrapping, sterilization, and sterilization conditions (all
physical and chemical parameters).
 The in-charge should ensure proper equipment maintenance according to the manufacturer’s
recommendations. Any failure or defect of the physical/chemical/biological indicators should be
reported to the administration, maintenance, infection control and other appropriate clinical
units or personnel.
 All outdated sterile units should be removed at regular intervals.
8.5 Sterilization procedures

A. Steam under pressure (Autoclaves)
 Essential parameters: Steam (dry, saturated), time, temperature and pressure.
 Time to sterilize: usual cycles: 121 0 C x 30 minutes, 132 0 C x 4 minutes.
Precautions:
 Follow the manufacturer’s instructions.

 Arrange items in a way that allows the steam to circulate freely.
 Keep the loads at the sterilizing temperature for the recommended holding time.
 Exercise care during opening (potential for steam injuries).
Uses:
 It is the most efficient and reliable method of sterilization (wide margin of safety).
 Use for sterilization of all critical and semi-critical heat and moisture-resistant items (surgical
instruments, surgical drapes, some respiratory and anesthetic equipment, microbiological waste
and sharps).
Monitoring of steam sterilization process:
a. Residual air detection for vacuum sterilizers (Bowie- Dick test):

An air removal test is designed to detect inadequate air removal in pre-vacuum sterilizers. Air
not removed from the sterilizer chamber prevents steam from contacting the items in a load
and, therefore, interferes with sterilization. Follow manufacturer instructions for how to
perform the test and the frequency of testing. If a sterilizer fails the air removal test, it should
not be used until it passes inspection by sterilizer repair personnel.
 A commercially available Bowie-Dick-type test sheet should be placed in the center of the
pack.
 The test pack should be placed horizontally in the front, bottom section of the sterilizer rack,
near the door, and over the drain in an otherwise empty chamber and run at 134 0 C x 3.5
minutes.
 Residual air in the chamber will interfere with steam contact (the entrapped air will cause a
spot to appear on the test sheet due to the inability of steam to reach the chemical
indicator).
 If the sterilizer fails the test, do not use it until remedied.
b. Mechanical monitoring: Each cycle

c. Chemical monitoring: Each cycle
d. Biological monitoring: Geobacillus stearothermophilus spores
 Use at least weekly (preferably daily) and with each load of implantable devices.
 Loads containing implantable devices should ideally be quarantined until the results of
biological indicators are available.
B. Hot air sterilizer
Essential parameters: Temperature and time
Precautions:
 Follow the manufacturer’s instructions.

 Arrange items in such a way that the hot air circulates freely.
 Keep the load at sterilizing temperature for the recommended holding time
 Exercise care during opening (potential for thermal injuries).
 Take out the sterile items with sterile pick-ups, after they have reached room temperature.
Uses: Should be used only for heat tolerant materials that may be damaged by/ impermeable to moist
heat. Examples: powders, petroleum products, sharp instruments, glass wares.
Time to sterilize: 170 0C x 60 minutes/ 160 0C x 120 minutes/ 150 0C x 150 minutes.
Monitoring of cycle processes:
a. Mechanical: Each cycle

b. Chemical: Each cycle

c. Biological monitor: B. atrophaeus spores
Use at least weekly (preferably daily) and with each load of implantable devices.
 Loads containing implantable devices should ideally be quarantined until the results of biological
indicators are available.
C. Low-temperature sterilization
Ethylene Oxide (EtO): Ethylene oxide is gaseous, low-temperature sterilant.
Essential parameters: Gas concentration (450-1200 mg/L), temperature (37-630C), relative humidity (40-
80%), vacuum, pressure and exposure time (1-6 hours; aeration requires an additional 8-12 hours).
Precautions:
 EtO gas must penetrate the entire load

 Must be handled according to strict guidelines
 Manufacturer’s instructions must be followed for packaging, sterilizing, validation, and aeration.
 Items must undergo aeration to remove residual EtO
 OSHA standards cover most occupational exposures to EtO.
 OSHA has established a PEL of 1 ppm airborne EtO in work place.
 Ensure regular environmental monitoring, employee information, training, and medical
examination. Warning signs must be posted near EtO plants. Only authorized persons should
enter the area.
 Effectiveness is altered by lumen length, diameter, inorganic and organic contamination. Time
to sterilize: 12-24 hours
Uses:
 Appropriate for sterilization of heat and moisture labile critical and semi-critical items.
 Sterilization of devices containing electronic components.
Monitoring of process:
 Mechanical: Each cycle (time, temperature, pressure). The essential components of gas
concentration and humidity cannot be monitored.
 Chemical: Each cycle
 Biological monitor: B. atrophaeus spores
Use at least weekly (preferably daily) and with each load of implantable devices. Loads containing
implantable devices should ideally be quarantined until the results of biological indicators are available.
Hydrogen peroxide (H2O2) Gas plasma Principle
 Gas plasmas are referred to as the fourth state of matter.

 They are generated by exciting a chemical precursor (H2O2) under a deep vacuum in an
enclosed chamber using radiofrequency/ microwave energy.
 This produces highly reactive and biocidal charged particles, many of which are free radicals.
 The free radicals react and inactivate essential cellular components (enzymes, nucleic acids) of
microbes.
Precautions:
 Items should be totally dried before loading.

 H2O2 may be toxic at levels greater than 1 ppm TWA (time weighted average).
 Time to sterilize: 47-75 minutes.
Monitoring of procedure:
 Physical and Chemical monitoring: is inbuilt with each cycle (it records the concentration of
active ingredients).
 Biological monitor: Spores of G stearothermophilus (read at 48 hours): The system has its own
monitor in plastic vials, which should be incorporated at least weekly (preferably daily).
Uses:
 Sterilization of devices that are heat and moisture-sensitive (plastic, electronic devices,
corrosion-sensitive metals).
 Examples: Arthroscope & its instruments, micro instruments, vascular instruments, spine sets,
pneumatic drills, dermatomes, micro and mini drill, implants, urethroscope & its instruments,
laparoscope& its instruments, thoracoscopes & its instruments, laparotomy set, nephrectomy
set, microvascular instruments, dental implants, craniotomy sets, tracheostomy set, image
intensifying cover, retractors, bone nibblers, ophthalmic instruments.
8.6 Sterilizing Practices

 Ensuring sterilization depends not only on the effectiveness of the sterilization process but also
on the pre-cleaning, disassembling, and packaging of the device, loading the sterilizer,
monitoring of sterilization, sterilant quality and quantity, assessing the appropriateness of the
cycle for the load contents, and other aspects of device reprocessing.
 The cleaning, disinfection, and sterilization of medical and surgical equipment should preferably
be done at a central processing area by trained personnel.
 Must comply with the manufacturer’s recommendations.
 Apart from routine testing, biological indicators are also required to be used in the following
situations:
o Installation of a new sterilizer after the relocation of an existing sterilizer, after a
sterilizer malfunction, after major repairs to a sterilizer that is outside the scope of
routine or preventive maintenance, and after repairs to the steam generator/delivery
system.

 The CDC recommends that "objects, other than implantable objects, do not need to be recalled
because of a single positive spore test unless the steam sterilizer or the sterilization procedure is
defective." If the mechanical and chemical indicators suggest that the sterilizer was functioning
properly, a single positive spore test probably does not indicate sterilizer malfunction, but the
spore test should be repeated immediately.
 If the spore tests remain positive, use of the sterilizer should be discontinued until it is serviced.
For EtO and H2O2 gas plasma, a single positive spore test may be considered significant. All
loads should be retrieved for re-processing.
Table 8.1 Monitoring of Sterilization procedure.
Mechanical checking the sterilizer gauges, computer displays, or

printouts and documenting in your sterilization
records that pressure, temperature, and exposure
time have reached the levels recommended by the
sterilizer manufacturer
Biological Indicators
Measure the sterilization process directly by using the

most resistant microorganisms
Steam & low temp sterilizer- at least weekly
Sterilizer used frequently(several loads/day)- daily
**Each load should be monitored if it contains
implantable objects
Chemical Indicators
Heat or chemical-sensitive inks that change color
Indicate that the item has been exposed
Used in conjunction with BIs
Affixed on the outside of each pack & preferably inside
each pack
Bowie Dick test
Perform daily in an empty dynamic-air-removal

sterilizer
To ensure air removal

Annexure-1
Disinfection Policy
9. Annexure Page 150


Annexure-2
Hand hygiene Audit Form


Annexure-2
Needle Stick Injury (NSI) Reporting Form

Annexure-3
HAI Surveillance Form














Annexure-4
BMW Checklist

REFERENCE
 National Guidelines for Infection Prevention and Control in Healthcare Facilities (Ministry of
Health and Family Welfare Government of India).
 Hospital Infection Control Manual 2019, AIIMS Raipur
 Hospital Infection Control Manual, AIIMS Delhi
 Hospital Infection Control Manual, AIIMS Jodhpur
 Principles Of Asepsis: The Rationale for Using Aseptic Technique, CDC Guidelines
 Guidelines for Implementation Of “Kayakalp” Initiative, https://nhm.gov.in/images/pdf/in-
focus/Implementation_Guidebook_for_Kayakalp.pdf
 https://www.mohfw.gov.in/pdf/National%20Guidelines%20for%20IPC%20in%20HCF%20-
%20final%281%29.pdf.
 www.nabh.co/images/pdf/RevisedGuidelines_Airconditoning_OT.docx.
 Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare
Settings. CDC Atlanta. Accessed from https://www.cdc.gov/hai/prevent/ppe.html
 (https://www.cdc.gov/dialysis/clinician/ce/infection-prevent-outpatient-hemo.html)
 http://naco.gov.in/post-exposure-prophylaxis-pep
 Hospital infection Prevention and control manual AIIMS, JODHPUR December 2017 pg no.22-33
 NACO PEP Guidelines
 CDC Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Post exposure Prophylaxis
 MMWR. DEC 8, 2006/55(RR16)
 Vaccines, 6th Edition Edited by Stanley Plotkin, Walter Orenstein, and Paul A. Offit. Philadelphia,
PA: Elsevier, 2013, pp. 1290–1309.
 Recommended Vaccines for Healthcare Workers (accessed from
https://www.cdc.gov/vaccines/adults/ rec-vac/hcw.html)
 Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on
Immunization Practices (ACIP)(accessed from
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm)
 Healthcare Personnel Vaccination Recommendations accessed from
http://www.immunize.org/catg.d/ p2017.pdf
 Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures
to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis accessed from
https://www.cdc.gov/ mmwr/preview/mmwrhtml/rr5011a1.htm
 IDSA, SHEA, and PIDS Joint Policy Statement on Mandatory Immunization of Healthcare
Personnel According to the ACIP-Recommended Vaccine Schedule accessed from
http://www.idsociety.org/
uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Immunizations_and_Vac
cines/
10. Reference Page 170

Health_Care_Worker_Immunization/Statements/IDSA_SHEA_PIDS%20Policy%20on%20Mandat
ory%20 Immunization%20of%20HCP.pdf
 National Guidelines For Infection Prevention And Control In Healthcare Facilities By
Mohfw January 2020
 Foxman B. Epidemiology of urinary tract infections: incidence, morbidity and economic
costs. Am J Med. 2002;113 Suppl 1A:5S–13S.
 Kamat US, Fereirra A, Amonkar D, Motghare DD, Kulkarni MS. Epidemiology of
hospital acquired urinary tract infections in a medical college hospital in Goa. Indian J
Urol.2009; 25: 76–80.
 CDC. National Healthcare Safety Network (NHSN) Patient Safety Component
Manual,January 2019(https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf,
accessed 1 August 2019).
 Standards for Microbiology Investigation
website(https://www.gov.uk/governmentcollections/standards-for microbiology-
investigations-smi, accessed 26 July 2019).
 Sarkar BB. Postoperative infections: physician’s perspective. Medicine Update. 2012;22:67–71
(http://www.apiindia.org/pdf/medicine_update_2012/infectious_disease_12.pdf, accessed 26 July
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 WHO. Global guidelines on the prevention of surgical site infections. WHO; November
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 Infection Control and Waste Management Plan for National AIDS Control Support
Project (NACSP) 2012–17. National AIDS Control Organization, Ministry of Health and
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 https://india.healthfacilityguidelines.com/Guidelines/ViewPDF/HFGIndia/part_b_sterile_
supply_unit
10. Reference Page 171

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CONTRIBUTORS

Dr. Shashank Purwar Mr. Ajay Kumar Ghodela

Dr. Navinchandra M. Kaore Mr. Anil Kumar

Dr. Lily Podder Mr. Ramlakhan Singh

Dr. Anurag Bhai Patidar Mr. Hansraj Phageria

Mrs. Geeta Bhardwaj Mr. Naeem Akhtar

Mrs. Aparna Vajpeyee Mrs. Khushboo Patel

Mr. Hansraj Kumawat Mr. Rohit Kumar

Dr. Pramod Sharma Dr. Abhishek Goyal

Dr. Rehan Ul Haq Dr. Girish Bhatt

Dr. Md. Yunus Dr. Anshul Rai

Dr. Shyam Lal Dr. Sunaina Tejpal Karna

Dr. Saurabh Saigal Dr. Jyoti Nath Modi

Dr. Lakshmi Prasad Dr. Devashish Kaushal

Dr. Murali M Dr. Syrpailyne Wankhar

Dr. Navinchandra M Kaore Dr. Jayanthi Yadav

Dr. Manal Md. Khan Dr. Saikat Das

Dr. Alkesh Kumar Khurana Dr. Ajay Haldar

Dr. T. Karuna Dr. Mahendra Atlani

Dr. Manoj Nagar Dr. Abhishek Singhai

Dr Sumit Raj Dr. Pankaj Prasad

Dr. Ajeet Pratap Maurya Dr. Ujjawal Khurana

Dr Kawal krishen Pandita Dr. Zainab Ahmad

Dr. Samendra Kumar Karkhur Dr. Kumar Madhavan

Dr. Maxie Martis Dr. Arati Ankushrao Bhabde

Executive Director & CEO

Dr. Shashank Purwar

S.No. Chapter Name Page No.

9. My 5 Movements of Hand hygiene Focus on caring for a patient with a central 43

10. My 5 Movements of Hand hygiene Focus on caring for a patient with an 49

19. Bio-Medical Waste Transportation Trolley of CBWTF 80

HAI Healthcare-Associated Infection

NCDC National Centre for Disease Control

GLOSSARY Page III

1.1 Components of Hospital Infection Control Program

1.1.1 Preventive Measures

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 1

Medical Records Reporting by

1.2 Hospital Infection Control Committee (HICC) at AIIMS Bhopal

1.2.1 Objectives of HICC

S.No. Name Of Committee Member Position

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 2

9 Dr. Pramod Sharma, Addl. Prof. Dept. of Paediatrics Surgery Member

S.No. Name Of Committee Member Position

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 3

1.2.2 Meetings of HICC

1.2.3 Responsibilities of HICC

1.3 Infection Control Team at AIIMS Bhopal

1.3.1 Responsibilities of the Infection Control Team (ICT)

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 4

 Recommend antibiotic policy for different areas of the hospital.

1.3.2 Duties of Infection Control Nurse (ICN)

1.3.3 Infection Control Officer (ICO)

1.3.4 Duties of Infection Control Officer (ICO)

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 5

• Keep track of any developing outbreaks.

1. Organization of Hospital Infection Control Programme at AIIMS Bhopal Page 6

2.2 Burden of HAI

2.3 Economic Impact

The economic loss is in terms of -

2.4 Risk factors for healthcare-associated infections:

2. Fundamentals of Healthcare Associated Infections (HAIs) Page 6

2.5 Epidemiological Chain of Healthcare Associated Infection (HAI):

Table 2.1:- Elements of Chain of infection