The document discusses hospital-acquired infections (HAIs), detailing the chain of infection and factors contributing to HAIs such as hospital environment, invasive procedures, and antibiotic resistance. It outlines strategies for infection control, including surveillance, preventive measures, and the establishment of a hospital infection control committee. Additionally, the document highlights specific care bundles aimed at preventing various types of infections associated with healthcare settings.

1. Unit - I
Hospital Acquired
Infection
By, Ahmed Sodha
M.Sc.(N). – M.S.N.

2.  INTRODUCTION
• The Germs / Microbes / Microorganisms Are Everywhere &
Thus Make An Important Part Of Our Daily Life.
• The Microorganisms Are Found Abundantly In Water, Soil,
Air & Also On The Bodies Of Human Beings.
• The Microorganism Uses That Person’s Body To Sustain
Itself, Reproduce, And Colonize. These Infectious
Microscopic Organisms Are Known As Pathogens, And They
Can Multiply Quickly.
 Definition Of Infection:- “The Infection Can Be Defined As
The Entry Of Germs In The Body Of An Individual Followed
By The Multiplication, Leading To The Formation Of A
Specific Or A Non-specific Reaction By The Body With Or
Without Any Clinical Symptoms And Or Disease.”

4.  CHAIN OF INFECTION
• The Chain Of Infection Also Referred To As The Chain Of
Transmission. It Describes How An Infection Spreads.
• The Spread Of An Infection Within A Community Is
Described As A “Chain,” Several Interconnected Steps That
Describe How A Pathogen Moves About.
• The Spread Of Infection Can Be Described As A Chain With
Six Links:
1. Infectious Agent (Pathogen)
2. Reservoir (The Normal Location Of The Pathogen)
3. Portal Of Exit From The Reservoir
4. Mode Of Transmission
5. Portal Of Entry Into A Host
6. Susceptible Host

5.  1. Infectious Agent (Pathogen):-
• It Include Not Only Bacteria But Also Viruses, Fungi, And
Parasites.
• The Virulence Of These Pathogens Depends On Their
Number, Their Potency, Their Ability To Enter And Survive
In The Body, And The Susceptibility Of The Host.
• For Example, The Smallpox Virus Is Particularly Virulent,
Infecting Almost All People Exposed. In Contrast, The
Tuberculosis Bacillus Infects Only A Small Number Of
People, Usually People With Weakened Immune Function,
Or Those Who Are Undernourished And Living In Crowded
Conditions.

6.  2. Reservoir (The Normal Location Of The Pathogen):-
• A Reservoir Is Any Person, Animal, Plant, Soil Or Substance
(Or Combination Of These) In Which An Infectious Agent
Normally Lives And Multiplies.
• The Infectious Agent Depends On The Reservoir For
Survival, Where It Can Reproduce Itself In Such Manner
That It Can Be Transmitted To A Susceptible Host.
• There Are Two Categories Of Reservoir. These Are
Following.
• Animate Reservoirs Include People, Insects, Birds, And
Other Animals.
• Inanimate Reservoirs Include Soil, Water, Food, Feces,
Intravenous Fluid, And Equipment.

7.  3. Portal Of Exit From The Reservoir:-
• Portals Of Exit From The Reservoir Is The Means By Which
A Pathogen Exits From A Reservoir.
• For A Human Reservoir, The Portal Of Exit Can Include
Blood, Respiratory Secretions, And Anything Exiting From
The Gastrointestinal Or Urinary Tracts.

8.  4. Mode Of Transmission:-
• Once A Pathogen Has Exited The Reservoir, It Needs A
Mode Of Transmission To Transfer Itself Into A Host.
• Transmission Can Be By Direct Contact, Indirect Contact, Or
Through The Air.
• Indirect Contact Includes Both Vehicle-Borne And Vector
Borne Contact.
• A Vehicle-Borne is inanimate Objects Such As Cooking Or
Eating Utensils, Handkerchiefs And Tissues, Soiled Laundry,
Doorknobs And Handles, Surgical Instruments, Blood,
Serum, Plasma, Water, Food, And Milk Etc.
• A Vector-Borne Contact Is Transmission By An Animal,
Insect, Or Parasite That Transports The Pathogen From
Reservoir To Host.
• Ex. Mosquitoes Are Vectors For Malaria

9.  5. Portal Of Entry Into A Host:-
• Infectious Agents Get Into The Body Through
Various Portals Of Entry, Including The Mucous
Membranes, Non-intact Skin, And The Respiratory,
Gastrointestinal, And Genitourinary Tracts.
• Pathogens Often Enter The Body Of The Host Through The
Same Route They Exited The Reservoir.
• Ex. Airborne Pathogens From One Person’s Sneeze Can
Enter Through The Nose Of Another Person.

10.  6. Susceptible Host:-
• The Final Link In The Chain Of Infection Is A Susceptible
Host, Someone At Risk Of Infection.
• Infection Does Not Occur Automatically When The
Pathogen Enters The Body Of A Person Whose Immune
System Is Functioning Normally.
• When A Virulent Pathogen Enters An Immune-
compromised Person, However, Infection Generally
Follows.

11.  HOSPITAL ACQUIRED INFECTIONS (HAIS) /
 HEALTH CARE ASSOCIATED INFECTIONS (HCAIS) /
 NOSOCOMIAL INFECTIONS (NIS)
• Hospital-Acquired Infections, Also Known As Healthcare-
associated Infections / Nosocomial Infections, Are Acquired
Infections That Are Typically Not Present At The Time Of
Admission.
• Nosocomial Infections Are Acquired Under At Least Any
One Of The Following Mentioned Conditions:
• Within 48 Hours Of Admission To A Hospital Or Any Health
Care Facility.
• Within 30 Days Of Any Surgical Operation In The Hospital
Premises.
• Within The 3 Days Of The Discharge From The Hospital Or
Any Health Care Facility.

12. INVASIVE
PROCEDURES
SUSCEPTIBLE
PATIENTS
HOSPITAL
AMBIENCE
IMPROVED
MEDICAL
TECHNOLOGY
ANTIBIOTIC
RESISTANT
PATHOGENS
Risk Factors For
Hospital-Acquired
Infections

13.  Risk Factors For Hospital-Acquired Infections:- The Risk
Factors That Play A Key Role In The Eventuality Of The HAIS
Are Follows:
• 1. Hospital Ambience:- The Environment In The Hospital
Gets Highly Contaminated With Various Disease Causing
Micro-organisms. The Various Sources Are As Follows:
• Body Of The Patient
• Hands & Clothes Of The Hospital Personnel
• Hospital Equipment
• Air & Dust Within Hospital
• 2. Invasive Procedure:- The Various Invasive Procedures
Done For Therapeutic Or Diagnostic Purposes Like
Catheterization, Endoscopy Procedure, Endotracheal
Intubation, Surgical Drains, Nasogastric Tube, IV Infusion
Etc.

14. • 3. Susceptible Patient:- The Patients Whose Immune
System Is Weak / Impaired, The Aged Patients, Children,
Heavy Smokers, Alcoholics & Diabetic Patients Are More
Susceptible To The Surrounding Infectious Environment
Within The Hospital.
• 4. Anti-Biotic Resistant Pathogens:- Most Of The
Pathogens Responsible For Causing The HAIs Are Resistant
To A Broad Spectrum Antibiotics (Ex. Cephalosporin's Class
- Ceftriaxone) Due To The Over Usage Of The Latter.
• 5. Improved Medical Technology:- The Various
Advancements In The Medical Field Like Organ
Transplantations, Cancer Treatments etc. Have Led To
Increase In The HAIs As Per A Study Subject To Updation
From Time To Time.

15.  HOSPITAL INFECTION CONTROL PROGRAM (HICP)
• In Any Healthcare Setting Both The Patients & The
Healthcare Workers Need A Premier Quality Care & A
Probable Risk Free Working Environment Respectively.
• Therefore A Better Program / Protocol For The Infection
Control Is Required To Almost Eliminate The Risk Of
Dissemination Of Infection.
 Elements Of Hospital Infection Control Manual:-
• 1. Preventive Measures
• 2. Surveillance
• 3. Continuing Education
• 4. Bundle Approach

16. • 1. Preventive Measures:- The Following Should Be The
Necessary Preventive Criteria For The Infection Control
Program In Any Healthcare Setting:
• Standard Precautions.
• Isolation Precautions Under Outbreak Situation.
Ex. Covid-19 Outbreak, Swine Flu Outbreak.
• Immunization Of Healthcare Workers.
• Medical Instruments & Environment Should Be Sterilized,
Disinfect & Decontaminated Properly.
• Appropriate Use Of PPE.
• Use Of Single Use Devices.
• Spill Management.
• Hospital Bio-Medical Waste Management With Guidelines

17. • 2. Surveillance:-
• The Surveillance Of Hospital Acquired Infections Is A Close
Observation Of The Occurrence, The Probability Of
Occurrence Or The Rate Of Occurrence Of The Nosocomial
Infections Thus Helping In The Control & Prevention Of
Such Infections.
• The Surveillance Can Be Done By Both The Trained As Well
As The Non-trained Health Workers Through Touching The
Different Aspects Of The Surveillance As Required.
• The Purpose Of Any Surveillance Program Is To Reduce The
Hospital Acquired Infections.

18. • 3. Continuing Education:-
• Continuing Education Is Most Important For All Health Care
Professions.
• Caring For Patient In Rural/Urban Areas Required
Specialized Skills To Overcome Specific Nursing Challenges.
• The Main Aim Of In-service Education Is To Improve Nurse
Performance Regarding Infection Control Program.

19. • 4. Bundle Approach:-
• Care “Bundles” In Infection Prevention And Safety Are
Simple Sets Of Evidence-based Practices That, When
Implemented Collectively, Improve The Reliability Of Their
Delivery And Improve Patient Outcomes.
• It’s A Tool Made Up Of Approx. 3-5 Well Established
Evidence-based Clinical Procedures.
• Bundles Also Help To Create Reliable And Consistent Care
Systems In Hospital Settings Since They Are Simple (Three
To Five Elements), Clear, And Concise.
• Health Care Providers Are Advised To Follow Each Bundle
Element For Every Patient.

20. • 1. Bundle For The Prevention Of Catheter-associated
Urinary Tract Infections (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.
• It Is The Most Common Health-care Associated Infection
Worldwide. CAUTI Includes 4 Evidence-based Interventions
As Follows:
• Avoid Unnecessary Urinary Catheterization
• Insert Urinary Catheters Using Aseptic Technique.
• Daily Assessment Of The Presence Of Catheter
• Remove Urinary Catheter Promptly.

21. • 2. Bundle For The Prevention Of Surgical Site Infections
(SSI):- SSI Are Infections Of The Incision Or Organ Or Space
That Occur After Surgery.
• The Following Evidence Based Interventions Should Be
Provided As Part Of A Bundle Of Care To Prevent SSI:
• Appropriate Use Of Prophylactic Antibiotics. (Antibiotic
Prophylaxis Should Be Administered Within 60 Minutes
Prior To Incision, Including For Cesarean Section).
• Appropriate Hair Removal / Avoid Hair Removal (Use
Alcohol-based Disinfectant For Skin Preparation In The
Operating Room)
• Maintain Intraoperative Glycemic Control (With Target
Blood Glucose Levels <200mg/dL In Patients With /
Without Diabetes)
• Maintain Peri-operative Normothermia.

22. • 3. Bundle For The Prevention Of Ventilator Associated
Pneumonia / Events (VAP / VAE):- VAP Defined As A New
Pneumonia Occurring > 48 Hours After Endotracheal Intubation,
Is A Common And Serious Hospital-acquired Infection.
• It Occurs In Up To 20% Of Patients Receiving Mechanical
Ventilation. It Has Been Estimated That Over Half The Cases Of
VAP May Be Preventable With Evidence-based Strategies.
• The Following Evidence Based Interventions Should Be Provided
As Part Of A Bundle Of Care To Prevent VAP / VAE:
• Elevate The Head Of The Bed To Between 30 And 45 Degrees.
• Daily “Sedation Interruption” And Daily Assessment Of
Readiness To Extubate.
• Daily Oral Care With Chlorhexidine.
• Prophylaxis For Peptic Ulcer Disease.
• Prophylaxis For Deep Venous Thrombosis.

23. • These Interventions Should Be Implemented Together With
Standard Precautions (Hand Hygiene And Use Of Gloves
When Handling Respiratory Secretions) As Well As
Adequate Disinfection And Maintenance Of Equipment And
Devices.
• Other Components Of The VAP Bundle May Include /
Maintenance Bundle:
• A. Utilization Of Endotracheal Tubes With Subglottic
Secretion Drainage (Only For Patients Ventilated For Longer
Than 24 Hours)
• B. Initiation Of Safe Enteral Nutrition Within 24-48 Hours
Of ICU Admission

24. • 4. Bundle For The Prevention Of Central Line-Associated
Bloodstream Infections (CLABSI):-
• CLABSI Central Lines Are Used Commonly In Intensive Care
Units And In Non-ICU Populations Such As Dialysis Units,
Intraoperatively, And Oncology Patients.
• Most Hospital-Acquired Bloodstream Infections Are
Associated With A Central Line (Including Peripherally-
inserted Central Catheters) And CLABSI Are Responsible For
Excess Mortality And Morbidity, Prolonged Hospital Stays,
And Increased Costs.

25. • CLABSI Prevention Bundles Include The Following Components:
• Hand Hygiene.
• Maximal Sterile Barrier Precautions (Surgical Mask, Sterile
Gloves, Cap, Sterile Gown, And Large Sterile Drape)
• Skin Cleaning With Alcohol-based Chlorhexidine (Rather
Than Iodine)
• Avoidance Of The Femoral Vein For Central Venous Access
In Adult Patients; Use Of Subclavian Rather Than Jugular
Veins.
• Maintenance Bundle:- Daily Review Of Central Line
Necessity
• Daily Chlorhexidine Washes (In ICU, Patients > 2 Months)
• Replace Administration Sets Within 96 Hours (Immediately
If Used For Blood Products Or Lipids)
• Change Dressings And Disinfect Site With Alcohol-based
Chlorhexidine Every 5 – 7 Days (Change Earlier If Soiled)

26.  HOSPITAL INFECTION CONTROL COMMITTEE (HICC) /
INFECTION CONTROL TEAM (ICT)
• The HICC Is An Integral Component Of The Infection
Prevention & Control Program Of Any Hospital Care Facility.
• This Committee Is Responsible For Establishing &
Maintaining The Infection Prevention & Control Program &
It’s Various Functions Of Monitoring, Surveillance,
Reporting, Research & Education.

27.  Structure Of HICC / ICT:-
• 1. Chairperson: Head Of The Institute.
• 2. Secretary / Infection Control Officer
• 3. Members:-
• Infection Control Nurse (ICN)
• Representation Member From Administration Service
• Representation Member From CSSD, OT, Pharmacy,
Laundry, Store Dept., Sanitation Dept., Microbiologist

28.  Responsibilities Of The HICC / ICT:-
• Develop A Manual Of Policies & Procedures For Aseptic,
Isolation & Antiseptic Techniques.
• Carry Out Surveillance, Data Analysis For Presentation In
HICC Meeting & Take Corrective Steps.
• Advice Staff On All Aspects Of Infection Control & Maintain
A Safe Environment For Patient & Staff.
• Supervise & Monitor Cleanliness & Hygienic Practices.
• Waste Management
• Oversee Sterilization, Disinfection & Monitor The Use &
Quality Control Of Disinfectants.
• Assist In Training Of All New Employees As To The
Importance Of Infection Control & The Relevant Policies &
Procedures.

29.  Responsibilities Of The HICC / ICT:- Cont….
• Organize regular training program for the staff to ensure
implementation of infection control practices.
• Audit infection control procedures.
• Monitor healthcare workers safety program.

30.  INFECTION CONTROL NURSE (ICN):-
• A Full Time Nursing Staff Should Be Appointed As The ICN.
• He / She Should Have Training In Infection Prevention &
Control.
• Nurse Is Enabled By Specifically Designated Link Nurses In
Each Ward, ICU, OT Or Other Unit Of The Health Care
Facility.
 Responsibilities Of The ICN:-
• Visit The Microbiology Laboratory & Conduct Infection
Control Rounds Daily & Track All Infected Cases & Maintain
Surveillance Data.
• Conduct Daily Ward Rounds To Monitor Implementation Of
Infection Prevention & Control Practices & Standard
Operating Procedures Properly.

31. • Education & Training To Healthcare Workers Under The
Supervision Of The Infection Control Officer (ICO).
• Submit The Reports Of Education & Training Of Health
Workers To Chairperson Of HICC / ICT.
• Ensure Compliance With Hospital’s Bio-medical Waste
Management Policy.
• Initiate & Facilitate Immunization / Vaccination (Ex.
Hepatitis-B Vaccine) For The Staff, Especially In High Risk
Areas.
• Facilitate Provision Of First-aid & Appropriate Consultation
In Case Of Suspected Exposure Of Any Hospital Worker.
• Provide Feedback On Instances Of Any Communicable
Diseases Reported By Head Nurses.
• Conduct & Participate In Regular Meetings To Evaluate The
Situation At Any Given Time.