Hospital associated infections need special attention. Seven strategies are suggested to reduce the high prevalence of hospital associate infections.

1. Seven strategies to prevent
hospital associated infections
Prof. Ashok Rattan,
MD,MAMS
Ex Laboratory Director, CAREC PAHO/WHO,
Ex Secretary, Hifcom, AIIMS, New Delhi
Ex Secretary, Infection Prevention & Control, Medanta The Medicity, Gurgram

2. 1.
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Massino Sartelli

3. Study of effectiveness of nosocomial infection control
SENIC
LRTI SSI UTI BSI Total

4. Target ZERO
Healthcare Associated Infections
Zero tolerance
for
preventable healthcare associated infections
&
inappropriate practices

5. Infection control objectives for healthcare workers
should be an integral part of a healthcare
organization's overall program for
infection prevention & control
• Objectives:
• 1. Educating personnel about the principles of infection control and stressing
individual responsibility for infection control
• 2. Collaborating with the other departments in monitoring and investigating
potentially harmful infectious exposures and outbreaks among personnel
• 3. Providing care to personnel for work-related illnesses or exposures
• 4. Identifying work-related infection risks and instituting appropriate
preventive measures
• 5. Containing costs by preventing infectious diseases that result in
absenteeism and disability

6. Infection Prevention & control
• is a critical concern for
• Patients (clients),
• healthcare workers,
• facility administrators, and
• government agencies.
• Infection control measures are designed to combat everything
from the spread of
• colds and flu to hepatitis B and C,
• SARS, HIV/AIDS, and
• other potentially life threatening diseases.

7. Appropriate infection control measures
• may range from something as simple as
• following proper hand washing hygiene to
• coordinated policies involving
• worker health screening,
• immunization, and
• treatment.
• All these measures should be incorporated into synchronized,
organization-wide infection control programs at healthcare
facilities of all sizes and types.

8. INFECTION CONTROL TRAINING
Infection Prevention & control
needs to be everyone's concern
• Training Goals
• Ensure that health professionals understand how blood-borne and
other pathogens can be transmitted in the work environment:
• patient to healthcare worker,
• healthcare worker to patient, and
• patient to patient
• Apply current scientifically accepted infection control principles as
appropriate for the specific work environment
• Minimize opportunity for transmission of pathogens to patients and
healthcare workers

9. Element II
Modes and mechanisms of transmission of pathogenic organisms in the healthcare
setting and strategies for prevention and control.
The Chain of Infection
• 1. A pathogen or causative (infectious) agent
• 2. The reservoir
• 3. A portal of exit from the reservoir
• 4. A mode of transmission
• 5. A portal of entry into a host
• 6. A susceptible host

10. Reservoir : Any person, animal, arthropod, plant, soil, or
substance (or combination of these) in which an causative agent
normally lives and multiplies, on which it depends primarily for
survival, and where it reproduces in such numbers that it can be
transmitted to a susceptible host. Reservoirs are usually wet
• Ill people.
• Well people. Our normal flora (the germs we live with) include bacteria that
can be pathogens if they get into the wrong part of the body. For example, our
mouths contain many different kinds of bacteria.
• Raw meat; may harbor pathogens
• Soil; has rich microbial life which may include pathogens.
• Water from fish tanks or flower vases; may contain pathogens, especially for
compromised patients.

11. HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS
Reservoir Transmission Vehicle Infectious Agent
Blood
Blood, needle stick, other
contaminated equipment
Hepatitis B and C; HIV/AIDS,
S. aureus, S. epidermidis
Tissue
Drainage from a wound or
incision
S. aureus,, E. coli, Proteus spp
Respiratory tract
Droplets from sneezing or
coughing
Influenza viruses, Strep spp.,
S. aureus, SARS CoV 2
Gastrointestinal tract Vomitus, feces, bile, saliva
Hepatitis A, Shigella spp,
Salmonella spp, Rota virus
Urinary tract Urine E. coli, enterococci
Reproductive tract and
genitalia
Urine and semen
N. gonorrhoeae, T. pallidum,
Herpes simplex virus type 2,
Hepatitis B

12. Portal of exit. The way the causative agent gets out of the
reservoir. In a person, this is often by a body fluid, and some
bacteria, such as MRSA, can live and grow on the skin.
• Actions we take to reduce risk from portals of exit include:
• Covering coughs and sneezes with a tissue
• Handling body fluids with gloves, then doing hand hygiene
• Keeping draining wounds covered with a dressing
• Not working when you have exudative (wet) lesions or weeping
dermatitis

13. In the community

15. In Modern Hospitals
4/1/2022 15

16. Inside Hospitals
Risk of transmission
4/1/2022 16

17. In health care setting commonest means of
transmission of infection is by contact

18. Structure of Hospital Infection Prevention & Control
HIFCOM
• MS / Director = Chairman
• Microbiologist = Secretary
• Clinicians +one from every team
• Nursing Superintendent
• Infection Control Nurses
• Allied Health care staff
• Policy making & approving group
• Meets once a month
IPC TEAM
• Microbiologist = team leader
• Pharmacologist
• Epidemiologist (if available)
• Infection control nurses
• Lab technicians
• Policy implementation group
• Daily work
• Inform HIFCOM sos

20. Hand Washing

22. Staphylococcus aureus

27. Which bacteria is this ? Escherichia coli

35. Ignaz Semmelweis,
1815-1865
Father of Infection Control

36. Ignaz Semmelweis,
1815-1865
• 1840’s: General Hospital of
Vienna
• Divided into two clinics,
alternating admissions every 24
hours:
• First Clinic: Doctors and medical
students
• Second Clinic: Midwives
16
7
0
2
4
6
8
10
12
14
16
Maternal
mortality,
1842
First Clinic Second
Clinic

37. The Intervention:
Hand scrub with chlorinated lime solution
Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

38. Hand Hygiene: Not a New Concept
1841
1842
1843
1844
1845
1946
1847
1848
1849
1850
MDs
0
2
4
6
8
10
12
14
16
Maternal
Mortality
(%)
Maternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
MDs Midwives
Semmelweis’ Hand
Hygiene Intervention
~ Hand antisepsis reduces the frequency of patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

39. Ignaz Semmelweis,
1815-1865
• Father of Hand Hygiene concept to prevent infection
• Was Clinical assistant at that time
• Demoted
• Rediculed
• Committed to Viennese Insane asylam
• Died in 1865 age 50

40. Take home message from
Ignaz Semmelweis’ life
Just because you are right,
Donot expect HCW to follow you
and your good advice

42. Responsibility of ALL HCW to adhere to scientifically accepted
principles and practices of infection control and to monitor the
performance of those for whom the professional is responsible.
• In USA, 1.7 million patients get infected in hospitals while being treated for
other ailments and 99,000 die as a consequence.
• Indian data is incomplete, scantly & unavailable
• In AIIMS, newspaper indicate HAI have fallen from 20% to 7%
• HAI not only cause increased mortality, but leads to increased hospital stay
and cost USA 5 billion $
• HAI: Infections acquired by patients during their stay in hospitals. These
infections are neither present nor incubating at the time of admission (they
may appear after discharge)
• For convenience, infections that appear after 48 hrs of stay in the hospital
are considered as HAI

43. Deaths in USA due to medical error are
Equivalent to ONE Fully loaded Jumbo jet
crashing every day of the year

44. Hospital Acquired Infections
Hospital Associated Infections
Nosocomial Infections
Parato Principles
• 5 pathogens
1. Escherichia coli
2. Staph aureus
3. Pseudomonas aeruginosa
4. Acinetobacter baumanni
5. Klebsiella pneumoniae
5 x 4
• 4 sites
1. UTI
2. SSI
3. RTI
1. HAP
2. VAP
4. BSI

45. Hospital Associated Infections

46. Preventable Infections and costs of getting it wrong

48. Environmental Hygiene

49. Use engineering and work practice controls to reduce the
opportunity for patient and healthcare worker exposure to
contact with potentially infectious material in all healthcare
settings for blood-borne pathogens.
• The OSHA Blood-borne Pathogens Standard requires the use, in this order, of:
• 1. Engineering controls
• 2. Work practice controls
• 3. Personal protective equipment

50. Engineering control
• Engineering controls used to prevent transmission of airborne infections include:
• Isolation rooms with appropriate air exchanges (negative pressure and/or direct
exhaust)
• HEPA filtration
• Ultraviolet irradiation
• Safety sharps devices and containers are another type of engineering control, since
they isolate or contain the hazard—used sharps.
• Giving injections, disposing syringes with needles, or reprocessing needles and other
sharps all hold potential risk for exposure to pathogens.
• The average risk of transmission from a single needle-stick contaminated with
• HIV has been estimated to be approximately 0.3%.
• hepatitis B ranges from 1% to 30%,
• hepatitis C is 1.8 %.

51. Work Practice Controls
• General Practices
• Prompt cleanup of blood and body fluid spills with appropriate disinfectant
• Proper disposal/handling of blood and body fluid, including contaminated
patient-care items
• Safe handling of used linen and waste
• Specific Practices
• Using care in the handling and disposal of needles and other sharps
• Not recapping unless absolutely medically necessary and then using one-hand
technique or safety device to recap
• Disassembling sharp equipment by using forceps or other devices
• Closing and replacing sharps containers when they are full (rather than
overfilling) according to the manufacturer's instructions

52. Spalding Classification for
disinfection & sterilization

54. Actions we take to eliminate the mode of
transmission include:
• Hand hygiene
• Wearing gloves to minimize contamination of hands and discarding them after
each patient
• Maintaining Contact, Droplet and Airborne Precautions as indicated.
• Cleaning, disinfection, or sterilization of equipment used by more than one
patient
• Cleaning of the environment, especially high-touch surfaces

55. Portal of entry. The break in the skin that allows the infectious
agent to get into the body. Common portals of entry include the mouth,
nose, eyes, rashes, cuts, needle-stick injuries, surgical wounds and IV sites.
• Examples of portals of entry include:
• Mouth, nose, and eyes
• Other anatomical openings
• Skin breaks (cuts, rashes)
• Surgical wounds
• Intravenous sites
• Anatomical openings with tubes in place (more susceptible than those
without)
• Needle puncture injuries

56. Actions we take to protect portals of entry
(our own and our patients) include:
• Dressings on surgical wounds
• IV site dressings and care
• Elimination of tubes as soon as possible
• Masks, goggles and face shields
• Keeping unwashed hands and objects away from the mouth
• Actions and devices to prevent needle-sticks
• Food and water safety

57. Susceptible host. A person or animal lacking effective
resistance to a particular infectious agent.

58. Preventing the spread of infectious organisms includes:
• Using Standard Precautions with
every patient so that precautions
are used with unknown carriers
of most diseases.
• Prompt isolation of the patient
when indicated, using the
appropriate type of precautions.
• Early identification of the
infectious organism and initiation
of appropriate treatment

59. Standard Precautions

60. Standard Precautions

61. Standard Precautions

62. Transmission Based Precautions
PRECAUTIONS
1. Standard Precautions
2. Specific Precautions

63. Transmission Based Precautions

64. Prevention of spread of infection
Screening & cohorting of patients

66. Surveillance : Ongoing systematic collection & analysis of health
data essential to planning, implementation & evaluation of public
health practices . A. Langmuir 1963
Strategies
• 1. Active vs Passive
• 2. Clinical vs Laboratory based
• 3. Retrospective vs Prospective
Methods
• 1. Hospital wide
• 2. Limited period
• 3. Prevalence
• 4. Targeted

67. WHAT
• Facility-based HAI surveillance should be performed to identify the most
frequent HAIs and detect HAI outbreaks, including AMR surveillance.
• Timely feedback of results should be provided to health care workers and
managers, as well as through national networks, and should guide IPC
interventions.
• • Surveillance should be an essential and well-defined component of the
IPC programme.
• • Adequate microbiology laboratory capacity is needed to support
surveillance.

68. WHY
• • Surveillance of HAI and AMR can provide critical information on the incidence
and prevalence of HAIs and AMR in health care facilities (that is, identify “the
problem”) to:
• guide IPC strategies and priorities and assess the effectiveness and impact of
interventions;
• develop benchmarking and assess trends over time;
• detect clusters or outbreaks of importance and inform wider public health decision-
making and actions;
• assist national decision-makers and the IPC national team to identify priorities for IPC; and
• develop targeted evidence-based standards and policies.
• • Evidence has shown significant reductions in HAI rates after the
implementation of HAI surveillance programmes, including mechanisms for
timely feedback.

69. WHEN
• • An approach to the surveillance of HAIs should be considered during the
establishment of your IPC programme.
• However, the implementation sequence of the core component
recommendations for evidence-based guidelines, education and training,
monitoring, audit, feedback and surveillance should be determined according
to the specific local context.
• • While it is recognized that HAI surveillance can provide critical information on
the magnitude of the problem for awareness-raising and could be useful from
the start of the implementation sequence, it is important to recognize that
surveillance requires expertise, laboratory capacity and an established IPC
programme and thus, may require time to set up.

70. WHO
• The responsibility for planning and conducting surveillance and analyzing,
interpreting and disseminating the collected data rests usually with the IPC
committee and the IPC team.
• • The named person responsible for surveillance (usually the IPC focal
person/lead) should be trained in basic epidemiology, surveillance and IPC.
• • Epidemiologists, statisticians, data managers and information technology
experts with the appropriate capacity to accurately and efficiently collect,
analyze and interpret data at the facility
• • In the absence of an IPC team, data collection can still be undertaken by
dedicated staff with access to medical documentation, patient charts,
laboratory findings, microbiology and virology results and other relevant
registries. However, this staff should receive specific training.

71. HOW (1/2)
• • Health care facility surveillance should be based on national recommendations and standard
definitions and customized to the facility needs and priorities according to available resources with
clear objectives and methods.
• If national recommendations and standard definitions are unavailable, international
recommendations/definitions should be referred to.
• • A prioritization exercise should be undertaken to determine which HAI(s) to target for surveillance
according to the local context.
• Possible recommended infections for surveillance in healthcare include:
• surgical site infections;
• device-associated infection (for example, catheter-associated urinary tract infections, central line-associated BSI,
peripheral line-associated BSI, ventilator-associated pneumonia);
• clinically defined infections (for example, in the absence of microbiological testing);
• colonization or infections caused by multidrug-resistant organisms (MDROs) according to local epidemiology;
• local priority epidemic-prone infections (for example, norovirus, influenza, TB, severe acute respiratory syndrome
, Ebola, Lassa fever);
• infections in vulnerable populations (for example, neonates, those housed in the intensive care unit,
immunocompromised individuals, burn patients);
• infections that may affect health care workers in clinical, laboratory or other settings (for example, hepatitis B or
C, HIV, influenza).

72. HOW (2/2)
• • Reliable surveillance case definitions should be used (that is, defined numerator and
denominator according to international definitions
• [United States Centers for Disease Control and Prevention National Healthcare Safety Network
[CDC/NHSN]/European Centre for Disease Prevention and Control [ECDC]] or locally adapted
definitions through an evidence-based adaptation process and expert consultation).
• • Active surveillance should be used to detect infections.
• Different surveillance strategies could include the use of prevalence or incidence studies with
clear and focused data collection forms.
• • Surveillance reports should be disseminated in a timely manner to those at the managerial or
administration level (decision-makers) and the unit/ward level (frontline health care workers).
• • Informatics support to conduct surveillance should be in place (for example, equipment,
mobile technologies, electronic health records).
• • A system for surveillance data quality assessment is of the utmost importance (for example,
assessment of case reports, review of microbiology results, denominator determination, etc.).
Additionally, regular evaluation of surveillance should be undertaken in line with current needs
and priorities.

74. Antibiotic Stewardship

75. Antibiotic Use Bundle:
Initiation bundle:
1. 1. Clinical rationale for antibiotic initiation documented
2. 2. Appropriate samples for smear & culture collected & submitted to the
laboratory
3. 3. Antibiotic selected according to local policy & risk group
4. 4. Antibiotic ordered as per plan
1. (name, dose, route, frequency & tentative duration)
5. 5. Removal of foreign body or ID, as appropriate, considered

76. Day 3 bundle:
1. 1. Was an antibiotic plan documented
1. (name, dose, route, frequency & planned duration ?)
2. 2. Review patient’s condition & diagnosis after lab reports ?
3. 3. If positive microbiology results, was there any adaptation :
streamlining or discontinuation
4. 4. Was IV -> oral switch considered & implemented
5. 5. Were all four above mentioned steps followed ?

77. Individualizing antibiotic therapy:
[ Making sense of MIC ]
• Parameters of Antimicrobial Activity
• Potency:
• MIC
• MBC
• Time course of activity
• Rate of killing & effect of increasing concentration
• Persistant effects
• PAE, SMPAE, PALE

78. PK / PD consideration
& application
Clinical cure
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects

79. What the body does to the drug
Dosage
Regimen
Time course of
serum levels
Time course of levels
in tissues
Time course of
pharma & tox effect
Time course of
levels at site
Time course of
antimicrobial activity
Absorption
Distribution
Metabolism
Elimination
Pharmacokinetics Pharmacodynamics
What the drug does to the body & bacteria
Pharmacology of Antimicrobial Therapy

80. PK/PD terminology &
central role of MIC
0
Serum
Conc.
(ug/ml)
16
8
4
2
1
0.5
0.25
0.12
0.06
32
C max
MIC
Time > MIC
C max/ MIC
AUC / MIC
t > MIC

81. PK/PD parameters predictive of success
• Cmax / MIC > 10
• AUC / MIC > 100
• T > MIC > 40 % of dosing interval
• Variables affecting concentration:
• Volume of distribution (Vd)
• Clearance (Cl)
• T ½ = 0.693 x Vd
• Cl

82. PK / PD Parameters of antimicrobial action
Cmax/MIC or AUC /MIC
>10 >100
• Aminoglycosides
• Fluoroquinolones
• Metronidazole
• Daptomycin
• Ketolides
• Azithromycin
• Streptogramin
• Glycopeptides
• Amphotericin B
• Fluconazole
T > MIC (>40%)
• Penicillin
• Cephalosporins
• Carbapenems
• Monobactam
• Macrolides
• Clindamycin
• Oxazolidinones
• Glycylcyclines
• Flucytosine

83. Proof of the pudding is in the eating
How to convert Good intention into reality ?
Dr. Dharmendra Sharma
Excel Program
Will give free to
Microbiologists
interested in
Using this

84. Home Screen

90.  Circulating cumulative antibiogram will help clinicians choose right empirical therapy
Report on individual isolate
would help target therapy 

91. Following Guidelines to prevent infection

94. 7 keys to creating a Safety Culture
• 1. Hazard identification & remediation
• 2. Recognize safe be haviour
• 3. Avoid the blame game
• 4. Use of positive consequences
• 5. Build trust and relationship
• 6. Build safety into daily processes
• 7. Celebrate success often

105. Follow locally developed
antibiotic guidelines &
clinical pathways
Enhance infection
prevention & control
activities
Control source of
infection
Prescribe antibiotics
when they are truly
required
Prescribe appropriate
antibiotic (s) with adequate
dosage
Reassess treatment when
culture results are available
Use the shortest duration
of antibiotics based on
evidence (PCT ?)
Educate staff on prudent
use of antibiotics
Support surveillance of
antibiotics resistance &
antibiotic consumption