TRANSMISSIONOF
INFECTIONS IN HEALTHCARE
FACILITIES
I.HEALTHCAREASSOCIATED
INFECTIONS
MUDr. Bohdana Rezková, Ph.D.
Department of Public Health FM MU
HAI
introduction
• Occurres in a patient during the proces of care in a hospital or
other health care facility.
• Is not present and incubating at the time of admission.
• Can also appear after discharge.
• Represents the most frequent adverse event during care delivery.
• Is worthy of a big attention across the world.
Healthcare
Associated
Infection
HAI
Definition
 Healthcare associated infection means diseases or pathologies
related to the presence of infectious agens or its products in
association with exposure to healthcare facilities or healthcare
procedures or treatments.
(definition for the purpose of Recommandation of the Council of
the European Union, 2009)
in hospital
in outpatient medical facilities
in long-term care facilities
in day- care centres
in assisted living facilities etc.
HAI definition
from:
1)EU law
http://eur-
lex.europa.eu
2)National
Healthcare
Safety Network
(NHSN)
 A nosocomial infection associated to the current hospital stay is
defined as infection that matches one of the case definitions
AND
 — the onset of symptoms was on Day 3 or later (day of admission
= Day 1) of the current hospital admission
OR
 — the patient underwent surgery on day 1 or day 2 and develops
symptoms of a Surgical Site Infection before day 3
OR
 — an invasive device was placed on day 1 or day 2 resulting in an
HAI before day 3.
En exampleof
the case
definition of
„nosocomial“
infection
CRI:CATHETER-
RELATED
INFECTION
CRI3-CVC: microbiologically confirmed CVC-related
bloodstream infection
 — BSI occurring 48 hours before or after catheter removal
AND positive culture with the same micro-organism of either:
 — quantitative CVC culture ≥ 103 CFU/ml or semi-quantitative CVC
culture > 15 CFU
 — quantitative blood culture ratio CVC blood sample/peripheral
blood sample > 5
 — differential delay of positive blood cultures: CVC blood sample
culture positive two hours or more before peripheral blood culture
(blood samples drawn at the same time)
 — positive culture with the same micro-organism from pus from
insertion site.
HAI
frequency
 Frequency of HAIs from WHO datas:
- In developed countries in average at least 7% of hospitalized
patients, among criticaly ill and vulnerable patients in intensive
care units (ICUs) around 30%.
- In developing countries in average 15,5% of hospitalized patients.
• The CDC (Centre of disease control and prevention, USA)
estimated that about 75 000 hospital patients with an HAI die
during their hospitalization.
• ECDC - Point prevalence survey of healthcareassociated infections
and antimicrobial use in European acute care hospitals 2011–2012:
- Prevalence of HAI in acute care hospitals in the PPS sample was
6.0% (country range 2.3%–10.8%).
- HAI prevalence was highest in patients admitted to ICU, where
19.5% patients had at least one HAI.
 Prevalence
of the HAIs in
high-income
coutries,
 WHO
 1995 - 2010
 Prevalence
of the HAIs in
middle- and
low-income
countries,
 WHO
 1995 - 2010
HAI
consequences
 Prolonged hospital stay
 Long-term disability
 Unnecessary death
 Increased additional cost for care
 High cost for patient and his family
 Increased resistence of microorganisms to antimicrobials
 Occupational hazards for healthcare workers (exposition to
infected patient or contaminated environment)
Prevention of HAIs Is worthy of a big attention across the world.
HAI
epidemiological
distribution
NON- SPECIFIC
 Common communityacquired
infections brought
by patient or other person.
 Primary pathogens
 e.g. respiratory or
gastointestinal infection
SPECIFIC
 Infection associated with
specific procedures in health
care facilities.
 Often caused by resistent
mikroorganisms (superbugs)
or opportunistic pathogens.
 e.g. urinary tract infection,
blood-stream infection,
ventilator-associated
pneumonia,…
HAI
causative
agens
A. Bacteria (Gram – positive,Gram- negative – enteric and nonenteric,
Mycobacteria,…)
B. Yeast and molds (Candida,Aspergillus)
C. Viruses (rotavirus, norovirus, viruses of hepatitisA,B,C,..)
D. Parazites
HAI
The commonest
pathogens
(Multistate pointprevalence
survey
of HAIs,USA,
2014)
1. Clostridium difficile (CDI)
2. Staphylococcus aureus
3. Klebsiella spp.
4. Escherichia coli
5. Enterococcus spp.
6. Pseudomonas aeruginosa
7. Candida spp.
8. Streptococcal spp.
9. Coagulase-negative staphylococci
10. Enterobacter spp.
Pathogens vary among different types of HAIs!
CHAINOF
INFECTION
SOURCE
TRANSMISSION
ROUTE
SUSCEPTIBLE
HOST
HAI
source
in healthcare
Enviroment
Other person
Health-care professional
Patient!
PATIENT
as
a source
 WHEN:
- misdiagnosed
- in incubation period
- abortive or latent form of infection
- underestimation of risk
- carrier of resistant agent (MRSA),
TBC,VHB,VHC,…
EACH PATIENT SHOULD BE SUSPECTEDTO BE INFECTIOUS!!!
You are certainly not healthy,
because medicine is so advanced
today that a healthy person
basically does not exist!
TRANSMISSION
in
healthcare
facilities
 The most frequent route is a contact, as direct or
mostly indirect way of transmission.
 The most of contact transmissions
of pathogens
happen via healthcare workers hands!
(WHO Guidelines on Hand Hygiene in Health Care)
HAI
susceptible
host
Intrinsic risk factors
Patient related
• Extremes of age
• Obesity or malnutrition
• Smoking, alcoholism,…
• Comorbiditis (diabetes, heart
failure,…)
NON-MODIFIABLE
Extrinsic risk factors
Procedur related
 Invasive procedures (apllying
invasive device, surgery, …
 Endoskopy
 Treating by specific
medicaments (ATB,
immunosupresive,..).
 Duration of hospitalization, re-
hospitalization.
 Artificial implants
MODIFIABLE
HAI
The most
frequent
=
The most
important
USA
 1. Urinary tract infections
(36%)
 2. Surgical site infections (20%)
 3. – 4.Ventilator-associated
pneumonias (11%)
 3. – 4. Catheter-associated
blood-stream infections (11%)
 Clostridium difficile infections
(epidemic and virulent ribotype
027 strain)
Europe
 1. Urinary tract infections
(27%)
 2.Ventilator-associated
pneumonias (24%)
 3. Surgical site infections
(17%)
 4. Catheter-associated bloodstream
infections (10,5%)
 Clostridium difficile
infections
HAI
Guidelines  Guidellines
HAI
Influencing
factors
of transmission
risks among the
various
healthcare
settings
1. the population characteristics (e.g., increased susceptibility to
infections, type and prevalence of indwelling devices),
2. intensity of care,
3. exposure to environmental sources,
4. length of stay,
5. frequency of interaction between patients/residents with each
other and with HCWs,
6. organizational characteristics : organizational priorities, goals,
and resources, influence how different healthcare settings
adapt transmission prevention guidelines to meet their specific
needs.
HAI
Specific risks in
various wards
 Intensive care units (ICUs) – for patients immunocompromised by
disease state and/or by treatment modalities, as well as patients
with major trauma, respiratory failure and other life-threatening
conditions.
 Burn units – burn wounds can provide optimal conditions for
colonization, infection, and transmission of pathogens.
 Pediatrics - a high prevalence of communityacquired infections
among hospitalized infants and young children who have not yet
become immune either by vaccination or by natural infection.
Pediatric intensive care unit patients and the lowest birthweight
babies have high rates of central venous catheter-associated
bloodstream infections.
Possibilities of
prevention
Standard
precautions
the basic level of
infection control
precautions
to be used, as a
minimum, in the care
of all
patients.
prevent transmision
from both recognized
and unrecognized
sources
Isolation
precautions
In specific situation
mostly aimed on
recogni pathogen
differ from the way of
transmission
TRANSMISSIONOF
INFECTIONS IN HEALTHCARE
FACILITIES
II.Standardprecautions
STANDARD
PRECAUTIONS
 a group of infection prevention practices that apply to all patients,
regardless of suspected or confirmed diagnosis or presumed
infection status.
 based on the principle that all blood, body fluids, secretions,
excretions except sweat, nonintact skin, and mucous membranes
may contain transmissible infectious agents.
STANDARD
PRECAUTIONS
WHO
1. Hand hygiene
2. Personal protective equipment - PPE (gloves, facial protection
for eyes, nose, and mouth, gowns)
3. Respiratory hygiene and cough etiquette
4. Prevention of needle stick and injuries from other sharp
instruments
5. Environmental cleaning
6. Linen - safe handling, transport, and processing of used linen
7. Safe waste disposal
8. Safe patient care equipment
Personal
protective
equipment
PPE
1. Gloves
2. Mask (have to cover mouth and nose)
3. Face shield (eye protection)
4. Gown (disposable)
5. Respitator
 Used PPEs are disposed off as wastes with infection risks.
 PPEs have to be put off immediately after finishing their use.
 Disposable PPEs need not be used repeatedly.
 PPEs have to be individualized.
 PPEs at the operating theatres have to cover also beard of
surgeon.
STANDARD
PRECAUTIONS
Respiratory
hygiene and
cough
etiquette
I
 Covering mouth and nose when coughing or sneezing.
 Hand hygiene after contact with respiratory secretions.
 Spatial separation of persons with acute febrile respiratory
symptoms.
 Education of health workers, patients and visitors.
STANDARD
PRECAUTIONS
Respiratory
hygiene and
cough
etiquette
II
Health-care facilities should:
 Place acute febrile respiratory symptomatic patients at least 1
metre (3 feet) away from others in common waiting areas, if
possible.
 Post visual alerts at the entrance to health-care facilities
instructing persons with respiratory symptoms to practise
respiratory hygiene/cough etiquette.
 Consider making hand hygiene resources, tissues and masks
available in common areas and areas used for the evaluation of
patients with respiratory illnesses.
STANDARD
PRECAUTIONS
Prevention of
needlestick and
injuries from
other sharp
instruments
I
 Protection especially from bloodborn pathogens transmission .
 Most exposures are preventable.
 Each sharp item (e.g., needle, scalpel,…) that is contaminated with
patient blood and saliva is potentially infective!!!
 Basic methods to reduce exposures to pathogens from sharp
instruments and needles are engineering and work-practice
controls.
STANDARD
PRECAUTIONS
Prevention of
needlestick and
injuries from
other sharp
instruments
II
 Engineering controls should be used as the primary method ((e.g.,
self-sheathing anesthetic needles, safety scalpels, and needleless
IV ports).
 Work-practice controls are behavior-based and should be used
when engineering controls are not available.
STANDARD
PRECAUTIONS
Prevention of
needlestick and
injuries from
other sharp
instruments
III
 Place used disposable syringes and needles, scalpel blades, and
other sharp items in appropriate puncture-resistant containers
located as close as possible to the area where the items are used.
New cases of
HIV+ persons
in
Czech Republic
(data from
„National Institute
of Public Health“)
After exposure
blood sampling
in
Czech Republic
Till 72
houres
Afted 90
days
After 180
days
HBV Anti - HBs + + - + HBs
Ag
(pouze u
neočkovaných)
+ + - + HCV
Anti - HCV + + +
HIV Anti – HIV
1,2
+ + Liver
tests ALT, AST + + +
STANDARD
PRECAUTIONS
Safe patientcare
items
A. Critical items - surgical instruments, periodontal scalers
(penetrate soft tissue or bone) should always be sterilized.
B. Semicritical items (e.g. laryngoskope, ) come in contact with
mucous membranes or non-intact skin should be also sterilized,
or if inpossible, at a minimum, be processed using high-level
disinfection.
C. Noncritical items (e.g. blood pressure cuff, thermometers),
contact intact skin cleaning, or if visibly soiled, cleaning
followed by disinfection with registered hospital disinfectant is
adequate.
Antiepidemic
measures on
the day of
hospitalization
 identification of a potentially infectious patient (epidemiological
anamnesis, microbiological screening – MRSA,VRE,…)
 implementation of prevention measures, including prompt
separation of potentially infectious patients and
 implementation of appropriate control measures (e.g.,
Respiratory Hygiene/Cough Etiquette and Transmission-Based
Precautions)
HELP DECREASETRANSMISSION RISKS
TRANSMISSIONOF
INFECTIONS IN HEALTHCARE
FACILITIES
III. Isolationprecautions
Isolation
precaution
 Syndromic or empiric application (likely pathogene) of
transmission-based precautions.
 Based on supposed transmission way:
1. Contact transmission – direct, indirect
2. Droplet transmission
3. Airborn transmission
 Indicated individualy regarding the compliance capability of the
patient and local proposition.
 Other posibilities: cohorting, keeping the patient with an existing
roommate, …
 For all persons in a contact with patient or medical equipment!!!
Isolation
precaution
Impact on the
patient
 anxiety, depression and other mood disturbances,
 perceptions of stigma,
 reduced contact with clinical staff.
Isolation
precaution
Impact on the
hospital ward
 Specific cleaning precaution
 Dedicated staff
 Organization of wards (last in the sequence)
and e.g. last position in patient day schedule of surgery
 Individualized patient-care items
 Increased costs
Contact
precautions
 Prevent transmission of infectious agents which are spread by
direct or indirect contact with the patient or the patient’s
environment (MDROs,CLD, norovirus, …)
 Patient placement: a single-patient room or in multi-patient
rooms, ≥ 1 m spatial separation between beds.
 PPE: gowns, gloves
Droplet
precautions
 Prevent transmission of pathogens spread through close
respiratory or mucous membrane contact with respiratory
secretions (B. pertussis, influenza virus, adenovirus, rhinovirus, N.
meningitides, and group A Streptococcus).
 Patient placement: a single patient room or spatial separation of
1,5 m and the curtain between patient beds.
 PPE: mask,….
 Patient trasported outside the room: mask (if tolerated) and
following Respiratory hygiene/Cough etiquette .
Airborne
precautions
 Prevent transmission of infectious agents that remain infectious
over long distances when suspended in the air (e.g., rubeola virus
[measles], varicella virus [chickenpox], M. tuberculosis, and
possibly SARS-CoV)
 Patient placement: a single-patient room that is equipped with
special air handling and ventilation capacity (HEPA,…).
 Mask or respirator or other PPE, depending on the disease-specific
recommendations.
TRANSMISSIONOF
INFECTIONS IN HEALTHCARE
FACILITIES
IV. Hand hygiene
Microflora of
the hand skin
 Resident flora (resident microbiota) - microorganisms residing
under the superficial cells of the stratum corneum and also found
on the surface of the skin (Staphylococcus epidermidis,
Streptococci, S. hominis and other coagulase-negative
staphylococci, followed by coryneform bacteria - propionibacteria,
corynebacteria, dermobacteria, and micrococci ….).
 ! Persistent colonization by pathogenic flora such as S. aureus,
Gram-negative bacilli, or yeast !
 Transient flora (transient microbiota) - microorganisms that
colonize the superficial layers of the skin and are more amenable
to removal by routine handwashing (Staphylococcus aureus,
Proteus mirabilis, Klebsiella spp.,….).
 Often acquired by HCWs during direct contact with patients or
contaminated environmental surfaces adjacent to the patient.
WHO
Definitions
Hygienic handrub
 Treatment of hands with an antiseptic handrub to reduce the
transient flora without necessarily affecting the resident skin flora.
These preparations are broad spectrum and fast-acting, and
persistent activity is not necessary.
Hygienic handwash.
 Treatment of hands with an antiseptic handwash and water to
reduce the transient flora without necessarily affecting the
resident skin flora. It is broad spectrum, but is usually less
efficacious and acts more slowly than the hygienic handrub.
Surgical hand antisepsis/surgical hand preparation/ presurgical hand
preparation
 Antiseptic handwash or antiseptic handrub performed
preoperatively by the surgical team to eliminate transient flora
and reduce resident skin flora.
History
Studies by Ignaz Semmelweis inVienna in the mid-1800s:
 maternal mortality rates, mostly attributable to puerperal fever,
were substantially higher in one clinic compared with the other
(16% versus 7%),
 doctors and medical students often went directly to the delivery
suite after performing autopsies and had a disagreeable odour on
their hands despite handwashing with soap and water before
entering the clinic.
 His hypothesis: “cadaverous particles” were transmitted via the
hands of doctors and students from the autopsy room to the
delivery theatre and caused the puerperal fever.
 Semmelweis recommended that hands be scrubbed in a
chlorinated lime solution before every patient contact and
particularly after leaving the autopsy room.
 Following the implementation of this measure, the mortality rate
fell dramatically to 3%!!!
Transmission
of pathogenes
by hands
 pathogens can be recovered not only from infected or draining
wounds, but also from frequently colonized areas of normal, intact
patient skin,
 diabetics, patients undergoing dialysis for chronic renal failure,
and those with chronic dermatitis are particularly likely to have
skin areas colonized with S. aureus,
 patient gowns, bed linen, bedside furniture and other objects in
the immediate environment of the patient become contaminated
with patient flora.
 certain microorganisms can also play an important role in
environmental contamination due to their long-time survival
capacities (G+ - Acinetobacte baumanii,….)
Jewellery!!!
 Several studies have shown that skin underneath rings is more
heavily colonized than comparable areas of skin on fingers without
rings.
 WHO: „The consensus recommendation is to strongly discourage the
wearing of rings or other jewellery during health care. If religious or
cultural influences strongly condition the HCW’s attitude, the
wearing of a simple wedding ring (band) during routine care may be
acceptable, but in high-risk settings, such as the operating theatre,
all rings or other jewellery should be removed.“
Fingernails??? Artificial fingernails
 WHO:„Consensus recommendations are that HCWs do not wear
artificial fingernails or extenders when having direct contact with
patients and natural nails should be kept short (0.5 cm long or
approximately ¼ inch long)“
Nail polish
 WHO: „Freshly applied nail polish does not increase the number of
bacteria recovered from periungual skin, but chipped nail polish may
support the growth of larger numbers of organisms on fingernails“.
Solutions for
handrubbing
Aqueous solution
 the need of immersion of
hands
 dilution, stability?
 the need od drying
 irritating
 colouring
 frequent use causes damage
of hand skin
Alcohol-based
disinfectant
 comfortable use
 application on dry hands
 quick drying
 content of protecting
substances
 parfumed
 availability at the point of
care (within arm’s reach)
 Risk: flammable
Alcohol
antiseptics
and their
efficacy
I
 contain either ethanol, isopropanol or n-propanol, or a
combination of two of these products,
 solutions containing 60–80% alcohol are most effective, with
higher concentrations being less potent,
 ethanol is less efficacious than isopropanol, and the latter is
less active than n-propanol,
 againstGram-positive and Gram-negative vegetative
bacteria (including multidrug-resistant pathogens such as
MRSA andVRE), M. tuberculosis, and a variety of fungi,
 no activity against bacterial spores or protozoan oocysts,
and very poor activity against some non-enveloped (nonlipophilic)
viruses.
Alcohol
antiseptics
and their
efficacy
II
 non-enveloped viruses (hepatitisA and enteroviruses -poliovirus)
may require 70–80% alcohol to be reliably inactivated.
!
5th May
International
hand hygiene
day
https://youtu.be/K-2XWtEjfl8
Handwashing
WHEN?
 When hands are visibly dirty, contaminated with
proteinaceous material, or visibly soiled with blood or
body fluids (also before eating or after using the toilet!)
 The only method of decontamination of hands in
exposure of spore-forming pathogenes (e.g.,
Clostridium difficile).
 Use an alcohol-based handrub as the preferred means
for routine hand antisepsis in all other clinical situations
How to
handwash
byWHO
 Wet hands with water and apply the amount of product necessary
to cover all surfaces.
 Rinse hands with water and dry thoroughly with a single-use
towel.
 Use clean, running water whenever possible.
 Avoid using hot water, as repeated exposure to hot water may
increase the risk of dermatitis.
The
technique
for
handwashing
Handrubbing
WHEN?
How to
handrub
byWHO
 Apply a palmful of alcohol-based handrub and cover all surfaces of
the hands. Rub hands until dry.
The
technique
for
handrubbing
Frequently
missed areas
(byCDC)
BBE
BBE = Bare Below the Elbows
(Iniciative of SHEA, Special Report, Medscape Infectious Diseases, 2014)
 Preventive strategy to improve the effectivenes of hand hygiene.
 Hands and forearms are free of jewellery and sleeves are above
the elbow.
 Long sleeves have been found to be contaminated with pathogens
MRSA) , and can impede appropriate hand hygiene.
Use of
examination
glowes
Indications
DIRECT PATIENT EXPOSURE:
 contact with blood;
 contact with muscous membrane and with non-intact skin;
 potential presence of highly infectious and dangerous organism;
 epidemic or emergency situations;
 IV insertion and removal; drawing blood; discontinuation of
 venous line;
 pelvic and vaginal examination;
 suctioning non-closed systems of endotracheal tubes.
INDIRECT PATIENT EXPOSURE:
 emptying emesis basins;
 handling/cleaning instruments; handling waste; cleaning up spills
of body fluids.
Use of sterile
gloves
Indication
 Any surgical procedure;
 Vaginal delivery;
 Invasive radiological procedures;
 Performing vascular access and procedures (central lines);
 Preparing total parental nutrition and chemotherapeutic agents.
Rules for use of
gloves!!!
1. Handwashing or handrubbing must be performed before
donning gloves to prevent glove contamination and possible
cross-transmission in case of glove damage or improper
use/efficacy.
2. Gloves must be removed to perform handwashing or
handrubbing to protect a body site from the flora from another
body site or skin area previously touched within the same
patient.
3. Hand hygiene must be performed immediately after glove
removal to prevent HCW contamination and further
transmission and dissemination of microorganisms.
THE END