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Special Problems IV
A  Nosocomial Infections

Infection Prevention in the Health

300  Care Setting
Michael B. Edmond and Richard P. Wenzel

HISTORICAL BACKGROUND improvement and patient safety are also undertaken through the
Infection control as a formal discipline in the United States developed hospital epidemiology program. In the academic setting, additional
during the late 1950s, primarily to address the problem of nosocomial functions of the program may include research and the provision
staphylococcal infections. Over the next 50 years, the field of infection of consultative services to other acute-care and long-term care facili-
control developed slowly, initially focused on surveillance for health ties, public health agencies, and the university campus. The major
care–associated infections (HAIs), then incorporating the science of functions of the effective hospital epidemiology program are listed in
epidemiology to elucidate risk factors for HAIs. However, three pivotal Table 300-1, and some of them are discussed in further detail here.
events signaled the beginning of a new era in health care epidemiology—
the Institute of Medicine’s 1999 report on errors in health care, which Surveillance
included HAIs1; the 2002 Chicago Tribune exposé on HAIs,2 which was The first aim of surveillance is to determine endemic rates of infection.
the beginning of the mainstream media’s interest in this topic; and the Once these rates have been established, an outbreak can be identified
publication in 2004 and 2006 of dramatic reductions in bloodstream when its rate of occurrence is significantly higher than the endemic
infection rates by simply standardizing the process of central venous rate. The importance of surveillance was demonstrated nearly 3 decades
catheter insertion.3,4 This new era in health care epidemiology is char- ago by the Study on the Efficacy of Nosocomial Infection Control,
acterized by consumer demands for more transparency and account- which found a 32% reduction in HAIs in hospitals with active surveil-
ability, increasing scrutiny and regulation, and expectations for rapid lance programs compared with hospitals without such programs.8 Data
reductions in HAI rates.5 The paradigm shifted from viewing most from hospitals in the National Nosocomial Infection Surveillance
HAIs as an unpreventable “cost of business” to the vast majority being System demonstrated that from 1990 to 1999, nosocomial bloodstream
preventable. Accordingly, the focus for hospital programs shifted from infections decreased by 44% in medical intensive care units (ICUs),
infection control to infection prevention, which required rapid identi- 32% in pediatric ICUs, and 31% in surgical ICUs.9 As hospitals gained
fication of infections and timely actions to analyze them, as well as experience in standardization of patient care processes (e.g., central
playing an active role in the implementation of interventions for infec- venous catheter insertion, head of bed elevation), further reductions
tion reduction. in HAIs have been observed. The Centers for Disease Control and
Prevention (CDC) recently reported that in the time period 2008
ROLE OF INFECTION CONTROL through 2011 there was a 41% reduction in central line–associated
The primary role of an infection prevention program is to reduce the bloodstream infections and a 17% reduction in surgical-site infections,
risk for hospital-acquired infection, thereby protecting patients, with only a 7% reduction in catheter-associated urinary tract infections
employees, health sciences students, volunteers, and visitors. HAIs in the time period 2009 through 2011.10 Over the past several years,
develop in 1.7 million patients yearly in the United States, accounting many hospitals have begun to monitor compliance with process mea-
for approximately 100,000 deaths,6 at a direct cost of $37 to $45 billion.7 sures, because feedback to health care workers on compliance with best
However, these estimates are now 10 years old, and given the intense practices more forcefully drives compliance than simply providing
efforts under way since then, it is highly likely that significant reduc- feedback on infection rates.11,12
tions have occurred. Surveillance for HAIs has generally targeted areas of the hospital
The functions of an infection prevention program vary from insti- where the highest rates of infection, highest impact of infection,
tution to institution but can generally be divided into the following and antibiotic resistance are likely to be found. These areas include
areas: (1) surveillance, (2) isolation of patients with transmissible ICUs, cardiothoracic surgery units, and hematology/oncology units.
pathogens, (3) outbreak investigation and management, (4) education, However, with the current scrutiny on HAIs, hospital-wide surveil-
(5) employee health, (6) the monitoring and management of institu- lance (i.e., concurrent surveillance throughout the hospital) is becom-
tional antimicrobial use and antibiotic resistance, (7) the development ing more prevalent and has been mandated in some states. As more
of infection prevention policies and interventions, (8) environmental hospitals implement electronic medical records, hospital-wide sur­
hygiene, and (9) new product evaluation. In some hospitals, quality veillance has become less daunting from a resource perspective. For
3286
 3286.e1
KEYWORDS
airborne precautions; antibiotic stewardship; contact precautions;
droplet precautions; hand hygiene; health care–associated infections;

Chapter 300  Infection Prevention in the Health Care Setting

health care epidemiologist; health care epidemiology; infection
control; infection prevention; infection preventionist; isolation
precautions; nosocomial infections
 3287

TABLE 300-1  Functions That May Be Served By isolation guidelines are based on current understanding of the mecha-
Infection Prevention Programs nisms of the transmission of organisms, few well-controlled studies
have been performed to demonstrate their efficacy. Because HAIs are
Surveillance for health care–associated infections relatively uncommon events, any study designed to demonstrate effi-

Chapter 300  Infection Prevention in the Health Care Setting

Outbreak detection and management
Management of isolation precautions cacy requires sample sizes that are often prohibitively large. Thus,
Education of patients, patients’ families, and health care workers studies evaluating the efficacy of infection prevention interventions
Occupational health program for health care workers: often lack the power to allow one to conclude confidently that there
Postexposure prophylaxis for health care workers with occupational exposures has been a lack of effect (i.e., such studies have a high probability of
Management of the infected health care worker
Respiratory protection program type II error).
Antimicrobial stewardship Because patient isolation is expensive, time consuming, and
Development and implementation of interventions and policy to decrease the uncomfortable for patients, impedes care, and generates large volumes
risk for health care–associated infection of trash because of the use of disposable products, it should be imple-
Environmental infection control:
Monitoring of environmental hygiene and infectious hazards mented only when necessary. Conversely, failure to isolate a patient
Construction infection control (via design process and monitoring of with a transmissible disease may lead to morbidity and mortality and
infectious hazards associated with demolition, renovation, and construction) may ultimately be expensive when one considers the direct costs of an
Infectious waste management investigation of an outbreak and excess length of stay and the indirect
Sterilization and disinfection of medical instruments and devices
New product evaluation costs of lost productivity. The practice of isolating patients has moved
Bioterrorism and disaster preparedness from the requirement for separate infectious disease hospitals to sepa-
Patient safety program rate wards for these patients and, ultimately, to providing precautions
Quality assessment in the general hospital environment. In 2006, the American Institute
Regulatory compliance
of Architects, in its Guidelines for Design and Construction of Health
Care Facilities, made single-patient rooms the standard.14 Hospitals
that have single-patient rooms exclusively are able to isolate patients
example, collection of device days (denominator data), which previ- with transmissible diseases without disrupting patient flow.15 However,
ously required a daily review of patients, often by an infection preven- existing facilities often still have a significant proportion of double-
tionist, can now be accomplished via extraction of data entered into patient rooms.
the electronic record by the bedside nurse as part of the daily patient In 2007, the CDC and the Healthcare Infection Control Practices
nursing assessment. It is important for hospitals to consider imple- Advisory Committee issued a revision of the recommended guidelines
menting surveillance outside of the ICU setting because the proportion for isolation.16 These guidelines outlined a two-tiered approach: stan-
of patients with invasive devices is increasing, and in many hospitals dard precautions, which apply to all patients, and transmission-based
interventions to reduce infection have primarily been targeted to ICU precautions, which apply to patients with documented or suspected
patients. Although the rates of infection may be lower in the non-ICU infection or colonization with certain microorganisms. These guide-
setting, given that ICU beds typically make up a minority of beds in lines are summarized in Table 300-2.
most hospitals, the burden of infections in the non-ICU setting may
actually be higher. STANDARD PRECAUTIONS
Hospitals with sophisticated information systems may be able to Standard precautions are based on the assumption that any patient may
streamline surveillance through the development of computer-based potentially be colonized or infected with organisms that are transmis-
algorithms that identify patients at highest risk for an HAI. Surveil- sible. Therefore, standard precautions apply to all patients, in all set-
lance for some infections (e.g., bloodstream infections or infections tings, at all times. The essential elements of standard precautions are
with antimicrobial-resistant organisms) is primarily microbiology hand hygiene, personal protective equipment (gowns, gloves, masks,
based; therefore, hospital-wide surveillance for targeted infections can and eye protection), and safe needle practices.
be implemented relatively easily.
The highest quality surveillance methodology for HAIs was devel- Hand Hygiene
oped by the CDC and is unit based, infection site specific, and risk Because most HAIs are transmitted by contact, primarily via the hands
adjusted (i.e., expressed in terms of device-specific denominators).13 of health care workers,17 hand hygiene remains the single most impor-
Because the National Healthcare Safety Network (NHSN) methodol- tant means to prevent transmission of nosocomial pathogens. Compli-
ogy is the most widely accepted, hospitals that use it are able to compare ance by health care workers remains suboptimal although improving
their institutional rates to those of a large group of hospitals across the through numerous efforts, including The Joint Commission’s mandate
country. The NHSN has rapidly expanded from a network of slightly to measure hand hygiene via the National Patient Safety Goals program.
more than 200 hospitals in 200614 to nearly 3500 in 2011,10 primarily The microorganisms on hands can be divided into transient flora
owing to mandatory reporting requirements by the Center for Medi- and resident flora.18 The resident flora include organisms of low viru-
care and Medicaid Services (CMS). lence (e.g., coagulase-negative staphylococci, Micrococcus, Corynebac-
Unit-based surveillance trends should periodically be reported terium) that are rarely transmitted to patients except when introduced
back to the health care workers in the unit. Although HAI rates (e.g., by invasive procedures.19 They are not easily removed through hand
bloodstream infections per 1000 catheter-days) are useful for interhos- washing. The transient flora, however, are important causes of HAIs.
pital comparisons and the analysis of institutional long-term trends, These organisms are acquired primarily by contact, are loosely attached
feedback to frontline providers is more meaningful when expressed as to the skin, and are easily washed off. Thus, the purpose of hand
a raw number of infections (e.g., four central line–associated blood- hygiene in the hospital is to remove the transient flora recently acquired
stream infections in the past 3 months). by contact with patients or environmental surfaces.18 In addition, HAIs
have been attributed to bacterial contamination of artificial fingernails;
Reporting therefore, health care workers should not wear them.
Infectious diseases of public health importance should be reported to Alcohol-based hand rubs have become the recommended agents
public health agencies, whose requirements vary by state. Increasingly, for hand hygiene in the health care setting.19 In situations in which
states are mandating surveillance for HAIs with public reporting and the hands are visibly soiled, washing with soap (antimicrobial or non-
the CMS now also mandates reporting of some HAIs. antimicrobial) and water is recommended. Soap and water is also
preferred when caring for patients with Clostridium difficile infection
ISOLATION (owing to the poor sporicidal activity of alcohols)20 or norovirus infec-
The purpose of isolation is to prevent the transmission of microorgan- tion.21 Hand hygiene should be performed before and after contact
isms from infected or colonized patients to other patients, hospital with patients, before any aseptic task, after contact with inanimate
visitors, and health care workers, who may subsequently transmit them objects in the patient’s surrounding environment, and immediately
to other patients or become infected or colonized themselves. Although after removing gloves.22
 3288

TABLE 300-2  Essential Elements of Isolation Precautions

STANDARD TRANSMISSION-BASED PRECAUTIONS
Part IV  Special Problems

ELEMENTS PRECAUTIONS Contact Droplet Airborne

Room Single-patient room preferred; Single-patient room preferred; Single-patient room preferred; Negative pressure, single-patient
door may remain open. door may remain open; use door may remain open. room required with air exhausted
disposable, noncritical, to outside or through HEPA
patient care equipment or filters; door must be closed.
dedicate to a single patient.
Mask Surgical mask for those N95 or portable respirator for
entering room; place surgical entering the room; place surgical
mask on patient if transport mask on patient if transport out
out of room is required. of room is required.
Eye, mouth, nose For any activity likely to generate
protection a splash, spray, or aerosol
Gowns For any activity likely to generate On room entry
a splash, or spray
Gloves For contact with any body fluid, On room entry
mucous membrane, or
nonintact skin
Hand hygiene Before and after patient contact;
before any aseptic task; after
contact with any body fluid,
mucous membrane, or
nonintact skin; after contact
with inanimate objects in the
immediate vicinity of the
patient; after glove removal
HEPA, high-efficiency particulate air.

Wall-mounted dispensers with alcohol-based, waterless hand rubs Injection Safety

should be installed in all hospital and outpatient rooms. In areas where Needles and syringes should be used only once and, when possible,
this is not feasible, individual health care workers should carry small single-dose medication vials should be used.24 Single-use vials of medi-
containers of waterless agents. Technologic interventions to improve cation should not be used for more than one patient, and when possible
hand hygiene compliance include electronic dispensing counters, multiuse vials should be assigned to a single patient. Intravenous solu-
radiofrequency identification, alcohol vapor detection sensors, and tion bags should not be used as a common source of supply for more
videosurveillance.23 than one patient. Needles should not be recapped, bent, or broken but
should be disposed of in puncture-resistant containers.
Gloves Because of the potential for transmission for bloodborne patho-
Gloves should be worn by health care workers to prevent contamina- gens, fingerstick devices for glucose monitoring should never be used
tion of the hands with microorganisms, to prevent exposure of the for more than one person.25 If blood glucose meters must be shared,
health care worker to bloodborne pathogens, and to reduce the risk for they should be cleaned and disinfected after every use. Insulin pens
transmission of microorganisms from the hands of the health care and other medication cartridges and syringes should never be used for
worker to the patient. Standard precautions stipulate that gloves should more than one person.
be worn to touch any of the following: blood, all body fluids, secretions,
and excretions, except sweat, regardless of whether they are visibly Bare Below the Elbows
bloody, nonintact skin, and mucous membranes.20 Gloves should be For the past several years, the National Health Service in the United
changed during the care of a patient when moving from a contaminated Kingdom has mandated a “bare below the elbows” approach to patient
body site (e.g., wound or perineal care) to a clean body site. However, care.26 To ensure optimal hand hygiene, this mandate requires that all
gloves do not replace the need for hand hygiene. Contamination of the health care workers wear either short-sleeved garments or long sleeves
hands can occur with organisms on the surface of the gloves when they that are rolled up. In addition, wrist watches, bracelets, and rings with
are removed, and some gloves have small perforations that may allow stones are not allowed. Neckties, if worn, must be kept tucked in.
organisms to contaminate the hands. Thus, gloves should be viewed as
an adjunctive protective barrier but not as a substitute for hand hygiene, TRANSMISSION-BASED
which should be performed immediately after gloves are removed. PRECAUTIONS
Transmission-based precautions apply to selected patients based on a
Personal Protective Equipment suspected or confirmed clinical syndrome, a specific diagnosis, or colo-
For procedures that are likely to generate splashes or sprays of body nization or infection with epidemiologically important organisms.
fluid, a mask with eye protection or a face shield to protect the mucosa Transmission-based precautions are always implemented in conjunc-
of the eyes, nose, and mouth, as well as a gown, should be worn. Dis- tion with standard precautions. Three types of transmission-based
posable gowns should be made of an impervious material to prevent precautions have been developed for the major modes of transmission
penetration and subsequent contamination of the skin or clothing. of infectious agents in the health care setting—airborne, droplet, and
Standard precautions also stipulate that health care workers per- contact.20 A few diseases (e.g., varicella, severe acute respiratory syn-
forming procedures involving lumbar puncture wear masks to prevent drome) require more than one isolation category. Essential elements of
contamination of the spinal needle or the procedure site with the oral each category are outlined in Table 300-2, and indications for imple-
flora of the operator, which may occur when the operator is talking. mentation are delineated in Table 300-3.
Standard precautions also address respiratory hygiene, which includes
instructing patients to cover their nose and mouth with a tissue when Airborne Precautions
coughing or sneezing, performing hand hygiene after contact with Airborne precautions are designed to prevent the transmission of dis-
respiratory secretions, placing a surgical mask on the coughing patient eases by droplet nuclei (particles <5 µm) or dust particles containing
in common areas, and spatially separating patients with respiratory the infectious agent.20 These particles can remain suspended in the air
tract infections from other patients when feasible.20 and travel long distances. If the particles are inhaled, a susceptible host
 3289

TABLE 300-3  Indications for Transmission-Based Precautions

CONTACT PRECAUTIONS DROPLET PRECAUTIONS AIRBORNE PRECAUTIONS

Chapter 300  Infection Prevention in the Health Care Setting

Syndromes (Before Pathogen Identification)
Acute diarrhea with likely infectious cause Meningitis Vesicular rash*
Vesicular rash* Petechial or ecchymotic rash Maculopapular rash with cough, coryza, and fever
Respiratory tract infection in infants and young children* with fever Cough, fever, upper lobe pulmonary infiltrate
History of infection or colonization with MDRO† Paroxysmal or severe persistent Cough, fever, any pulmonary infiltrate in an
SSTI or UTI with recent stay in a facility where MDROs† are prevalent cough during periods of HIV-infected patient (or at high risk for HIV
Abscess or draining wound that cannot be covered pertussis activity infection)
Cough, fever, any pulmonary infiltrate, and recent travel to regions with Respiratory tract infection in Cough, fever, any pulmonary infiltrate, recent travel to
outbreaks of SARS or avian influenza* infants and young children* regions with outbreaks of SARS or avian influenza*
Known or Suspected Pathogens or Infections
Adenovirus pneumonia*; conjunctivitis* Adenovirus pneumonia*; Measles
Burkholderia cepacia pneumonia in cystic fibrosis conjunctivitis* MERS*†
Clostridium difficile infection Diphtheria, pharyngeal Monkeypox*
Conjunctivitis, acute viral Haemophilus influenzae Tuberculosis, pulmonary, laryngeal; draining lesion
Decubitus ulcer, infected, drainage not contained meningitis, epiglottitis; (e.g., from osteomyelitis)*
Diarrhea, infectious, in diapered or incontinent patient pneumonia (infants, children) SARS*
Diphtheria, cutaneous Influenza Smallpox*
Ectoparasites (lice, scabies) Meningococcal infections Varicella*
Enteroviral infections (infants, young children) Mumps Zoster (disseminated; immunocompromised patient
Furunculosis (infants, young children) Mycoplasma pneumoniae until dissemination ruled out)*
Hepatitis A, E (diapered or incontinent patient) pneumonia
HSV (neonatal, disseminated, severe primary mucocutaneous) Parvovirus B19
Human metapneumovirus Pertussis
Impetigo Plague, pneumonic
MDRO† infection or colonization Rhinovirus*
MERS*† Rubella
Monkeypox* SARS*
Norovirus Streptococcal (group A)
Parainfluenza infection (infants, children) pneumonia; serious invasive
Rhinovirus* disease; major SSTI*;
Rotavirus pharyngitis, scarlet fever
RSV infection (infants, children, immunocompromised) (infants or young children)
Rubella, congenital Viral hemorrhagic fevers*
SARS*
Smallpox*
Staphylococcus aureus major SSTI
Streptococcal (group A) major SSTI*
Tuberculous draining lesion
Vaccinia: fetal, generalized, progressive, eczema vaccinatum
Varicella*
Viral hemorrhagic fevers*
Zoster (disseminated; immunocompromised until dissemination ruled out)*
*Condition requires two types of precautions.
†
MDRO, multidrug-resistant organism (e.g., carbapenem-resistant Enterobacteriaceae [CRE], extended-spectrum β-lactamase [ESBL], MDR-Acinetobacter, methicillin-
resistant Staphylococcus aureus [MRSA], resistant Streptococcus pneumoniae, vancomycin-resistant enterococci [VRE], vancomycin-intermediate S. aureus [VISA],
vancomycin-resistant S. aureus [VRSA]).
HIV, human immunodeficiency virus; HSV, herpes simplex virus; MDR, multidrug-resistant; MERS, Middle East respiratory syndrome; RSV, respiratory syncytial virus; SARS,
severe acute respiratory syndrome; SSTI, skin and soft tissue infection; UTI, urinary tract infection.

may develop infection. Airborne precautions are indicated for patients that there is leakage of 10% or less, and be able to be checked for fit
with documented or suspected tuberculosis (pulmonary or laryngeal), each time the health care worker puts on the mask. The Occupational
measles, varicella, or disseminated zoster. Patients who are infected Safety and Health Administration requires that health care workers
with, or at high risk for infection with, human immunodeficiency virus who manage patients with tuberculosis undergo fit testing and train-
(HIV), with fever, cough, and a pulmonary infiltrate, should be empiri- ing for self-fit checking,30 and this must be performed annually.31
cally placed under airborne precautions until tuberculosis can be ruled Transport of the patient from the isolation room should be limited,
out.2 Although open tuberculous skin wounds are uncommon, they and the patient should be fitted with a standard surgical mask before
have been presumptively associated with nosocomial transmission leaving the room.20 Before transport, hospital personnel in the area
after manipulation of the wound (surgical débridement, dressing receiving the patient should be notified so that proper precautions can
changes, irrigation).27-29 Therefore, such patients should be placed be implemented. Gowns and gloves are used as dictated by standard
under airborne precautions. Patients with nontuberculous (atypical) precautions.
mycobacterial pulmonary disease need not be isolated because person- Any patient with confirmed or suspected tuberculosis should be
to-person transmission does not occur. instructed to cover his or her mouth and nose with a tissue when
Under airborne precautions, patients should be placed in a private coughing or sneezing. Patients should remain in isolation until tuber-
room with monitored negative air pressure in relation to surrounding culosis can be ruled out. Patients with confirmed tuberculosis who are
areas, and the room air must undergo at least 6, but preferably 12, receiving effective antituberculous therapy, are clinically improving
exchanges per hour.30 The door to the isolation room must remain with decreased cough frequency, and have three consecutive sputum
closed. Air from the isolation room should be exhausted directly to smears each at least 8 hours apart, with no detectable acid-fast bacilli,
the outside, away from air intakes, and not recirculated. If outdoor can be released from isolation.30 Patients with multidrug-resistant
exhaust is not possible, air should be exhausted through high-efficiency disease should remain in isolation for the duration of their hospital
particulate filters before it is returned to the general ventilation stay. Patients with active tuberculosis who require surgery present a
system.30 special problem because operating rooms are typically at positive pres-
All persons entering the room of patients with suspected or con- sure. Thus, special precautions are necessary. Hospitalization is not
firmed tuberculosis must wear a personal respirator that filters 1-µm warranted solely to provide isolation for clinically stable patients who
particles with an efficiency of at least 95% (N95 mask). These special are compliant with antituberculous therapy and agree to stay in their
masks must fit different facial sizes and characteristics, be fit-tested so homes.
 3290
Patients with known or suspected measles, varicella, or dissemi- Numerous studies have documented contamination of noncritical
nated zoster require airborne precautions and isolation. Nonimmune patient care equipment (e.g., stethoscopes, blood pressure cuffs) with
health care workers should avoid entering the rooms of these patients vancomycin-resistant enterococci and MRSA. These items should
when possible and, if they are required to enter the room, should wear remain in the isolation room and not be used for other patients. If the
Part IV  Special Problems

an N95 mask.20 items must be shared, they should be cleaned and disinfected before
reuse. Transport of the patient from the isolation room should be kept
Droplet Precautions to a minimum.
Droplet precautions are used to prevent transmission by large-particle The concept of contact precautions was developed at a time when
(droplet) aerosols. Unlike droplet nuclei, droplets are larger, do not hand hygiene compliance in health care settings was quite low. As hand
remain suspended in the air, and do not travel long distances. They are hygiene compliance improves, it is likely that the incremental benefit
produced when the infected patient talks, coughs, or sneezes and of contact precautions is diminished, and it may be that when hand
during some procedures (e.g., suctioning, bronchoscopy). A suscepti- hygiene compliance is sustained at high rates, the incremental benefit
ble host may become infected if the infectious droplets land on the of contact precautions will be very small. As with much of the domain
mucosal surfaces of the nose, mouth, or eye. of infection prevention, there is little evidence available to guide prac-
Droplet precautions require patients to be placed in a private room, tice and further research is needed to address many important
but no special air handling is necessary.20 Alternatively, patients with questions.
the same disease can be placed in the same room with the privacy
curtain between beds drawn if a private room is not available. Because OUTBREAK INVESTIGATION AND
droplets do not travel long distances (usually no more than 3 feet, MANAGEMENT
although occasionally 6 to 10 feet), the door to the room may remain Data accumulated by ongoing surveillance allow detection of nosoco-
open. Health care workers should wear a standard surgical mask when mial outbreaks. When the monthly rate for a particular infection
entering the room. Gowns and gloves should be worn when dictated exceeds the 95% confidence interval based on the previous years’ rates
by standard precautions. When transported out of the isolation room, for that month, the possibility of an outbreak exists and an investiga-
the patient should be fitted with a standard surgical mask.20 tion is warranted. At other times, an astute observation of a potential
Some illnesses that require droplet precautions include invasive cluster of infections by physicians, nurses, or the microbiology labora-
Haemophilus influenzae type b and meningococcal infections, Myco- tory technologists should prompt at least an initial investigation.
plasma pneumoniae pneumonia, pertussis, mumps, rubella, and par- When the cluster involves a common organism, hospitals with the
vovirus B19 infections. Although influenza is generally transmitted via capability of performing molecular typing more rapidly may do so first.
droplets, on rare occasions airborne transmission can occur.32 Patients Pulsed-field gel electrophoresis has been commonly used for outbreak
with seasonal influenza can generally be managed under droplet pre- investigation and is generally adequate for this purpose. More recently,
cautions, except when undergoing aerosol-generating procedures, such whole-genome sequencing has been used. Although this method pro-
as bronchoscopy, sputum induction, elective intubation and extuba- vides greater detail with regard to tracking an organism in the hospi-
tion, and autopsies, during which management requires airborne tal,34 in most cases pulsed-field gel electrophoresis is adequate. If the
precautions.33 cluster appears to be polyclonal, it is most likely due to antimicrobial
usage patterns, a technical problem, or an importation of strains; a
Contact Precautions formal case-control study may not be necessary. A clonal outbreak
Contact precautions are implemented to prevent the transmission of suggests a point source or nosocomial transmission, in which case a
epidemiologically important organisms from an infected or colonized case-control study may be warranted.
patient through direct contact (touching the patient) or indirect The primary investigating team should include the hospital epide-
contact (touching contaminated objects or surfaces in the patient’s miologist, the director of employee health, the infection preventionists,
environment). Patients with contact precautions should be placed in a and the director of the microbiology laboratory. External consultants
private room, although patients infected with the same organism may are necessary in some cases.
be placed in the same room when private rooms are not available.20 Most outbreaks in health care settings are due to pathogens that are
Multidrug-resistant organisms, such as vancomycin-resistant entero- transmitted via direct or indirect contact and often involve multidrug-
cocci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA), resistant organisms. Control of such outbreaks involve cohorting the
contaminate the environment (surfaces and items) in the vicinity of patients and staff (i.e., geographically separating colonized or infected
the infected or colonized patient. Therefore, barrier precautions to patients from the noncolonized and uninfected and assigning nursing
prevent contamination of exposed skin and clothing should be used. staff to care only for one group or the other to minimize the potential
Contact precautions are indicated for patients infected or colonized for cross-transmission), heightening environmental cleaning and pos-
with multidrug-resistant bacteria (e.g., MRSA, VRE, multidrug- sibly using environmental cultures or other technology to monitor the
resistant gram-negative bacilli).20 Other indications include C. difficile cleaning process, performing active surveillance cultures on patients
infection, infections transmitted by the fecal-oral route (e.g., Shigella, to identify newly colonized patients, ensuring high levels of hand
rotavirus, hepatitis A virus infections) in patients who are diapered or hygiene compliance and strictly enforcing contact precautions, and
incontinent, and acute diarrheal diseases likely to be infectious in communicating frequently with hospital staff to maintain vigilance.
origin. Because of the propensity for norovirus to cause institutional Early on, the microbiology laboratory should be alerted and asked to
outbreaks, patients with this infection should be placed under contact archive all isolates potentially related to the outbreak for future molec-
precautions.21 Infants and young children with respiratory syncytial ular typing to assess genetic relatedness.
virus, parainfluenza, or enteroviral infection and patients with neona-
tal, disseminated, or severe primary mucocutaneous herpes simplex EDUCATION
virus infection should also be placed under contact precautions. Ecto- A substantial role for the infection preventionist is to educate hospital
parasitic infestations (lice and scabies) are additional indications. personnel in the areas of communicable disease transmission, steriliza-
Patients with varicella or disseminated zoster require both contact and tion, disinfection, and institutional infection prevention policies. In
airborne precautions. many hospitals the epidemiology team is responsible for bloodborne
Gowns and gloves should be worn when caregivers enter the pathogen training and in some hospitals for airborne isolation mask
patient’s room and removed before leaving it. Gowns should be training and fit testing. Some hospitals have successfully established an
removed before leaving the isolation room, and care must be taken to infection prevention liaison program, whereby each hospital unit
prevent contamination of clothing while removing the gown.20 After appoints a nurse who attends educational sessions periodically and
removing gloves, the hands must be decontaminated immediately with helps disseminate infection prevention information to colleagues.
a medicated hand-washing agent or an alcohol-based hand rub, and Likewise, the hospital epidemiologist should be available to provide
care should be taken to prevent recontamination of the hands before physicians with education targeting specialty-based infection preven-
leaving the room. tion topics.
 3291

Chapter 300  Infection Prevention in the Health Care Setting

ESBL VRE MRSA CRE ESBL VRE MRSA CRE
FIGURE 300-1  Comparison of vertical (left) and horizontal (right) infection prevention strategies. CRE, carbapenem-resistant Enterobac­
teriaceae; ESBL, extended spectrum β-lactamase gram-negative bacilli; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant
enterococci.

EMPLOYEE HEALTH whereas others apply to specific areas of the hospital. Policies are gener-
The infection prevention program must work closely with the employee ally developed by the infection control committee after a review of data
health service. Issues such as the management of exposure to blood- generated in-house, as well as information available from the medical
borne pathogens and other communicable diseases (e.g., varicella, literature. Recommendations from the infection control committee
influenza, meningococcal disease, tuberculosis) require a concerted may then need to be forwarded to other committees for review and
effort by the two groups. In addition, the employee health service is approval before dissemination of the new policy.
responsible for ensuring that health care workers are fit for duty and Infection prevention interventions can be classified as vertical or
free of communicable diseases. At the time of employment, workers horizontal (Figure 300-1).39,40 Vertical interventions are aimed at
should be reviewed to ensure that they have adequate immunity against reducing risk from a single pathogen and often involve a microbiologic
illnesses such as rubella, measles, mumps, pertussis, tetanus, hepatitis testing component. Examples include active surveillance cultures and
B, and varicella. In addition, baseline and periodic testing for latent subsequent isolation of patients found to be colonized with multidrug-
tuberculosis should be performed, as well as postexposure testing. The resistant organisms such as MRSA and VRE. Horizontal interventions
employee health service should proactively and creatively devise deliv- are multipotent interventions aimed at reducing risk from all patho-
ery systems that encourage compliance with and remove barriers to gens transmitted via the same mechanisms. Examples include hand
annual influenza vaccination by all health care workers. hygiene, chlorhexidine bathing, the central line insertion bundle, and
“bare below the elbows.” With regard to influenza prevention in the
ANTIMICROBIAL STEWARDSHIP health care setting, vaccination of health care workers is a vertical
Approximately 60% of hospitalized patients receive antimicrobial intervention; efforts to reduce presenteeism (working while ill) are
agents, and antimicrobial usage varies widely across hospitals.35,36 horizontal because all causes of influenza-like illnesses, and even other
Recent analysis from a consortium of teaching hospitals demonstrated types of infections (e.g., viral gastroenteritis), could be reduced by a
that over 80% of patient days are associated with administration of an reduction in presenteeism.
antimicrobial agent.36 Increasingly, hospitals are establishing antimi- Vertical and horizontal interventions are not mutually exclusive.
crobial stewardship programs, which are designed to prevent the emer- However, the economic and opportunity costs of vertical activities can
gence of antimicrobial resistance, improve patient outcomes, and be high. Some hospital infection prevention programs became con-
control costs. These programs are usually staffed by infectious diseases sumed by obtaining MRSA surveillance cultures on patients at admis-
physicians and clinical pharmacists.37 Interventions implemented by sion and weekly and then ensuring that colonized patients were
stewardship programs can be classified as active or passive and can be appropriately isolated. But even if a vertical intervention for MRSA had
targeted to the pre- or post-prescription periods.38 Examples of active 100% efficacy, it would have no impact on other multidrug-resistant
pre-prescription interventions include formulary restriction, preau- organisms. Alternatively, investment in horizontal interventions such
thorization, and order sets, whereas passive interventions include as improving compliance with hand hygiene has an impact on all
treatment guidelines, education, feedback of antimicrobial utilization pathogens transmitted via contact, even newly emergent organisms for
data, and selective reporting of antimicrobial susceptibility by the which rapid screening tests have not yet been developed. Infection
microbiology laboratory. In the post-prescription period, active inter- prevention programs that are primarily horizontal require long-term
ventions including the provision of real-time feedback to clinicians commitments to difficult targets (e.g., the behavior changes necessary
regarding antimicrobial usage and automatic conversion of intrave- to drive high compliance with hand hygiene).
nous to oral formulations for drugs that are highly bioavailable. Passive
post-prescription interventions include de-escalation protocols and ENVIRONMENTAL HYGIENE
electronic alerts for prolonged antimicrobial therapy or bug-drug As the hospitalized population has become more immunosuppressed,
mismatches. the importance of environmental hygiene has significantly increased.
The program should monitor the antimicrobial susceptibility pro- Technical issues regarding air handling, construction, demolition,
files produced by the microbiology laboratory on a regular basis to water supply, pest control, and medical waste management may require
observe for trends in the development of antimicrobial resistance. The collaboration with engineers, architects, and other nonmedical profes-
results should be correlated with the antimicrobial agents currently sionals, including external consultants. The CDC has produced a docu-
used in the institution. The best data are obtained if nosocomial isolates ment on environmental infection control41 that is an excellent resource
are distinguished from community-acquired isolates and if only one for hospital epidemiologists on these issues.
isolate per patient is counted in the numerator and denominator.
NEW PRODUCT EVALUATION
POLICY AND INTERVENTIONS A large number of new medical products are marketed each year. These
The primary administrative function of the infection prevention products may be introduced into the hospital setting with few data to
program is to develop, implement, and continually evaluate policies support their efficacy or their advantage over existing products. Often
and interventions designed to minimize the risk for HAIs. Some poli- the new products are significantly more costly. The infection preven-
cies are designed to be implemented throughout the institution, tion program should play an active role in evaluating data on new
 3292
products designed to reduce infections or protect health care workers infection preventionist per 100 to 125 beds.44 A more recent expert
and then make recommendations regarding their introduction to the panel concluded that the optimal ratio is one infection preventionist
hospital. per 67 to 100 beds depending on the patient mix.42
Part IV  Special Problems

REGULATORY COMPLIANCE Infection Control Committee

Increasingly, infection prevention programs are involved in the main- A multidisciplinary infection control committee that meets at least
tenance of compliance with governmental regulations, certification quarterly is recommended. This committee should include representa-
programs for various services provided, and accreditation. In order for tives from the medical and nursing staffs, hospital administration, and
hospitals to receive reimbursement from the CMS, it must demonstrate the personnel directly responsible for management of the infection
via an accreditation process that it is in compliance with the conditions prevention program. The committee also typically includes the infec-
of participation. Infection prevention is an integral part of this process. tion preventionists and representatives from the microbiology labora-
Accreditation can be accomplished via routine surveys by a state tory, pharmacy, operating room, and departments of employee health,
survey agency. However, most hospitals seek accreditation via an alter- housekeeping, central services, and engineering and maintenance.
native agency, The Joint Commission. Two other alternative agencies Over the past few decades, preventing HAIs has become highly
are the Healthcare Facilities Accreditation Program (HFAP) and Det technical. Therefore, the bulk of the committee’s work is best accom-
Norske Veritas (DNV) Healthcare. plished by a core of experts that includes the hospital epidemiologist,
infection preventionists, a microbiologist, and the director of employee
ORGANIZATION OF THE INFECTION health. Policy formulations should be developed by this subgroup
PREVENTION PROGRAM along with other experts on an ad hoc basis and brought to the entire
The organizational structure for the infection prevention program committee for review, ratification, and support from political and
should be tailored to meet the demands of the hospital and to use administrative standpoints. Thus, the full infection control committee
available resources optimally. Large hospitals with a high proportion functions to educate key hospital administrators, provide the political
of tertiary care patients require a more complex system to meet their support that allows the core members to implement policy, and dis-
needs. seminate new policy.
Each hospital should develop an infection prevention plan that The meeting’s agenda should be well planned and circulated to
outlines the scope of the infection prevention program, the overarch- committee members before the meeting. In addition, the committee
ing and specific goals, and metrics used to assess progress toward those members should receive all policies to be reviewed before the meeting
goals. Periodically throughout the year, the plan should be reviewed to allow adequate time for review by individual committee members
and updated as goals are met and new issues develop. At the end of and to improve the efficiency of the meeting.
each year, a more formal risk assessment should be conducted in light The agenda should begin with an approval of the minutes of the
of yearly data trends and the findings reflected in the infection preven- previous meeting. This is followed by brief reports by representatives
tion plan for the upcoming year. of the pharmacy, employee health department, clinical microbiology
laboratory, and local public health department. In addition, all com-
Hospital Epidemiologist municable disease exposure workups from the previous month are
The hospital epidemiologist occupies a unique position. He or she summarized, as are bloodborne pathogen exposures in health care
must interface with many hospital departments, hospital administra- workers. Ideally, old business is kept to a minimum. Recent infection
tors, and extramural agencies; directly supervise the infection preven- rates and other trended metrics (e.g., hand hygiene compliance, influ-
tion program; and in some hospitals direct the quality improvement enza vaccine compliance) should be reviewed. The focus of the meeting
program. In areas where subspecialists are available, the position is then turns to more in-depth reports of a few current issues. Invited
generally held by a physician who is trained in infectious diseases. guests may discuss various aspects of these issues. It is also helpful to
However, only approximately one fourth have additional training in review, update, and reapprove a few existing policies at each meeting
health care epidemiology.42 on an ongoing basis.
Before assuming the position of hospital epidemiologist, the physi-
cian should meet with key hospital administrators to discuss the FUTURE CHALLENGES
responsibilities and expectations of the position and to negotiate the Increasingly, third-party payers and health care consumers are
human and material resources, including the salary support that will demanding reductions in complications of medical care, including
be made available to implement the infection prevention program. A HAIs, as well as public reporting of infection rates. These expectations,
survey performed in 2006 found that salary support for physician along with continued media attention, have propelled infection pre-
epidemiologists was on average 0.85 full-time equivalent for hospitals vention programs into a new era of much greater scrutiny and a
with fewer than 200 beds and increased to a mean of 1.79 full-time demand for higher accountability. Despite the increasing severity of
equivalent for hospitals with more than 600 beds.42 An excellent review illness of hospitalized patients, the greater prevalence of invasive tech-
of resources necessary to operate an infection control program is found nologies, and a higher prevalence of immunocompromised patients,
in the Society for Healthcare Epidemiology of America position paper some are calling for hospital epidemiologists to achieve the goal of
on infrastructure for infection control.43 eliminating HAIs (getting to zero). It is important that the infection
prevention community acknowledge that most HAIs are preventable
Infection Preventionists and respond with a strong commitment to decrease HAIs to the irre-
Talented infection preventionists are essential for the operation of an ducible minimum. However, unreasonable expectations can lead to
excellent infection prevention program. These individuals are usually adverse unintended consequences.45
registered nurses with clinical experience or medical technologists The hospital epidemiologist as a steward of scarce resources and
with experience in microbiology. The effective infection preventionist faced with unfunded mandates must decide how best to appropriate
must have a working knowledge of epidemiologic principles and basic resources within his or her purview but must also be able to justify the
microbiology and a sound understanding of the operations of the cost of the marginal benefits gained by enhanced infection prevention
health care institution. activities in light of the impact on other programs with different goals
During the 1980s, the CDC recommended that hospitals have one in the health system. When considering new interventions, the hospital
infection preventionist for every 250 beds.8 Since that time, the number epidemiologist should focus on and integrate clinical outcomes, eco-
of hospital beds has decreased, the severity of illness of hospitalized nomic impact, and customer (health care provider and patient) satis-
patients has markedly increased, with a corresponding increase in the faction to balance quality and cost.46
number of critical care beds, infection control issues in the ambulatory Emerging infectious diseases and multidrug-resistant pathogens
setting have increased, and many new duties have been assumed by require infection control programs to be able to respond quickly to
infection prevention programs. A 2002 study using the Delphi method protect patients and health care workers, even in some cases with few
determined that for acute-care hospitals the optimal ratio is one data on the mechanism of disease transmission. Protecting the health
 3293
care worker with a chronic bloodborne infection and his or her patients collected data critically when making decisions that affect the safety
remains a challenge, as does the protection of immunosuppressed of patients and health care workers. Ensuring that all decisions are
patients and of health care workers from environmental pathogens. evidence based and free of ideology, politics, conflict of interest, or
Last, and perhaps most important, it remains the responsibility of coercion of any form should be a deeply rooted ethic for all involved

Chapter 300  Infection Prevention in the Health Care Setting

the hospital epidemiologist to evaluate the medical literature and newly in this field.

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