Download Refer HIC MANUAL

Infection Control Manual
Indira Gandhi Medical College and Research Institute
(A Government of Puducherry Institution)
Kadirkamam, Puducherry 605 009
1
IGMC & RI, Puducherry
Infection Control Protocols
This booklet is intended for in-house use only, in particular for doctors & nurses. It covers the basic
protocols in infection control. We request you to read it carefully and use it in daily practice.
Hospital Infection Control Committee
IGMC & RI
Contents
Page
Standard precautions
2
Handwashing
4
Biomedical waste segregation
6
General disinfection and antisepsis
6
Infection control in catheterisation
7
Infection control in surgery
9
Immunisation for HBV
10
Testing for HIV
10
Post exposure prophylaxis
10
Specimen collection in infections
11
Antimicrobial testing policy
12
Control of MRSA
13
Contact isolation policy
13
2
Standard Precautions
Treating all patients in the health care facility with the same basic level of ‘standard precautions’
involves work practices that are essential to provide a high level of protection to patients, health care
workers and visitors.
These include the following:
1. Handwashing (hand hygiene)
Wash hands with soap and water

after handling any blood, body fluids, secretions and contaminated items

between contact with different patients

between procedures on the same patient

after removing gloves
Antiseptics (70% alcohol/ 0.5% chlorhexidine/ 7.5% povidone iodine) on hands are
recommended prior to performing invasive procedures on a patient.
2. Personal protective equipment (PPE) includes
Gloves

Wear gloves when touching blood, body fluids, secretions and excretions

Change gloves between contacts with different patients. If unsoiled, gloves maybe
disinfected with 70% alcohol in between patients e.g. at blood collection.

Wash hands after removing gloves, with soap and water
Masks

Wear a mask when undertaking procedures that are likely to generate splashes of
blood, body fluids, secretions and excretions

Do not reuse disposable masks

Walking around with the mask is not advisable.
Protective eye wear (goggles)

Wear protective eye wear to protect the mucous membranes of the eyes when
conducting procedures that are likely to generate splashes of blood, body fluids.
Gowns & plastic aprons

Wear a gown to protect the skin and prevent soiling of clothing during procedures that
are likely to generate splashes of blood, body fluids, secretions and excretions
especially in the OT and autopsy room.
Cap and boots/ shoe covers

Wear caps and boots/ shoe covers where there is likelihood the patient’s blood, body
fluids, secretions may splash.
3
Personal protective equipment (PPE) should be used by HCW’s, laboratory staff, support staff
who provide direct care to patients and who work in situations where they may have contact
with blood, body fluids.
Use of PPE does not replace the need to follow basic infection control measures such as
hand hygiene.
PPE should be chosen according to the risk of exposure
3. Appropriate handling of patient care equipment and soiled linen

Handle, transport and process used linen that is soiled with blood, body fluids,
secretions or excretions to ensure that there is no leaking of fluid. Soiled instruments
and linen for reuse are to be disinfected with 1% sodium hypochlorite prior to
cleaning.
4. Prevention of needlestick and sharp injuries

Do not recap needles following blood collection or injection.

Needles must be destroyed prior to disposal in puncture proof containers.

Ensure care in handling sharp instruments; do not pass from hand to hand but
handover via a tray.

Discard used disposable syringes and other sharp items in a puncture resistant
container.
5. Environmental cleaning and spills management

Daily disinfection of working surfaces with 7% phenol/ lysol.

In case of spillage- disinfect prior to cleaning: place absorbent material (newspaper/
tissue paper/ cotton/ gauze) on the spillage; pour 1% sodium hypochlorite on it. Clean
after 20 mins.
6. Appropriate handling of biomedical waste as per the guidelines provided.
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Hand washing
Handwashing is the single most important step in the prevention of hospital acquired infection. There
are two kinds of handwashing: hygienic and surgical
An hygienic handwash (with soap & water) suffices in situations where there is no breach of mucosa/
skin in a patient whilst a surgical handwash is warranted when mucosa/ skin is breached.
Precautions:

Ensure that the nails are clipped short

Apply waterproof bandages on any cuts/ wounds on the hands
Procedure:

Remove jewellery (rings, bracelets) and wrist watch before washing hands.

A preliminary hand wash is done with soap and water for 4- 5 mins paying attention to the
finger nails, forearms and elbow as below: (see picture)
The hands are rubbed with five strokes for each movement, backwards and forwards, palm to
palm, right palm over left dorsum, left palm over right dorsum, palm to palm with fingers
interlaced, back of fingers to opposing palm with fingers interlaced, rotational rubbing of right
thumb clasped in left palm and left thumb in right palm, rotational rubbing with clasped fingers
of the right hand in the palm of left hand and the left hand in the palm of the right hand,
complete hands and wrist.

Dry hands with sterile towel.

Apply 7.5% povidone iodine or 0.5% chlorhexidine gluconate on both the hands.

Allow to dry and wear gloves.

Do not wear gloves on wet hands.
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6
Biomedical waste segregation
IGMC & RI follows colour coding for the segregation of biomedical waste:
INFECTIOUS WASTE

Yellow plastic bag: Disposal of all tissue & body parts e.g. placenta, amputated leg,
anatomical viscera.

Red plastic bag: Disposal of all contaminated disposable waste other than sharps e.g.
soiled dressings, used tubings etc
NON INFECTIOUS WASTE
Black plastic bag: Paper, wrappers, fruit peels, coffee cups etc
SHARPS
 All sharps, infectious or non infectious are to be disposed in puncture proof
containers containing disinfectant.
Disposal of syringes & needles following use:

Destroy the needle with a needle cutter and then discard syringe in the sharps
container containing disinfectant. The container has to be emptied daily.
General disinfection and antisepsis
S.
no
1.
Disinfectant
Use
7% phenol or lysol
inanimate surfaces, spillages
2.
Freshly prepared 1% sodium hypochlorite for 20 mins
spillages
3.
2% gluteraldehyde for 30 mins (2 hrs if TB is suspected)
Endoscopes
4.
Stabilised 11% hydrogen peroxide with 0.01% (w/v) silver
nitrate
OT disinfection
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Urinary bladder catheterisation

Follow aseptic technique and use sterile equipment.

Wash hands, apply antiseptic solution, wear gloves.

Clean periurethral area, followed by the urethral meatus with an antiseptic solution.

Instil sterile anaesthetic (1- 2% lignocaine gel) into the urethra to minimise pain. To maintain
sterility, discard the initial part of the gel and then without touching the nozzle instil into the
urethra.


Gently insert the catheter by holding the inner sterile sleeve, avoiding contact with non sterile
surfaces.
Inflate the balloon by instilling sterile water.

Connect the catheters to a sterile closed urinary drainage system.

Hang the drainage bag below the level of the bed to stop reflux, prevent the bag from
touching the floor.
Secure the catheter to the patient’s thigh or abdomen to prevent movement and urethral

meatal ulceration.

Wash hands on de-gloving.
Care of the catheter

The drainage bag should be completely emptied at regular intervals via the drainage tap.

Wash hands and wear unsterile disposable gloves before emptying the bag.

Wash and dry hands thoroughly after touching the drainage bag.

Specimen collection: If a sample of urine is required for bacteriological examination, it should
be obtained from a sampling port.

The optimal limit for replacing catheters depends upon individual circumstances and the type
of catheter used.

Routine bladder irrigation with antiseptics or antimicrobial agents does not prevent catheter
associated infection.

Routine administration of prophylactic antibiotic in catheterised patients is not recommended.
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Intravascular catheter insertion
Peripheral IV catheter

Wash hands, dry and apply antiseptic

Select an appropriate site and disinfect the site with 10% povidone iodine or 70% isopropyl
alcohol

Use an upper extremity site in preference to a lower extremity for catheter insertion.

The venepuncture site should not be touched once the vein has been selected and the skin
prepared.

Insert the catheter aseptically.

Look for flashback of blood and then advance the catheter slowly.

Apply dry sterile dressing (gauze)

Secure the catheter to avoid movement.

Ensure all sharps are safely discarded into sharps bin.
Central venous catheter

Subclavian rather than jugular or femoral sites should be selected for catheter insertion.

Wash hands with an antiseptic, wear gloves, gown and mask.

Disinfect the insertion site with antiseptic– 10% povidone iodine.

Allow the site to dry before inserting the catheter.

Insert the CVC aseptically. Blood should be aspirated freely to ensure that the catheter is in
vascular space.

Secure the catheter with a sterile dressing.

Ensure all sharps are discarded into sharps bin.

The gauze dressings should be changed every 2 days.

Administration sets and add on devices should be replaced not more frequently than 96 hrs.
Replacement of catheters

The peripheral venous catheters should be removed if the patient develops signs of phlebitis.

Do not routinely replace CVC, replacement is necessary if catheter related sepsis is
suspected.

If catheter related infection is suspected, collect 2 sets of blood cultures from peripheral veins
and a swab from the site of catheter insertion.
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Infection control in surgery
Preoperative policy
 Patients to be admitted not more than 48 hours prior to surgery.

Preoperative bath with soap and water- no antiseptics.

Shaving of the operative site.
Antimicrobial prophylaxis
Definition of clean surgery: Non traumatic, uninfected operative wounds in which no inflammation is
encountered; and the respiratory, gastrointestinal or genitourinary tracts or oropharyngeal cavities are
not entered.

A single dose of cefazolin 2 gm should be administered intravenously with the induction of
anaesthesia. Repeat dose should be given in the case of massive haemorrhage (> 2 litres of
blood) or when the duration of surgery exceed 3 hours. Prophylaxis should not exceed 24
hours following surgery.

Use of 3rd generation cephalosporins (e.g. cefotaxime, ceftazidime, cefoperazone) is not
recommended as it promotes emergence of bacterial resistance.
Operative policy
Patient’s operative site to be prepared with 10% povidone iodine or 4% chlorhexidine.
Postoperative Surveillance of SSI as per WHO proforma.
Wound care:

Soak old dressing with diluted liquid antiseptic for ease of removal.

After removal, discard in yellow bag.

Wash hands, dry, apply antiseptic & wear gloves.

Alcohol or ether is not to be used on the wound but may be used around the wound if
needed.

Examine wound. If infected, collect pus for culture.

Apply povidone iodine ointment, cover with sterile gauze, fix gauze with tape
(micropore).
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Immunisation for HBV
Hepatitis B vaccine is available in the ‘Injection Room’ in the OPD for health care workers.
Dose: One injection IM in the deltoid region at 0, 1 & 6 months. Full course of three injections
must be completed for protection.
If desired, anti-HBs titres may be checked (at own expense) to determine level of protection
achieved. A titre > 10 IU/ ml is considered protective. However, the higher the titer achieved,
the longer is the duration of protection, delaying the need for a booster.
Post exposure prophylaxis following occupational exposure to HBV warrants prophylaxis with
HB immunoglobulin within 72 hours of the exposure.
Dose: 0.06 mg/ kg body weight
Testing for HIV
In accordance with NACO guidelines testing for HIV is recommended only in:
1. Patients with AIDS indicator disease
2. Those attending STI clinic
3. Patients registered with the RNTCP
4. Ante natal cases
5. Occupational exposure in health care workers
Preoperative testing for HIV is not recommended.
Occupational exposure and post exposure prophylaxis
Infectious: Blood, CSF, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid
Not infectious: Faeces, urine, nasal secretions, sputum, saliva, tears, sweat, vomitus (unless
contaminated with blood)
In case of accidental exposure to blood or body fluids, wash the part with soap & water.
Use of antiseptic/ squeezing the wound has not be shown to confer any advantage in prevention of
transmission.
Report immediately to the Casualty. The MO on duty will evaluate the nature of injury, the source and
the health care worker and propose prophylactic anti retroviral medication if required. Further follow
up to be done with the Head, Dept of Medicine.
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Specimen collection in infections
1. Obtain sample prior to antimicrobial therapy.
2. Avoid contamination of specimen with commensal flora.
3. Transport sample to the laboratory, without delay.
4. Provide a completed requisition form with each sample.
5. Do not refrigerate sample.
Provide sample as follows:
Sample
Blood
Test
Culture
Adults
Paeds
Culture
Quantity
Container
Turn Around Time (TAT)
5-10ml
3-5 ml
2 ml
50 ml of broth in BC bottle
30 ml of broth in BC bottle
sterile penicillin bulb
Body
fluids
Urine
Culture
2 ml
sterile penicillin bulb
Culture
2 ml
sterile penicillin bulb
Stool
Culture
clean
screw
container
capped
No growth – 48 hrs
If growth - 72hrs
No growth – 48 hrs
If growth - 48 hrs
No growth – 48 hrs
If growth - 48 hrs
No growth – 24 hrs
If growth - 48 hrs
Negative – 24 hrs
If growth - 48 hrs
Ova/cyst
clean
screw
container
clean
screw
container
capped
1 hr
capped
Negative – 24 hrs
If growth – 48 hrs
CSF
Sputum
Culture
Smear for
AFB*
clean
screw
capped
container
sterile penicillin bulb
Pus/ swabs in sterile test
tube
No growth – 48 hrs
If growth – 48 hrs
Pus
/
tissue
Culture
Blood
Serology
3-5 ml
sterile test tube
4 – 5 hrs
HIV
3-5 ml
Screw capped vial
with consent form
4- 5 hrs
*Two samples to be sent- spot and early morning
Emergency tests
CSF - Gram stain
Stool - Hanging drop
Throat swab – Albert’s stain
Tissue (Gas gangrene) – Gram stain
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Antimicrobial testing policy
The policy accounts for use of antimicrobials taking into consideration the identity of the pathogen,
site of infection and bacterial resistance.
The 2nd line agents (broad spectrum antimicrobials ) will be tested only if the organisms are resistant
to the 1st line agents. The testing policy proposed is as follows:
Antimicrobials tested for isolates from blood, body fluids, exudates and respiratory samples:
Staphylococcus aureus
1st line : penicillin, cloxacillin, ciprofloxacin, erythromycin, gentamicin, clindamycin, cotrimoxazole
2nd line: chloramphenicol, linezolid, teicoplanin, tetracycline, vancomycin
Streptococcus spp:
penicillin, erythromycin, clindamycin, chloramphenicol, ciprofloxacin, cotrimoxazole, tetracycline
Pneumococcus:
1st line : penicillin, ciprofloxacin, erythromycin, cotrimoxazole, tetracycline
2nd line: clindamycin, chloramphenicol, vancomycin
Enterococcus spp:
1st line: penicillin, ampicillin, ciprofloxacin, erythromycin, gentamicin, chloramphenicol
2nd line: vancomycin, teicoplanin, tetracycline, linezolid
Enterobacteriaceae ( E.coli, Klebsiella spp, Proteus spp):
1st line: ampicillin, cefuroxime, cefotaxime, amoxy-clav, ciprofloxacin, amikacin, cotrimoxazole
2nd line: aztreonam, cefixime, cefepime, piperacillin-tazobactam, imipenem, meropenem
Salmonella spp:
ampicillin, ceftriaxone, nalidixic acid, ciprofloxacin, chloramphenicol, cotrimoxazole, tetracycline
Pseudomonas spp:
1st line: piperacillin, ceftazidime, cefoperazone, ciprofloxacin, amikacin, tobramycin
2nd line: aztreonam, cefepime, piperacillin-tazobactam, imipenem, meropenem
Isolates from urine:
Enterobacteriaceae ( E.coli, Klebsiella spp, Proteus spp)
1st line:
2ndline
ampicillin, cefuroxime, ceftriaxone, norfloxacin, amikacin, nitrofurantoin, cotrimoxazole
: cefepime, ampicillin- sulbactam, piperacillin-tazobactam, imipenem, meropenem
Staphylococcus spp:
ampicillin, cloxacillin, cefuroxime, norfloxacin, cotrimoxazole, nitrofurantoin
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Control of MRSA
If a patient is infected with MRSA
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patient should be preferably isolated to a separate room or within the ward.
Restrict movement of the patient, if ambulant.
Wash hands and apply antiseptic before and after touching the patient.
Wear gloves.
Routine cleaning of the ward.
Proper disposal of patient’s linen in separate bags.
Screen the patient for MRSA from nose, groin/ perineum.
If more than 1 patient is infected in the same ward, contact Infection Control Doctor.
If MRSA is isolated immediately after a surgery, screen the staff involved during the
procedure.
10. If MRSA is isolated from a draining or decubitus lesions, keep the lesions covered.
Treatment of carrier (HCW or patient)
Nasal carriers
Mupirocin (2% in a paraffin base) applied three times daily for 5 days.
Carriage at other sites
Daily bathing, with 4% chlorhexidine for 1 week.
HCW should be relocated to a non surgical speciality till clearance.
Colonised patient/ HCW should be screened weekly– 3 negative screening indicates clearance.
Contact isolation policy
Tuberculosis patients with sputum positive for AFB or XRC suggestive of active disease, and patients
with viral exanthematous disease require isolation from other patients.
References:
G. A. J. Ayliffe Control of hospital infection: A practical handbook, 1st ed, Oxford University Press,
2000.
Prevention of hospital acquired infections. A
communicable disease, surveillance and response.
practical
guide
2 nd
ed,
WHO
Dept
of
N. N. Damani. Manual of infection control procedures, 2nd ed, London: Greenwich Medical Media Ltd,
2003.
Performance standards for antimicrobial disk susceptibility tests, CLSI, Vol 28, No 1, Jan 2008.
Contacts:
1.Dr.Nandita Banaji Prof & Head, Dept of Microbiology – 9345012927 (Secretary, HICC)
2.Dr.S.Srinivasan Asso Prof, Dept of Microbiology – 9444149424 (Infection Control Doctor, HICC)
3 Dr. R. Balasubramanian Prof & Head, Dept of Medicine – 9677917942 (for Antiretroviral therapy)
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