Indira Gandhi Medical College and Research Institute

Infection Control Manual

(A Government of Puducherry Institution)

Kadirkamam, Puducherry 605 009

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

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:

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.

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.

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

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.

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.

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.

Appropriate handling of biomedical waste as per the guidelines provided.

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.

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 / Disinfectant / Use
1. / 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

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.

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.

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).

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:

Patients with AIDS indicator disease
Those attending STI clinic
Patients registered with the RNTCP
Ante natal cases
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.

Specimen collection in infections

Obtain sample prior to antimicrobial therapy.
Avoid contamination of specimen with commensal flora.
Transport sample to the laboratory, without delay.
Provide a completed requisition form with each sample.
Do not refrigerate sample.

Provide sample as follows:

Sample / Test / Quantity / Container / Turn Around Time (TAT)
Blood / Culture
Adults
Paeds / 5-10ml
3-5 ml / 50 ml of broth in BC bottle
30 ml of broth in BC bottle / No growth – 48 hrs
If growth - 72hrs
CSF / Culture / 2 ml / sterile penicillin bulb / No growth – 48 hrs
If growth - 48 hrs
Body fluids / Culture / 2 ml / sterile penicillin bulb / No growth – 48 hrs
If growth - 48 hrs
Urine / Culture / 2 ml / sterile penicillin bulb / No growth – 24 hrs
If growth - 48 hrs
Stool / Culture
Ova/cyst / clean screw capped container
clean screw capped container / Negative – 24 hrs
If growth - 48 hrs
1 hr
Sputum / Culture
Smear for AFB* / clean screw capped container
clean screw capped container / Negative – 24 hrs
If growth – 48 hrs
Pus / tissue / Culture / sterile penicillin bulb
Pus/ swabs in sterile test tube / No growth – 48 hrs
If growth – 48 hrs
Blood / Serology
HIV / 3-5 ml
3-5 ml / sterile test tube
Screw capped vial
with consent form / 4 – 5 hrs
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

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: ampicillin, cefuroxime, ceftriaxone, norfloxacin, amikacin, nitrofurantoin, cotrimoxazole

2ndline : cefepime, ampicillin- sulbactam, piperacillin-tazobactam, imipenem, meropenem

Staphylococcus spp:

ampicillin, cloxacillin, cefuroxime, norfloxacin, cotrimoxazole, nitrofurantoin

Control of MRSA

If a patient is infected with MRSA

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.
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 practical guide 2nd ed, WHO Dept of communicable disease, surveillance and response.

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)