Healthcare-associated Infections
water, are less time-consuming, involve less hand drying and show higher rates of compliance with the guidelines (only in Clostridium difficile infections is hand washing with soap the only effective measure against the produced spores). Although there are no strict guidelines, many experts recommend also the avoidance of artificial fingernails and hand jewellery.
Gloves, Gowns, Face and Respiratory Protection Gloves, gowns and face protection accessories, such as masks, goggles and face shields, are characterised as personal protective equipment. They are used as barriers for the skin, mucous membranes, airway and clothing protection from contamination. Gloves should always be used when a direct contact with blood, body fluids, mucous membranes, non-intact skin or possibly contaminated patient equipment or surfaces is anticipated and in every direct contact with patients who are colonised with pathogens transmitted by the contact route (vancomycin-resistant enterococci [VRE], methicillin-resistant Staphylococcous aureus [MRSA], etc). They are used in order to protect from infectious agents transmission from patients to HCW’s and vice versa, as well as to reduce the chance of the HCW’s hands colonisation. Masks are recommended for the protection of HCWs from the patients’ respiratory secretions and body fluid aerosols and for the protection of patients from HCW-produced respiratory aerosols during sterile procedures (for example, lumbar puncture). Goggles and face shields are used for eye or face protection in the context of specific procedures where a splash or spray of blood or other biological fluid is likely. For respiratory protection, the Centers for Disease Control and Prevention (CDC) currently recommends N95 or higher-level respirators when exposure to patients with suspected or confirmed tuberculosis is anticipated, as well as in cases of other diseases possibly transmitted through the airborne route such as influenza, severe acute respiratory syndrome (SARS) and smallpox. Personal protective equipment accessories should always be disposed in designated containers after removal and hand hygiene should necessarily follow as the last precaution.
Transmission-based (Isolation) Precautions These precautions are applied when specific, epidemiologically important pathogens are suspected or proved to be present in order to prevent transmission to other patients (source control). They are performed when general infection measures are not adequate for transmission control and are always used in addition to them, singly or in combination, depending on the pathogen and their route of transmission.10,11
There are three types of precautions:
• contact precautions – contact precautions are required in cases of epidemiologically important pathogens, such as MDR bacteria. Patients who require contact precautions should be placed in a private room or be cohorted with other patients sharing the same colonisation or infection and they should never share medical equipment with other patients. HCW must apply general infection measures before and after every contact with the patient or the patient’s environment;
•
droplet precautions – droplets are particles of respiratory secretions larger than five micron that remain suspended in the air for limited periods. Human-to-human transmission of droplet-borne pathogens (such as Neisseria meningitis, Bordetella pertussis, human influenza virus, Mycoplasma pneumoniae, rubella, mumps, Haemophilus influenzae type b, SARS, Streptococcus group A) usually requires exposure within less than one metre (sometimes
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up to two metres). When droplet precautions are needed, single patient room is preferred and the use of facemasks by HCW within two to three metres of the patient is advised. Patients themselves should wear facemasks when they are moved outside their rooms. Special air-handling systems and higher-level respirator masks are not required; and
• airborne transmission – airborne droplets are particles of respiratory secretions smaller than five microns that can be suspended in the air for longer periods, constituting an infectious source. Mycobacterium tuberculosis is the most characteristic pathogen of this type, as well as measles, varicella and perhaps smallpox. In those cases, special air handling and ventilation systems should be applied. Patients with airborne droplet infections must be isolated in rooms with negative air pressure and a minimum of six to 12 air changes per hour with closed doors must be performed. All persons entering the room must wear respirators offering filtering capacity of 95 % with a tight seal over the nose and mouth.
Antibiotic Utilisation Policies
Clinicians do not always comply with guidelines, mainly due to the lack of convincing evidence. This however, gives a good excuse to the antibiotic evaluation committees for a strict survey of staff compliance.13
Surveillance
The surveillance techniques are considered as prerequisite for effective HAI prevention predominantly in high-risk hospital settings such as the ICUs. Surveillance is defined as the systematic and continuous investigation for the early detection of single cases or clusters of HAI by epidemiologically important infectious agents. The analysis and presentation of the collected information aims towards the adequate and appropriate treatment of HAI in order to improve the related morbidity and mortality. Surveillance allows the early recognition and management of epidemics and outbreaks, the recognition of systemic faults in the daily clinical practice and the evaluation of infection control programmes.
Colonisation surveillance has been proposed as an important tool of surveillance systems in the ICU, where the high incidence of MDR pathogens makes the empirical antimicrobial treatment of septic patients a difficult decision. The hypothesis is that nosocomial pathogens predominate early on patients’ flora before they induce
EUROPEAN INFECTIOUS DISEASE
Multi-drug antibiotic resistance increases dramatically among Gram-positive and Gram-negative bacteria worldwide, while antimicrobial agents with new mechanisms of actions are lacking. As a result, infections by MDR pathogens are rising and they are associated with significant morbidity, mortality and financial costs. This phenomenon particularly affects intensive care units where patients have multiple risk factors (long hospital stay, prior use of antibiotics, severity of illness, absence of normal anatomical barriers, high frequency of medical and nursing interventions). Extended spectrum beta-lactamases (ESBL), enterobacteriaceae, carbapenem resistant Pseudomonas aeruginosa, VRE and MRSA represent the most commonly reported MDR pathogens in the ICU.6–9 Apart from general infection control measures that are considered valuable and irreplaceable, strict antibiotic hospital policies are of urgent need. Several methods have been proposed for the restriction of broad spectrum antibiotics use, including antibiotic cycling, broad empiric antibiotic treatments, prompt de-escalation accordingly to cultures’ results and shorter courses of antimicrobial treatment.12–15
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