Healthcare-Associated Infections A Compendium of Prevention Reccomendations

Last updated May 24, 2022

Hand Hygiene

Hand Hygiene

Figure 1

World Health Organization’s 5 Moments for Hand Hygiene in acute care settings. Reproduced, with permission of the publisher, from “Five Moments for Hand Hygiene,” World Health Organization, 2009, http://www.who.int/gpsc/tools/Five_moments/en/, accessed July 2014. All rights reserved.

Figure 2

Patient zone defined to assist in teaching healthcare personnel about indications for hand hygiene. Reproduced, with permission of the publisher, from “WHO Guidelines on Hand Hygiene in Health Care,” Figure I.21.5a, p. 122, World Health Organization, http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf?ua=1, accessed January 2014. All rights reserved.

Table 1. Recommended Practices for Hand Hygiene in the Perioperative Setting

Preoperative Hand Preparation Steps Traditional Surgical Scrub Surgical Alcohol-based Hand Rub
Remove all jewelry from hands and wrists. Don surgical mask. X X
Wash hands using either nonantimicrobial or antimicrobial soap to ensure that they are clean at the beginning of the day. Repeat soap-and-water hand wash anytime hands are visibly soiled. X X
Use a nail pick or brush with running water at the beginning of the day to remove debris from under the nails. X X
Ensure that hands are dry after hand wash. X
Apply alcohol product to hands according to manufacturer’s instructions: usually 2 or 3 applications of 2 mL each. X
Rub hands to dry completely before donning sterile surgical gloves. Do not wipe off the product with sterile towels. X
After initial wash, wet hands and forearms under running water and apply the antimicrobial agent to wet hands and forearms using a soft, nonabrasive sponge according to the manufacturer’s directions. In general, the time required will be 3-5 minutes. X
Visualize each finger, hand, and arm as having 4 sides.
Wash all 4 sides effectively, keeping the hand elevated.
Repeat the process for the opposite arm.
X
Rinse hands and arms under running water in one direction from fingertips to elbows. X
Hold hands higher than elbows and away from surgical attire. X X
In the OR, dry hands and arms with a sterile towel. X

Basic Practices for Hand Hygiene: Recommended for All Acute Care Hospitals

Select appropriate products. (II – Moderate)
  • For routine hand hygiene, choose an alcohol-based hand rub (ABHR) with at least 62% alcohol.
  • Antimicrobial or nonantimicrobial soap should be available and accessible for routine hand hygiene in all patient care areas.
  • For surgical antisepsis, use an ABHR that is specially formulated for surgical use, containing alcohol for rapid action against microorganisms and another antimicrobial for persistence, or use an antimicrobial soap and water. Scrub brushes should be avoided because they damage skin.
660
Provide convenient access to hand hygiene equipment and products by placing them strategically and assuring that they are refilled routinely as often as required. (III – Low)
  • Sinks should be located conveniently and in accordance with the local applicable guidelines.
  • Dispenser location may be determined by assessing staff workflow patterns or use of a more formal framework, such as Toyota Production Systems shop floor management. Counters in product dispensers can show which dispensers are frequently used and which are rarely used.
◦ It is important to place hand hygiene products in the flow of work to promote adherence.
◦ Location of dispensers and storage of ABHR should be in compliance with fire codes.
660
Involve HCPs in choosing products. (III – Low)
Various components of hand hygiene products can cause irritation, and products that are not well accepted by HCPs can negatively affect hand hygiene adherence.
660
Perform hand hygiene with an ABHR or, alternatively, an antimicrobial or nonantimicrobial soap for the following indications.
  • Before direct patient contact.
  • Before preparing or handling medication in anticipation of patient care (eg, in medication room or at medication cart before patient encounter).
  • Before inserting an invasive device.
  • Before and after handling an invasive device, including before accessing intravenous devices for medication administration.
  • Before moving from a contaminated body site to a clean body site on the same patient.
  • After direct patient contact.
  • After removing gloves.
  • After contact with blood or bodily fluids.
  • After contact with the patient environment.
660
Perform hand hygiene with antimicrobial or nonantimicrobial soap when hands are visibly soiled. (II – Moderate)
660
Assess unit- or institution-specific barriers to hand hygiene with frontline HCPs for the purpose of identifying interventions that will be locally relevant (III – Low)
660
Implement a multimodal strategy (or “bundle”) for improving hand hygiene adherence to directly address the organization’s most significant barriers. (II – Moderate)
  • Use a bundled approach including enhanced access to ABHR, education, reminders, feedback, and administrative support. This combination of interventions has a significant collective impact on hand hygiene adherence.
  • At a minimum, use a bundled approach including education, reminders, and feedback.
660
Educate, motivate, and ensure competency of HCPs (anyone caring for the patient on the institution’s behalf) about proper hand hygiene. (III – Low)
  • Educate HCPs through regular sessions at hire, when job functions change, and at least annually.
    • When possible use interactive means, such as fluorescing indicators, to simulate hand contamination and subsequent removal, and visual reminders, such as culture plates of hands or audience response systems, to keep the audience engaged.
  • Ensure competency of HCPs by testing knowledge of the indications for hand hygiene and requiring demonstration of appropriate hand hygiene technique.
  • Educate patients and families about hand hygiene on admission to healthcare facilities and when changes in circumstances warrant. Encourage patients and families to remind HCPs to clean their hands before care episodes.
  • Motivate HCPs to perform hand hygiene using positive message framing for hand hygiene messaging and posters.
  • Use behavioral frameworks and recognized behavioral techniques to plan and execute interventions.
660
Measure hand hygiene adherence via direct observation (human observers), product volume measurement, or automated monitoring. (II – Moderate)
  • Decide on the type of measurement system on the basis of resource availability and commitment to using the data collected productively. Consider the advantages and limitations of each type of monitoring.
  • Use direct observation to elucidate contextual barriers to and facilitators of hand hygiene and to provide corrective feedback to individuals.
  • Use product volume measurement for large-scale benchmarking but complement with direct observation when possible.
  • Use automated systems to provide real-time reminders and generate feedback for quality improvement.
Note: Be aware that such systems have been mainly used in research settings. They may be limited in their capacity to accurately measure opportunities within each patient care encounter. These systems can, however, measure a large sample of hand hygiene opportunities and can be useful for measuring trends over time and generating real-time displays for feedback.
660
Provide feedback to HCPs on hand hygiene performance.
  • Provide feedback in multiple formats and on more than one occasion.
  • Provide meaningful data with clear targets and an action plan in place for improving adherence.
    • Meaningful data may include unit- or role-based adherence data rather than overall performance.
    • Real-time displays of hand hygiene adherence may provide some incentive for improvement on a shift-by-shift basis.
660

Special Approaches for Hand Hygiene Practices

During norovirus outbreaks, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected norovirus infection (III – Low)
660
During C. difficile outbreaks or in settings with hyperendemic CDI, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected CDI. (III – Low)
660

Clostridium difficile

Clostridium difficile

  • Clostridium difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections (HAIs) in the United States, more than doubling its incidence between 2000 and 2009.
  • C. difficile infection (CDI) with onset outside the hospital may be more common than previously recognized, with ≥50% of CDIs having onset in the community. In addition, ≥75% of CDI cases have onset outside the acute care hospital.
  • There have been numerous reports of an increase in CDI severity. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile. Some studies have found that this strain produces more toxin A and B in vitro than most other strains of C. difficile, and it may produce more spores. It also produces a third toxin (binary toxin). BI/NAP1/027 is highly resistant to fluoroquinolones.
  • CDI increases hospital length of stay by 2.8-5.5 days.
  • In studies over the past 10 years, fluoroquinolones, previously infrequently associated with CDI, have been found to be primary precipitating antimicrobials.
    • Cephalosporins, ampicillin, and clindamycin remain important predisposing antibiotics.
  • Gastric acid suppression has been recognized as a risk factor for CDI in some studies.

Basic Practices for Prevention and Monitoring of CDI: Recommended for All Acute Care Hospitals

Encourage appropriate use of antimicrobials (II – Moderate)
660

Use contact precautions for infected patients, single-patient room preferred

  • for hand hygiene,
( III – Low )
660
  • for gloves,
( II – Moderate )
660
  • for gowns,
( III – Low )
660
  • for single-patient room
( III – Low )
660
Ensure cleaning and disinfection of equipment and the environment
  • for equipment,
( III – Low )
660
  • for environment
( III – Low )
660
Implement a laboratory-based alert system to provide immediate notification to infection prevention and control (IPC) and clinical personnel about newly diagnosed CDI patients. (III – Low)
660
Conduct CDI surveillance and analyze and report CDI data (III – Low)
660
Educate health care practitioners (HCPs), environmental service personnel, and hospital administration about CDI (III – Low)
660
Educate patients and their families about CDI as appropriate (III – Low)
660
Measure compliance with Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene and contact precaution recommendations (III – Low)
660

Special Approaches for Preventing CDI

Approaches to minimize C. difficile transmission by HCPs

Intensify the assessment of compliance with process measures (III – Low)
660
Perform hand hygiene with soap and water as the preferred method before exiting the room of a patient with CDI (III – Low)
660
Place patients with diarrhea under contact precautions while C. difficile testing is pending (III – Low)
660
After the patient becomes asymptomatic, prolong the duration of contact precautions until hospital discharge (III – Low)
660

Approaches to minimize C. difficile transmission from the environment

Assess the adequacy of room cleaning (III – Low)
660
Use a US Environmental Protection Agency (EPA)-approved sporicidal disinfectant or diluted sodium hypochlorite for environmental cleaning and disinfection. Implement a system to coordinate with environmental services if it is determined that sodium hypochlorite is needed for environmental disinfection (III – Low)
660

Approaches to reduce the risk of CDI if C. difficile is acquired

Initiate an antimicrobial stewardship program (II – Moderate)
660

Approaches that Should NOT be Considered a Routine Part of CDI Prevention

Patients without signs or symptoms of CDI should NOT be tested for C. difficile. (II – Moderate)
660
C. difficile testing should NOT be repeated at the end of successful therapy in a patient recently treated for CDI (III – Low)
660
Do NOT routinely place patients who are on antimicrobials for other indications on CDI treatment to prevent CDI (III – Low)
660

Table 2. Fundamental Elements of Accountability for Healthcare-Associated Infection Prevention

Senior management is responsible for ensuring that the healthcare system supports an infection prevention and control (IPC) program that effectively prevents healthcare-associated infections (HAIs) and the transmission of epidemiologically important pathogens.
Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the IPC program and adequate staffing of other departments that play a key role in HAI prevention (eg, environmental services).
Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are adequately trained and competent to perform their job responsibilities.
Direct HCPs (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as environmental service and equipment processing personnel) are responsible for ensuring that appropriate IPC practices are used at all times (including hand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment).
Senior and unit leaders are responsible for holding personnel accountable for their actions.
IPC leadership is responsible for ensuring that an active program to identify HAIs is implemented, that HAI data are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program.
Senior and unit leaders are accountable for ensuring that appropriate training and educational programs to prevent HAIs are developed and provided to personnel, patients, and families.
Personnel from the IPC program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program.

Catheter-Associated Urinary Tract Infections

Catheter-Associated Urinary Tract Infections

Key Points

Urinary tract infection (UTI) is one of the most common hospital-acquired infections; 70%-80% of these infections are attributable to an indwelling urethral catheter.
  • The burden of CAUTI in pediatric patients is not well defined.

Twelve to sixteen percent of adult hospital inpatients will have a urinary catheter at some time during admission.

The daily risk of acquisition of bacteriuria varies from 3%-7% while an indwelling urethral catheter remains in situ.

In one 3-year Canadian study, the incidence of urinary-to-bloodstream infections was 1.4/10,000 patient-days. All-cause 30-day mortality in these patients was 15%.

Catheter use is associated with negative outcomes in addition to infection, including nonbacterial urethral inflammation, urethral strictures, mechanical trauma, and mobility impairment.

Basic Practices for Preventing CAUTI (recommended for all acute care hospitals)


Appropriate infrastructure for preventing CAUTI

Provide and implement written guidelines for catheter use, insertion, and maintenance. (III – Low)
660
Ensure that only trained, dedicated personnel insert urinary catheters. (III – Low)
660
Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located. (III – Low)
660
Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal or justification for continued use. (III – Low)
660
Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes. (III – Low)
660

Surveillance for CAUTI (if indicated on the basis of facility risk assessment or regulatory requirements)

Identify the patient groups or units in which to conduct surveillance on the basis of risk assessment, considering frequency of catheter use and potential risk (eg, types of surgery, obstetrics, critical care). (III – Low)
660
Use standardized criteria, such as CDC's National Healthcare Safety Network (NHSN) definitions, to identify patients who have a CAUTI (numerator data). (III – Low)
660
Collect information on catheter-days and patient-days (denominator data) and indications for catheter insertion for all patients in the patient groups or units being monitored. (III – Low)
660
Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations. (III – Low)
660
Use surveillance methods for case finding that are documented to be valid and appropriate for the institution. (III – Low)
660
Consider providing unit-specific feedback. (III – Low)
660

Education and training

Educate healthcare personnel (HCP) involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters and procedures for catheter insertion, management, and removal. (III – Low)
660
Assess HCP competency in catheter use, catheter care, and maintenance. (III – Low)
660

Appropriate technique for catheter insertion

Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain. (II – Moderate)
660
Consider other methods for bladder management, such as intermittent catheterization, where appropriate. (II – Moderate)
660
Practice hand hygiene (based on CDC or WHO guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus. (III – Low)
660
Insert catheters following aseptic technique and using sterile equipment. (III – Low)
660
Use sterile gloves, drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly for insertion. (III – Low)
660
Use as small a catheter as possible consistent with proper drainage, to minimize urethral trauma. (III – Low)
660

Management of indwelling catheters

Properly secure indwelling catheters after insertion to prevent movement and urethral traction. (III – Low)
660
Maintain a sterile, continuously closed drainage system. (III – Low)
660
Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur. (III – Low)
660
For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant. (III – Low)
660
Obtain larger volumes of urine for special analyses aseptically from the drainage bag. (III – Low)
660
Maintain unobstructed urine flow.
  • Keep the collecting bag below the level of the bladder at all times. Do not place the bag on the floor.
()
660
  • Keep catheter and collecting tube free from kinking.
()
660
  • Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container.
()
660
Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is unnecessary (III – Low)
660

Special Approaches for Preventing CAUTI

Implement an organization-wide program to identify and remove catheters that are no longer necessary using one or more methods documented to be effective ( II – Moderate )
660
Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners ( II – Moderate )
660
Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (III – Low)
660
Perform a CAUTI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CAUTI rates or SIRs despite implementation of the basic CAUTI prevention strategies listed previously.

Approaches that Should NOT be Considered a Routine Part of CAUTI Prevention

Do NOT routinely use antimicrobial/antiseptic-impregnated catheters. (I – High)
660
Do NOT screen for asymptomatic bacteriuria in catheterized patients. (II – Moderate)
660
Do NOT treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures. (I – High)
660
Avoid catheter irrigation. (II – Moderate)
660
Do NOT use systemic antimicrobials routinely as prophylaxis. (III – Low)
660
Do NOT change catheters routinely. (III – Low)
660

Urinary Catheter Reminder

Date: ___/___/______

This patient has had an indewelling urethral catheter since ___/___/______

Please indicate below EITHER (1) that the catheter should be removed OR
(2) that the catheter should be retained. If the catheter should be retained, please state ALL of the reasons that apply.


❑ Please discontinue indwelling urethral catheter; OR
❑ Please continue indwelling urethral catheter because patient requires indwelling catheterization for the following reasons (please check ALL that apply):

❑ Urinary retention
❑ Very close monitoring of urine output and patient unable to use urinal or bedpan
❑ Open wound in sacral or perineal area and patient has urinary incontinence
❑ Patient too ill or fatigued to use any other type of urinary collection strategy
❑ Patient had recent surgery
❑ Management of urinary incontinence on patient's request
❑ Other — please specify:

Surgical Site Infections

Surgical Site Infections

Key Points

Surgical site infections (SSIs) occur in 2%-5% of patients undergoing inpatient surgery.

Approximately 160,000-300,000 SSIs occur each year in the US.

SSI is now the most common and most costly hospital-acquired infection.

Up to 60% of SSIs have been estimated to be preventable by using evidence-based guidelines.

Basic Practices for Preventing SSI

Administer antimicrobial prophylaxis according to evidence-based standards and guidelines. (I – High)
  • Adjust dosing on the basis of patient weight.
  • Redose prophylactic antimicrobial agents for long procedures and in cases with excessive blood loss during the procedure.
  • Use a combination of parenteral antimicrobial agents and oral antimicrobials to reduce the risk of SSI following colorectal procedures.
660
DO NOT remove hair at the operative site unless the presence of hair will interfere with the operation. Do not use razors. (I – High)
660
Control blood glucose during the immediate postoperative period for
  • cardiac surgery patients
()
660
  • and noncardiac surgery patients.
( II – Moderate )
660
Maintain normothermia (temperature of 35.5°C or more) during the perioperative period. (I – High)
660
Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation. (I – High)
660
Use alcohol-containing preoperative skin preparatory agents if no contraindication exists. (I – High)
660
Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (I – High)
660
Use a checklist based on the WHO checklist to ensure compliance with best practices to improve surgical patient safety. (I – High)
660
Perform surveillance for SSI. (II – Moderate)
  • Identify, collect, store, and analyze data needed for the surveillance program.
  • Perform postoperative surveillance for 30 days; extend the postoperative surveillance period to 90 days for certain procedure categories.
  • Surveillance should be performed on patients readmitted to the hospital.
660
Increase the efficiency of surveillance through utilization of automated data. (II – Moderate)
660
Provide ongoing feedback of SSI rates to surgical and perioperative personnel and leadership. (II – Moderate)
660
Measure and provide feedback to providers regarding rates of compliance with process measures. (III – Low)
660
Educate surgeons and perioperative personnel about SSI prevention. (III – Low)
660
Educate patients and their families about SSI prevention as appropriate. (III – Low)
660
Implement policies and practices aimed at reducing the risk of SSI that align with evidence-based standards (eg, CDC, Association for periOperative Registered Nurses, and professional organization guidelines). (II – Moderate)
660

Special Approaches for Preventing SSI

Screen for S. aureus and decolonize surgical patients with an antistaphylococcal agent in the preoperative setting for high-risk procedures, including some orthopedic and cardiothoracic procedures. (II – Moderate)
660
Perform antiseptic wound lavage. (II – Moderate)
660
Perform an SSI risk assessment. (III – Low)
660
Observe and review OR personnel and the environment of care in the OR (III – Low)
660
Observe and review practices in the postanesthesia care unit, surgical ICU, and/or surgical ward. (II – Moderate)
660

Approaches That should Not Be Considered a Routine Part of SSI Prevention

DO NOT routinely use vancomycin for antimicrobial prophylaxis. (II – Moderate)
660
DO NOT routinely delay surgery to provide parenteral nutrition. (I – High)
660
DO NOT routinely use antiseptic-impregnated sutures as a strategy to prevent SSIs. (II – Moderate)
660
DO NOT routinely use antiseptic drapes as a strategy to prevent SSIs. (I – High)
660

Selected Risk Factors for and Recommendations to Prevent Surgical Site Infections (SSIs) (Table 3)

Intrinsic, patient related (preoperative)

Unmodifiable
Age
No formal recommendation. Relationship to increased risk of SSI may be secondary to comorbidities or immunosenescence. (NA)
660
History Radiation
No formal recommendation. Prior irradiation at the surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia.
(NA)
660
History of SSTIs
No formal recommendation. History of a prior skin infection may be a marker for inherent differences in host immune function. (NA)
660
Modifiable
Glucose control
Control serum blood glucose levels for all surgical patients, including patients without diabetes. For patients with diabetes mellitus, reduce glycosolated hemoglobin A1c levels to <7% before surgery, if possible. (I – High)
660
Obesity
Increase dosing of prophylactic antimicrobial agent for morbidly obese patients. (I – High)
660
Smoking cessation
Encourage smoking cessation within 30 days of procedure. (I – High)
660
Immunosuppressive medications
Avoid immune-suppressive medications in perioperative period, if possible. (III – Low)
660
Hypoalbuminemia
No formal recommendation. Although a noted risk factor, DO NOT delay surgery for use of total parenteral nutrition. (NA)
660

Extrinsic, procedure related (perioperative)

Preparation of patient
Hair removal
DO NOT remove unless hair will interfere with the operation. If hair removal is necessary, remove outside the OR by clipping. (II – Moderate)
660
Preoperative infections
Identify and treat infections (eg, urinary tract infection) remote to the surgical site prior to elective surgery. DO NOT routinely treat colonization or contamination. (II – Moderate)
660
Operative characteristics
Surgical scrub (surgical team members’ hands and forearms)
Use appropriate antiseptic agent to perform preoperative surgical scrub. For most products, scrub the hands and forearms for 2-5 minutes.
(II – Moderate)
660
Skin preparation
Wash and clean skin around incision site. Use a dual agent skin preparation containing alcohol, unless contraindications exist. (I – High)
660
Antimicrobial prophylaxis
Administer only when indicated. (I – High)
660
Timing
Administer within 1 hour of incision to maximize tissue concentration.a (I – High)
660
Choice of prophylactic agent
Select appropriate agents on the basis of surgical procedure, most common pathogens causing SSIs for a specific procedure, and published recommendations. (I – High)
660
Duration of prophylaxis
Stop agent within 24 hours after the procedure for all procedures. (II – Moderate)
660
Blood transfusion
Blood transfusions increase the risk of SSI by decreasing macrophage function. Reduce blood loss and need for blood transfusion to the greatest extent possible. (II – Moderate)
660
Surgeon skill/technique
Handle tissue carefully and eradicate dead space. (III – Low)
660
Appropriate gloving
All members of the operative team should double-glove and change gloves when perforation is noted. (III – Low)
660
Asepsis
Adhere to standard principles of OR asepsis. (III – Low)
660
Operative time
No formal recommendation in most recent guidelines. Minimize as much as possible without sacrificing surgical technique and aseptic practice. (I – High)
660
Operating room characteristics
Ventilation
Follow American Institute of Architects’ recommendations for proper air handling in the OR. (III – Low)
660
Traffic
Minimize OR traffic. (III – Low)
660
Environmental surfaces
Use an EPA-approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment. (III – Low)
660
Sterilization of surgical equipment
Sterilize all surgical equipment according to published guidelines. Minimize the use of immediate-use steam sterilization. (II – Moderate)
660

Central Line-Associated Bloodstream Infections

Central Line-Associated Bloodstream Infections

Key Points

The risk of central line-associated bloodstream infection (CLABSI) in intensive care unit (ICU) patients is high.

However, the majority of CLABSIs occur in patients in hospital units outside the ICU or in outpatients.

Infection prevention and control efforts should include other vulnerable populations, such as patients receiving hemodialysis through catheters, intraoperative patients, and oncology patients.

Besides central venous catheters (CVCs), peripheral arterial catheters also carry a risk of infection.

Factors associated with increased risk:
  • Prolonged hospitalization before catheterization
  • Prolonged duration of catheterization
  • Heavy microbial colonization at the insertion site
  • Heavy microbial colonization of the catheter hub
  • Internal jugular catheterization
  • Femoral catheterization in adults
  • Neutropenia
  • Prematurity (ie, early gestational age)
  • Reduced nurse-to-patient ratio in the ICU
  • Total parenteral nutrition
  • Substandard catheter care (eg, excessive manipulation of the catheter)
  • Transfusion of blood products (in children)

Factors associated with reduced risk:
  • Female sex
  • Antibiotic administration
  • Minocycline-rifampin-impregnated catheters

Basic Practices for Preventing and Monitoring CLABSI: Recommended for All Acute Care Hospitals

Before insertion:

Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement. (III – Low)
660
Require education of HCPs involved in insertion, care, and maintenance of CVCs about CLABSI prevention.
660
Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. (I – High)
660

At insertion:

Have a process in place to ensure adherence to infection prevention practices at the time of CVC insertion in ICU insertion in ICU insertion in ICU insertion in ICU insertion in ICU insertion in ICU and non-ICU settings, such as a checklist. (II – Moderate)
660
Perform hand hygiene prior to catheter insertion or manipulation. (II – Moderate)
660
Avoid using the femoral vein for central venous access in obese adult patients when the catheter is placed under planned and controlled conditions. (I – High)
660
Use an all-inclusive catheter cart or kit. (II – Moderate)
660
Use ultrasound guidance for internal jugular catheter insertion. (I – High)
660
Use maximum sterile barrier precautions during CVC insertion. (II – Moderate)
660
Use an alcoholic chlorhexidine antiseptic for skin preparation. (I – High)
660

After insertion:

Ensure appropriate nurse-to-patient ratio and limit the use of float nurses in ICUs. (I – High)
660
Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter. (II – Moderate)
660
Remove nonessential catheters. (II – Moderate)
660
For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5-7 days or immediately if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp. (II – Moderate)
660
Perform surveillance for CLABSI in ICU in ICU in ICU in ICU in ICU in ICU and non-ICU settings. (I – High)
660

Special Approaches for Preventing CLABSI:

Use antiseptic- or antimicrobial-impregnated CVCs in adult patients. (I – High)
660
Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age. (I – High)
660
Use an antiseptic-containing hub/connector cap/port protector to cover connectors. (I – High)
660
Use silver zeolite–impregnated umbilical catheters in preterm infants (in countries where it is approved for use in children). (I – High)
660
Use antimicrobial locks for CVCs. (I – High)
660
Use recombinant tissue plasminogen activating factor once weekly after hemodialysis in patients undergoing hemodialysis through a CVC. (I – High)
660

Ventilator-Associated Pneumonia

Ventilator-Associated Pneumonia

Key Points

Although surveillance rates hover near zero, clinical surveys suggest that 5%-15% of ventilated patients develop nosocomial pneumonias.

The attributable mortality of VAP is estimated to be approximately 10% but varies considerably for different kinds of patients.

In addition, approximately 5%-10% of mechanically ventilated patients develop other ventilator-associated events (VAEs). These include acute respiratory distress syndrome, pneumothorax, pulmonary embolism, lobar atelectasis, and pulmonary edema.

Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Adult Patients (Table 4)

Best practices

Good evidence that the intervention decreases the average duration of mechanical ventilation, length of stay, mortality, and/or costs; benefits likely outweigh risks
  • Use noninvasive positive pressure ventilation in selected populations
()
660
  • Manage patients without sedation whenever possible
()
660
  • Interrupt sedation daily
()
660
  • Assess readiness to extubate daily
()
660
  • Perform spontaneous breathing trials with sedatives turned off
()
660
  • Facilitate early mobility
()
660
  • Utilize endotracheal tubes with subglottic secretion drainage ports for patients expected to require more than 48 or 72 hours of mechanical ventilation
()
660
  • Change the ventilator circuit only if visibly soiled or malfunctioning
()
660
  • Elevate the head of the bed to 30°-45°a
()
660

Special approaches

Good evidence that the intervention decreases the average duration of mechanical ventilation, length of stay, mortality, and/or costs; benefits likely outweigh risks
Selective oral or digestive decontaminationb
660
May lower VAP rates but insufficient data to determine impact on duration of mechanical ventilation, length of stay, or mortality
  • Regular oral care with chlorhexidine
()
660
  • Prophylactic probiotics
()
660
  • Ultrathin polyurethane endotracheal tube cuffs
()
660
  • Automated control of endotracheal tube cuff pressure
()
660
  • Saline instillation before tracheal suctioning
()
660
  • Mechanical tooth brushing
()
660

Generally NOT recommended

Lowers VAP rates but ample data suggest no impact on duration of mechanical ventilation, length of stay, or mortality
  • Silver-coated endotracheal tubes
()
660
  • Kinetic beds
()
660
  • Prone positioning
()
660
No impact on VAPc rates, average duration of mechanical ventilation, length of stay, or mortality
  • Stress ulcer prophylaxis
()
660
  • Early tracheotomy
()
660
  • Monitoring residual gastric volumes
()
660
  • Early parenteral nutrition
()
660

No Recommendation

No impact on VAP rates or other patient outcomes, unclear impact on costs
  • Closed/in-line endotracheal suctioning
()
660
a There are very few data on head-of-bed elevation, but it is classified as a basic practice because of its simplicity, ubiquity, low cost, and potential benefit.
b There are abundant data on the benefits of digestive decontamination but insufficient data on the long-term impact of this strategy on antimicrobial resistance rates.
May be indicated for reasons other than cVAP prevention.
No impact on VAPc rates, average duration of mechanical ventilation, length of stay, or mortality

Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Preterm Neonates (Table 5)

Best practices

May lower VAP rates and minimal risks of harm; benefits likely outweigh potential risk
  • Use noninvasive positive pressure ventilation in selected populations
()
660
  • Minimize the duration of mechanical ventilation
()
660
  • Assess readiness to extubate daily
()
660
  • Manage patients without sedation whenever possible
()
660
  • Avoid unplanned extubation
()
660
  • Provide regular oral care with sterile water
()
660
  • Minimize breaks in the ventilator circuit
()
660
  • Change the ventilator circuit only if visibly soiled or malfunctioning
()
660

Special approaches

Unknown impact on VAP rates, but risk of harm likely minimal; reasonable to consider implementing if rates remain elevated despite basic practices
  • Lateral recumbent positioning
()
660
  • Reverse Trendelenburg positioning
()
660
  • Closed/in-line suctioning systems
()
660

Generally NOT recommended

Unknown impact on VAP rates and inadequate data on risks
  • Regular oral care with antiseptics
()
660
May be harmful; risk-benefit balance does not favor intervention unless specifically indicated for reasons other than VAP prevention
  • Histamine 2 receptor antagonists
()
660
  • Prophylactic broad-spectrum antibiotics
()
660
  • Daily spontaneous breathing trials
()
660
  • Daily sedative interruptions
()
660
Not recommended because appropriate products are not available or approved for use in this population
  • Prophylactic probiotics or synbiotics
()
660
  • Endotracheal tubes with subglottic secretion drainage ports
()
660
  • Silver-coated endotracheal tubes
()
660

Summary of Recommendations for Preventing Ventilator-Associated Pneumonia (VAP) in Pediatric Patients (Table 6)

Best practices

Some data that the intervention lowers VAP rates and minimal risks of harm; potential benefits likely outweigh potential risks
  • Use noninvasive positive pressure ventilation in selected populations
()
660
  • Assess readiness to extubate daily using spontaneous breathing trials in patients without contraindications
()
660
  • Avoid unplanned extubations
()
660
  • Provide regular oral care (ie, toothbrushing or gauze if no teeth)
()
660
  • Elevate the head of the bed to 30°-45°
()
660
  • Change ventilator circuits only if visibly soiled or malfunctioning
()
660
  • Use cuffed endotracheal tubes
()
660
  • Prevent condensate from reaching the patient
()
660

Special approaches

Unknown impact on VAP rates, but risk of harm likely minimal; reasonable to consider implementing if rates remain elevated despite basic practices
  • Interrupt sedation daily
()
660
  • Prophylactic probiotics
()
660
  • Utilize endotracheal tubes with subglottic secretion drainage ports for older pediatric patients expected to require more than 48 or 72 hours of mechanical ventilation
()
660

Generally NOT recommended

Unknown impact on VAP rates and inadequate data on risks
  • Systemic antimicrobial therapy for ventilator-associated tracheobronchitis
()
660
  • Selective oropharyngeal or digestive decontamination
()
660
No impact on VAPa rates
  • Oral care with antiseptics, such as chlorhexidine
()
660
  • Stress ulcer prophylaxis
()
660
  • Early tracheotomy
()
660
  • Thromboembolism prophylaxis
()
660
Lowers VAP rates in adults, but no impact on duration of mechanical ventilation, length of stay, or mortality
  • Silver-coated endotracheal tubes
()
660

No recommendation

Limited data on pediatric patients; no impact on VAP rates or outcomes in adults; unclear impact on costs
  • Closed/in-line suctioning
()
660
May, however, be indicated for reasons other than aVAP prevention.

Methicillin-Resistant Staphylococcus aureus

Methicillin-Resistant Staphylococcus aureus

Key Points

  • Methicillin-resistant Staphylococcus aureus (MRSA) hospital-associated infections (HAIs) have been associated with significant morbidity and mortality.
  • In the United States, the proportion of hospital-associated S. aureus infections resistant to methicillin remains high.
  • The most recent data from the National Healthcare Safety Network (NHSN) reports that, from 2009 to 2010, 54.6% of S. aureus central line–associated bloodstream infections (CLABSIs), 58.7% of S. aureus catheter-associated urinary tract infections, 48.4% of S. aureus ventilator-associated pneumonia (VAP) episodes, and 43.7% of S. aureus surgical site infections (SSIs) were caused by MRSA.
  • The higher morbidity and mortality rates associated with MRSA are not necessarily due to increased virulence of resistant strains but rather to other factors, such as delays in initiation of effective antimicrobial therapy, less effective antimicrobial therapy for resistant strains, and higher severity of underlying illness among persons with infection due to resistant strains.

Colonization

  • A substantial proportion of colonized patients will subsequently develop a MRSA infection, such as pneumonia, soft tissue, or primary bloodstream infection (BSI). Among adults, this proportion has ranged from 18%-33%.
  • Among pediatric patients, 8.5% of children found to be colonized on admission subsequently developed a MRSA infection. In addition, among patients who acquired MRSA colonization while being cared for in the pediatric intensive care unit (ICU), 47% subsequently developed MRSA infection.
  • Risk factors for MRSA colonization include severe underlying illness or comorbid conditions, prolonged hospital stay, exposure to broad-spectrum antimicrobials, presence of invasive devices (such as central venous catheters), and frequent contact with the healthcare system or HCPs.
  • Recent studies have found that an increasing proportion of hospital-onset invasive MRSA infections are caused by community strains.

Reservoirs

  • In the healthcare facility, antimicrobial use provides a selective advantage for MRSA to survive.
  • The reservoir for MRSA in hospitals includes colonized or infected patients and HCPs as well as contaminated objects within the patient care environment. Transmission is complex but occurs largely through patient-to-patient spread.

Basic Practices for Preventing MRSA Transmission and Infection: Recommended for All Acute Care Hospitals

Conduct a MRSA risk assessment
  • The risk assessment should be attentive to 2 important factors: the opportunity for MRSA transmission and estimates of the facility-specific MRSA burden and rates of transmission and infection.
  • Findings from the risk assessment should be used to develop the hospital’s surveillance, prevention, and control plan and to develop goals to reduce MRSA acquisition and transmission.
660
Implement a MRSA monitoring program
The MRSA monitoring program should have 2 goals:
  • Identify any patient with a current or prior history of MRSA to ensure application of infection prevention strategies for these patients according to hospital policy (eg, contact precautions).
  • Provide a mechanism for tracking hospital-onset cases of MRSA for purposes of assessing transmission and infection and the need for response.
660
Promote compliance with CDC or WHO hand hygiene recommendations
660
Use contact precautions for MRSA-colonized and MRSA-infected patients
660
Ensure cleaning and disinfection of equipment and the environment
660
Educate HCPs about MRSA
660
Implement a laboratory-based alert system that notifies HCPs of new MRSA-colonized or MRSA-infected patients in a timely manner
660
Implement an alert system that identifies readmitted or transferred MRSA-colonized or MRSA-infected patients
660
Provide MRSA data and outcome measures to key stakeholders, including senior leadership, physicians, nursing staff, and others
660
Educate patients and their families about MRSA
660

Special Approaches

Note: Special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high MRSA rates despite implementation of the basic MRSA transmission and infection prevention strategies listed above.

Active surveillance testing (AST)

Implement a MRSAAST program as part of a multifaceted strategy to control and prevent MRSA
660
Screen HCP for MRSA infection or colonization if they are epidemiologically linked to a cluster of MRSA infections
660

Gowns and Gloves

Use gowns and gloves when providing care to or entering the room of all adult ICU patients.
660

MRSA decolonization therapy

Note: Special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high MRSA rates despite implementation of the basic MRSA transmission and infection prevention strategies listed above.
Provide targeted decolonization therapy to MRSA-colonized patients in conjunction with an AST program.
660
Provide universal decolonization to ICU patients
with daily chlorhexidine bathing and intranasal mupirocin.
660

Recommendation Grading

Abbreviations

  • ABHR: Alcohol-based Hand Rub
  • AST: Active Surveillance Testing
  • BSI: Bloodstream Infection
  • CAUTI: Catheter-associated Urinary Tract Infection
  • CDC: Centers For Disease Control And Prevention
  • CDI: Clostridium Difficile Infection
  • CLABSI: Central Line-associated Blood Stream Infections
  • CVC: Central Venous Catheter(s)
  • EPA: Environmental Protection Agency
  • HAI: Healthcare-associated Infection
  • HCP: Health Care Practitioner
  • ICU: Intensive Care Unit
  • IPC: Infection Prevention And Control
  • MRSA: Methicillin Resistant Staphylococcus Aureus
  • NA: Not Applicable
  • NHSN: National Healthcare Safety Network
  • OR: Operating Room
  • SIR: Standardized Infection Ratio
  • SSI: Surgical Site Infection
  • SSTI: Skin And Soft Tissue Infection
  • UTI: Urinary Tract Infection
  • VAE: Ventilator-associated Events
  • VAP: Ventilator-associated Pneumonia

Disclaimer

This pocket guide attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care, and providers at all levels. This pocket guide should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation. Neither IGC, the medical associations, nor the authors endorse any product or service associated with the distributor of this clinical reference tool.

Codes

ICD-10 Codes

Code Descriptor Documentation Concepts Quality/Performance
J95.859 Other complication of respirator [ventilator] HCC82
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere
R39.81 Functional urinary incontinence Type
A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent Type
R33.8 Other retention of urine Type