Annals 2012 (1)

ANNALS OF SBV Volume 1 Issue 1 Jan - Jun 2012

theme

Strategies To Combat Antimicrobial Resistance

A Publication of

SRI BALAJI VIDYAPEETH

Annals of SBV Editor-in-Chief N.Ananthakrishnan Core Committee T.R. Gopalan

Seetesh Ghose

K.A. Narayan

Karthiga Jayakumar

Usha Carounanidy

R. Pajanivel

S. Kamalam

R. Jagan Mohan Issue Editors M. Ravishankar V.N. Mahalakshmi Satistical Consultant G.Ezhumalai Editorial and Production Consultant A.N. Uma

M. Shivasakthy

Editorial Assistance

A. Kripa Angeline

Technical Assistance George Fernandez Published, Produced and Distributed by

Sri Balaji Vidyapeeth Editorial correspondence to Editorial and Production Consultant

Annals of SBV Sri Balaji Vidyapeeth

(Deemed to be University, Declared Under Section 3 of the UGC Act, 1956) Mahatma Gandhi Medical College & Research Institute Campus Pillaiyarkupam, Puduchery - 607 402 INDIA E.mail:annals@sbvu.ac.in | Phone : +91 413 2615449 to 58 | Fax : +91 413 2615457 Visit Annals of SBV Online at http://www.annals.sbvu.ac.in

From The Editor’s Desk M. Ravishankar * V. N. Mahalakshmi ** For centuries, infectious diseases have been the major cause of death in humans. Until recently, the scientific community believed that advances in the development of vaccines and effective antibiotic therapy would eliminate many infectious diseases by the 21st century. However, Infections continue to be a major healthcare challenge even today. Infections contribute to patient deaths and disability, promote resistance to antibiotics and generate additional expenditure to those already incurred by the patients’ underlying disease. According to the World Health Organization’s data, at any given time, more than 1.4 million people worldwide become seriously ill from such infections. Between 5 to 10% of these patients die. In developing countries’ the proportion of patients affected can exceed 25%. Also, patients from developing countries experience more of surgical site infections and neonatal Infections.

Infection control and prevention is one of the most challenging issues facing health care organizations today, from quality of care, patient safety and cost of care/ financial perspectives. As the number and spectrum of coverage of antimicrobial agents have increased, so have the resistance patterns, infectivity and communicability of the microbes.

However, lax attitudes among physicians regarding the application of the advances in healthcare, over the counter use and under dosing of antibiotics and the remarkable ability of microorganisms to adapt are threatening much of the progress made in the fight against infection. We now find ourselves faced with resistant strains of microorganisms that are appearing in epidemic proportions.

Strategies on infection control and prevention of health care associated infections has acquired an urgent dimension with the evolution of a number of organisms that are resistant to commonly used antimicrobial agents. Furthermore, shrinking geographical boundaries and increasing global travel allow these germs to spread worldwide rapidly. Almost all microorganisms known to man have started to develop resistance, at a rate much faster than newer drugs being developed. So much so, that there are only a handful of pharmaceutical companies willing to invest in the development of newer molecules. At this rate, in the very near future, there will not be any effective antibiotics for many of the life threatening infection like AIDS, tuberculosis, malaria, etc. Antimicrobial resistance is not a new problem but the one which has become more dangerous.

“Even as the controversy over the origin of the new antibiotic-resistant bacteria named after India continues, the World Health Organization (WHO) has virtually endorsed the study published in The Lancet Infectious Diseases journal saying that the article had drawn attention to the issue of antimicrobial resistance (AMR), and, in particular, raised the awareness of infections caused by multi-drug resistant bacteria. The World Health Organization (WHO) has advised that countries should be prepared to implement hospital infection control measures to limit the spread of multi drug resistant strains and to reinforce national policy on prudent use of antibiotics reducing the generation of antibioticresistant bacteria.” AMR was the WHO theme for the year 2010.

The first step of the solution to the problem is quite simple - judicious use of antibiotics. Infection control by other methodologies is equally important. It is of paramount importance for hospitals to have an effective infection control policy. Infection control in the health care setting has two primary goals. The first is to reduce the incidence of nosocomial infections in susceptible patients. The second is to protect health care workers from transmissible diseases.

The success of any infection control program depends on acceptance of recommended safe practices by clinicians, residents, interns, medical students and the nursing fraternity. Safe and rational use of anti-microbial agents is another pre-requisite to prevent propagation of anti-microbial resistance. Hence it is essential to create awareness on the scientific usage of these agents among the medical fraternity, so as to cultivate rational and scientifically sound prescription practices. One of the drawbacks of rapid expansion of information access is an ever-widening knowledge gap. It is obvious that practitioners who spend their time caring for patients, find it difficult to keep up with the latest developments in the field. A few have the sophistication to understand the myriad vistas of new knowledge that are unwrapped each passing day. Clearly there is a need to have complex information presented in an efficient and capsular format.

With these goals, the hospital infection control committee of MGMCRI had undertaken the task of organizing annual conferences on “Infection control and Rational Antimicrobial Therapy”. The first of these trans-disciplinary annual conferences was on “Infection Control and Rational Antimicrobial Therapy” on October 22 – 23, 2010, which was well received with over 1000 delegates taking part in the sessions. This felt need of our regional medical community has given us the momentum to continue our efforts every year and hence the second annual conference on 4th and 5th of November 2011. The conference theme, “Strategies to combat antimicrobial resistance-pursue or perish” was adopted from the WHO’s message for the world health day 2011,”Combat Antimicrobial Resistance – No action today; No cure tomorrow”. The third of the series, ‘The study of Regional Antibiotic sensitivity patterns and evolution of Standard treatment protocols’ is planned in Oct 2014 and initiatives have started.

The deliberations of the first two events are brought out as a special edition of the Annals of SBV for wider readership and dissemination of knowledge.

* Dr. M. Ravishankar Md, Frcp Professor And Head, Anaesthesiology And Critical Care, Organising Chairman, Hiccon 2010&11 Mgmc&Ri, Pondicherry

** Dr. V. N. Mahalakshmi M.S, M.Ch., Professor of Paediatric Surgery Organising Secretary, HICCON 2010&11 MGMCRI Pondicherry

Index Pharmacokinetics Principles in Selection of Antibiotics: - S. Balakrishman

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Rational Antimicrobial Therapy in Infective Endocarditis - Amirtha Ganesh

4

UTI in Women 6 - A.Bhupathy Antibiotics in Community Acquired Pneumonia 7 - K. Abdul Ghafur Reading in between the Lines in a Susceptibility Test Report - Iyer N Ranganathan

8

Surgical Site Infections – Strategies for Prevention - K.V.Rajan

9

Activities of the Hospital Infection Control Committee (HICC), 2011 - M.Varadarajan

11

“Communication – the Key Factor in Preventing Nosocomial Resistant Infections” - K.R. Sethuraman.

12

Infection Control is Everyone’s Business – Get Involved - V.N Mahalakshmi

15

Effective Surveillance in Practice – Specific Role of the Microbiology Laboratory in Infection Control 18 - Ranganathan Iyer Standard Precautions/Universal Precautions 20 - Robinson Smiles Antimicrobial Resistance - Causes, Implications and Strategies - M. Ravishankar

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Multi Drug Resistance Typhoid 26 - P. Ramachandran Perioperative Nursing Care 30 - Renuka Gugan Sterile Processing Unit – A Critical Partner in Infection Prevention - Joy Kezia

34

An Overview of Hospital Infection Control Program

36

Infection Control Practices & Policies for Nursing Professionals,

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Pharmacokinetics Principles in Selection of Antibiotics S.Balakrishnan * General Concepts

Antibiotic pharmacokinetics (PK) is concerned with the disposition of drugs in the body. Antimicrobial pharmacokinetics is concerned with absorption when the drug has an oral form and with the drug’s bioavailability. When antimicrobial agents are given intravenously, the rate of the antibiotic infusion determines peak serum concentrations.

Peak serum concentrations fall briefly and rapidly during the alpha phase of elimination.

Shortly thereafter, the beta terminal phase of elimination is a constant decrease in antimicrobial serum concentrations over time as the drug is excreted. It is the beta phase of elimination of an antimicrobial that determines its serum halflife (t1/2 ). The half-life is the amount of time that halves the concentration of a drug in the serum. After an antimicrobial agent is absorbed into the bloodstream by any route, it is reversibly bound to serum albumin, the predominant protein in the blood. Protein binding is expressed as a percent, and it represents the percentage of the antibiotic that is reversibly bound to serum albumin. Antibiotics also bind to tissue sites, but protein binding varies according to the type of tissue; this facet has not been well studied.

The serum compartment, which contains th e antibiotic reversibly bound to serum albumin, is transported via the circulation to all body sites. Moving along a concentration gradient, the antibiotic dissociates itself reversibly from albumin and penetrates a series of membrane barriers to reach the site of infection. After traversing a variable number of membranes, depending on the tissue being penetrated, the antibiotic becomes reversibly bound to tissue proteins. It is the free or unbound portion of an antibiotic in the serum or at the tissue level that is effective in microbial eradication.

As the concentration in the tissue decreases, more of the antibiotic, if it is available from the serum compartment, moves along a concentration gradient into the tissues. When the tissue concentration falls, the concentration gradient is reversed and the antibiotic can move back into the serum compartment until it is eliminated if it is not metabolized at the tissue level. The dose and dosing interval recommendations are based largely on peak serum concentrations and the beta elimination half-life to determine an appropriate dosing interval. Putting these three factors together, appropriate dosing provides for the interplay of these factors, which results in a concentration for a sufficient duration at the intended target site of infection.

Absorption

Some antibiotics are given via the intravenous (IV) or the intramuscular (IM) route because they are not well absorbed via the oral (PO) route. IV antibiotics achieve peak serum concentrations rapidly; IM antibiotics achieve somewhat lower serum concentrations but have more prolonged serum levels. The absorption of orally administered antibiotics is variable. The relative absorption is termed bioavailability and is expressed as the percentage absorbed.

High-bioavailability antibiotics (greater than 90%) are ideal for IV-to-PO switch programs, because serum/tissue levels are comparable. Antibiotics with low bioavailability (below 50%) are incompletely absorbed and are often associated with gastrointestinal side effects.

Route of Elimination

Most antibiotics are eliminated by hepatic or renal mechanisms. Some antibiotics are metabolized, although their precise mode of excretion is not entirely clear. Excessive amounts of drug in the serum compartment (or the amount of drug remaining after reaching tissue sites and returning to the serum compartment) are eliminated. Most antibiotics are eliminated via the kidney and are excreted into the urine as active or inactive drug, plus or minus active or inactive metabolites. Most antibiotics eliminated via hepatic mechanisms are excreted into the bile and into the feces as active or inactive drug, plus or minus active or inactive metabolites. The mode of elimination is also important in the treatment * S. Balakrishnan , Professor & Head, Pharmacology, Pondicherry Institute Of Medical Sciences, Pondicherry

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of urinary tract infections. Most antibiotics that are renally metabolized or inactivated are excreted into the urine at high concentrations. Antibiotics that are eliminated through the kidney, for the most part, are concentrated to supraserum levels in the bladder urine. This is therapeutically useful because some organisms that may appear to be resistant to antimicrobials at the usual serum concentrations may, in fact, be susceptible in the bladder to urinary concentrations of renally eliminated antibiotics. The converse is also true: antibiotics that are eliminated hepatically (e.g., moxifloxacin HCl) usually do not achieve adequate urinary concentrations.

Therefore, if a quinolone is selected to treat cystitis, then ciprofloxacin, ofloxacin levofloxacin or gatifloxacin should be used instead of moxifloxacin.

Tissue Penetration

Infectious diseases occur either in the bloodstream, as with bacteremia, or, as in most cases, in a particular organ site (e.g., the lungs) or in a target tissue (e.g., middle-ear fluid in patients with otitis media). When planning for effective antimicrobial therapy after the appropriate spectrum of coverage has been selected, we would next consider the agent’s pharmacokinetic properties. Antimicrobial agents with a proper spectrum are ineffective if they cannot reach the site of infection. Hence the phrase “tissue is the issue” summarizes the importance of pharmacokinetics in antibiotic selection.

With the appropriate dosing interval used to ensure concentration at the target tissue, the chosen antibiotic must be administered by a route and dose that are in excess of the minimal inhibitory concentration (MIC), or M90, for most of the dosing interval in order to eliminate the causative infectious microorganisms. There is a dynamic balance between the following factors: • the tissue compartment, with its high concentrations • the reversible binding to serum albumin • the loss of antibiotic concentration across various capillary and cellular membranes • entrance of the antibiotic into the tissue where the infection is occurring

Microbiologic Activity versus Antibiotic Concentration

Pharmacokinetic and activity relationships are also important in other clinical situations. For example, aminoglycosides have suboptimal antimicrobial activity in areas of local hypoxemia, increased cellular debris, and local acidosis. This is the case within the lungs with pneumonia and in other situations such as osteomyelitis. With respect to pneumonia, gentamicin achieves high concentration in pulmonary tissue; however, it is probably not the best choice as monotherapy in pneumonia even when the infection is caused by susceptible organisms, because the activity of gentamicin and other aminoglycosides is greatly diminished in the presence of the factors explained earlier. Vancomycin and the macrolides are large molecules that do not penetrate well into synovial fluid in patients with septic arthritis, simply because of their considerable molecular size. Other agents with an appropriate spectrum should be used in place of these agents if the infection involves the synovial fluid.

Protein Binding

High serum protein binding (over 90%) was initially thought to be a disadvantage in an antibiotic. Conceptually, high protein binding means that the antibiotic is bound to serum proteins and is not available in the unbound (free) state to attack the infecting microorganisms. Intuitively, it would seem that antibiotics with a low protein binding (10%) have an advantage of being nearly all free and available for microbial killing. It has also been noted for many years that an increase in protein binding increases the MIC against certain organisms (e.g., Staphylococcus aureus) with certain antimicrobials. All of this suggests that low protein binding is preferable. Actually, however, the answer to the question depends on the achievable serum concentrations.

For example, when cefazolin , which is 86% protein-bound, is compared with cephradine, which is 10% proteinbound, cefazolin on a gram-for-gram basis achieves higher blood serum concentrations than does cephradine. The serum concentrations after administration of 1 g of cefazolin (approximately 200 mg/ml) are sufficient to saturate the albuminbinding sites in the serum compartment and to still have an excess of free drug available in the serum for penetration into tissue sites. If we measure the amount of free antibiotic of cephradine versus cefazolin in tissue using a 2-g (IV) dose for each as a comparison, the free levels with cefazolin are still higher than with cephradine. Therefore, protein binding of antibiotics is not a clinically relevant issue as long as the serum concentrations are high. This is also true with ceftriaxone, which has high protein binding and yet, among third-generation cephalosporins, achieves very high serum levels of approximately 250 mcg/ml after a 1-g (IV) dose. Furthermore, high-protein antibiotics such as cefoperazone and ceftriaxone might have an additional advantage. The high-protein binding to serum albumin acts as an “antibiotic Annals of SBV

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reservoir” and reversibly releases antibiotics from the binding sites as serum and tissue concentrations decrease. This represents the equivalent of a depot formulation of an antibiotic that slowly releases antibiotic back into circulation after serum concentrations have fallen from serum-binding and tissue-binding sites.

In general, then, protein binding for most infectious diseases is not an issue, provided that serum concentrations are sufficiently high to provide adequate amounts of antibiotic to be effective and to eradicate the infection in the blood.

Volume of Distribution

The volume of distribution (Vd) represents the “apparent” volume into which an antibiotic is distributed. This value is derived by the amount of antibiotic in the body divided by the serum concentration (L/kg). The Vd is related to total body water distribution (Vd H2O = 0.7 L/kg). Water-soluble (hydrophilic) antibiotics are limited to extracellular fluid and have a Vd of 0.7 L/kg or less. Highly soluble (hydrophobic) antibiotics penetrate most body tissues well because of their large Vd. Most tissues are rich in lipids and are well penetrated by drugs with a high Vd. The Vd can be affected by organ profusion, lipid solubility, protein binding, and membrane diffusion or permeability. It can be increased in certain patient subsets with hydrophilic drugs, such as patients receiving dialysis, those with cirrhosis, those undergoing mechanical ventilation, patients with burns, or patients with heart failure. Decreases in the Vd for hydrophilic drugs can occur with pancreatitis, early loss of gastrointestinal fluid, trauma, or hemorrhage. Increases in the Vd may require increased daily antibiotic dosing to maintain drug effectiveness, and decreases in the Vd resulting from various pathological states may require a decrease in drug dosing.

Concentration-Dependent Susceptibility

Susceptibility is concentration-dependent; the usually recommended dose is not only optimal for achieving therapeutic serum and tissue concentrations but is also necessary to achieve the full therapeutic effect. The killing of organisms can be represented as a sigmoid curve of concentration versus the percentage of susceptible organisms. As an example, the usual dose of cefoxitin is 2 g (IV) every six hours. Some prescribers have tried to decrease the cost of antimicrobial therapy by decreasing the dose. Unfortunately, this measure also decreases the activity of the drug against the organism in its usual spectrum. Thus, given the 2-g (IV) dose of cefoxitin, approximately 85% of Bacteroides fragilis organisms would be inhibited. If the dose were cut to 1 g, however, only 15% of B. fragilis isolates would be inhibited.

This is an inadequate amount if cefoxitin is being used to treat an intra-abdominal or pelvic infection.

The pharmacokinetic parameters are essential for the optimal dosing of antibiotics. The usual recommended dose takes into account pharmacokinetic factors and represents the best dose for most pathogens at most body sites in normal adult patients. Some patients and infections in certain body sites, however, may warrant dosing modifications. For example, penetration into the central nervous system requires drugs with different physicochemical characteristics or dosing modifications to achieve therapeutic concentrations in the cerebrospinal fluid. Drugs that can be used in the usual dose to treat central nervous system infections include chloramphenicol, because of its high lipid solubility, and , minocycline, linezolid and TMP–SMX (trimethoprim–sulfamethoxazole. Another example is ceftriaxone sodium, an antibiotic with high serum levels that, even when given in the usual dose, penetrates the cerebrospinal fluid in adequate concentration. Other drugs require a higher than usual dose to achieve adequate concentration in the cerebrospinal fluid, for example: • cefepime: usual dose, 2 g IV every 12 hours; meningeal dose, 2 g IV every eight hours • meropenem : usual dose, 1 g IV every eight hours; meningeal dose, 2 g IV every eight hours.

Most other antibiotics do not penetrate the cerebrospinal fluid regardless of the dose given (e.g., cefazolin).

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Rational Antimicrobial Therapy in Infective Endocarditis Amirtha Ganesh * Antibiotic therapy has improved survival in IE by 70-80% and has been shown to reduce the incidence of complications of endocarditis. The fundamental goal of therapy—the eradication of the pathogen from the infected tissue—is made more difficult to achieve by specific and nonspecific defense mechanisms, e.g., biofilm formation and increasing tolerance or resistance to various antibiotics. If the patient’s general condition is critical, then empirical, broad-spectrum antimicrobial therapy is begun as soon as blood cultures have been drawn. The early initiation of appropriate antibiotic therapy is very important, because it can not only control the local infection, but also lessen the risk of complications such as septic embolization.

Two basic principles for eradication of the infective organisms from the vegetations 1. Prolonged course of antibiotic treatment (4-6 weeks) is necessary to eradicate infection because bacterial concentration within vegetations is as high as 109 to 1011 CFU/g of tissue and organisms deep within vegetations are in accessible to phagocytic cells. Consenses dictates that counting of days for recommended duration of treatment should begin on the first day of negative blood cultures in cases where blood cultures had bben positive previously. For patients who undergo valve replacements for endocarditis, the post operative course of antibiotic should be similar to that prescribed for prosthetic valve endocarditis rather than the native valve endocarditis.

2. In parental administration of antibiotic therapy is necessary to achieve adequate drug levels required to eradicate infection. Parental therapy is typically initiated in the hospital setting, and the patient may be transitioned to outpatient parental antibiotic therapy for the remaining duration after an initial period of observation to assess for clinical response to therapy (at least two weeks).

A distinction should be made between native-valve endocarditis and prosthetic-valve endocarditis, which can, in turn, be either early (less than 1 year after valve replacement) or late (more than one year after valve replacement).

A different spectrum of pathogens is to be expected in each of these cases. The spectrum of causative organisms in native-valve endocarditis and late prosthetic-valve endocarditis mainly consists of methicillin-sensitive S. aureus strains, various streptococcal species, and Enterococcus faecalis. Early prosthetic-valve endocarditis, on the other hand, is often due to methicillin-resistant S. aureus strains, coagulase-negative staphylococci, or gramnegative pathogens.

Current Aspects Of Antibiotic Therapy Treatment should be started on an empirical basis, then modified once resistance data have been obtained. The choice of a suitable antibiotic should take the minimal inhibitory concentration (MIC) into account and not merely be based on a discrete classification of antibiotic sensitivity, e.g., into the three categories “sensitive,” “intermediate,” and “resistant.” This holds particularly for treatment with glycopeptides: “vancomycin resistance,” though often discussed, has been seen only rarely to date, including among S. aureus (VRSA), while the true knot of the problem lies in S. aureus strains that are vancomycin-intolerant, i.e., that have only intermediate sensitivity to vancomycin (VISA). In such cases, treatment can be appropriately guided only by the precise determination of resistances, along with adequate monitoring of serum trough levels; according to the current recommendations, these should lie in the range of 15–20 μg/mL and not, as previously recommended, 5–10 μg/mL. Although most previously published guidelines recommended combination therapy with beta-lactams and gentamicin, this recommendation must be viewed critically, particularly with regard to the treatment of staphylococcal infections. More recent meta-analyses show that combination therapy with gentamicin is not clinically superior to betalactam monotherapy; it leads, instead, to significantly elevated nephrotoxicity. In the recent guideline, combination * Dr.Amirtha Ganesh, MD, DNB , Asst.Professor, Dept. of Cardiology, MGMCRI, Puducherry

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therapy with gentamicin is designated as optional for the treatment of staphylococcal infection. For the treatment of infective endocarditis due to methicillin-resistant streptococci, not just vancomycin, but also newer agents are currently being discussed. The lipopeptide daptomycin, for example, has been studied in a prospective, randomized trial in patients with right heart endocarditis and has been approved for this indication. Unlike vancomycin, daptomycin was at least as effective as the combination of a beta-lactam antibiotic and gentamicin in the treatment of methicillin-resistant staphylococcal infection.

While daptomycin has been found effective against secondary pulmonary abscesses caused by the embolization of infected vegetations, it is of no use against primary pulmonary infections, because the agent interacts with pulmonary surfactant. The nephrotoxicity of daptomycin was markedly less than that of comparable treatment with a combination of vancomycin, or a semisynthetic penicillin, with gentamicin. The oxazolidinone linezolide has also been used successfully in a number of cases of IE, but there are, as yet, no prospective data on this treatment.

Prophylaxis – When?

Over the past few decades the efficacy of antimicrobial prophylaxis in preventing IE has been questioned. Recently after an extensive review of all available literature and consensus of experts, the guidelines are updated. These guidelines have concluded that endocarditis was more likely to result from bacteremia associated with daily activities than with a dental procedure. Antibiotic prophylaxis even if 100% effective is estimated to prevent only an extremely small number of cases of infective endocarditis. These recommendations surmised that antibiotic prophylaxis should not be prescribed solely on the basis of an increased lifetime risk of endocarditis, but on the basis of cardiac conditions associated with highest risk of an adverse outcome from endocarditis. Conditions that warrant IE prophylaxis prior to dental procedures and procedures on respiratory tract, skin and musculoskeletal are 1. Patients with a prosthetic valve or a prosthetic material used for cardiac valve repair.

2. Patients with previous IE. 3. Patients with congenital heart disease a. Cyanotic congenital heart disease, without surgical repair, or with residual defects, palliative shunts or conduits b. Congenital heart disease with complete repair with prosthetic material whether placed by surgery or by percutaneous technique, up to 6 months after the procedure. c. When a residual defect persists at the site of implantation of a prosthetic material or device by cardiac surgery or percutaneous technique.

Antibiotic prophylaxis is no longer recommended in other forms of valvular or congenital heart disease. IE prophylaxis before GI or genitourinary procedure is no longer recommended.

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UTI in women A.Bhupathy *

It has been estimated that 60% of women develop UTI in their life time. The highest incidence is seen in the age group of 18 to 24 years, directly related to sexual activity. Next is menopausal age due to lack of estrogen, presence of cystocele and diabetes. The reasons for increased incidence are : short urethra, colonization of vagina by uropathogens where vaginal pH goes up due to use of condoms, spermicides, diaphragms, infrequent emptying of bladder, post void residual urine, cystocele, dilatation of urinary system during pregnancy, recent antibiotic use etc,. Uncomplicated cystitis is treated empirically by 3 day course of TMP-SMX/ ampicillin/ nitrofurantoin/ ciprofloxacin/cephalosporins.

Recurrent UTI requires urine culture and appropriate antibiotics for 7 to 14 days. Post menopausal UTI responds well to vaginal application of estrogens.

Honeymoon cystitis is managed by pre and postcoital voiding, increased fluid intake and in recurrent cases post coital antibiotic prophylaxis (TMP-SMX/ampicillin/ nitrofurantoin).

Asymptomatic bacteriuria during pregnancy(>100,000 organisms/ml ) should be treated because of the risk of developing acute pyelonephritis(30% incidence), preterm labour and low birth weight babies. Asymptomatic bacteriuria is treated by 7 day course of ampicillin or nitrofuratoin or cephalosporins. Acute pyelonephritis should be treated by hospitalization i.v fluids, i.v antibiotics(cephalosporins) for 48 hours and then oral antibiotics for 10 to 14 days.

Differential diagnosis of acute pyelonephritis during pregnancy includes: acute appendicitis, acute cholecystitis, preterm labour, abruptio placentae anrd red degeneration of fibroid. Post partum UTI due to prolonged labour, repeated bladder distension, dehydration and conduction anaesthesia, is difficult to treat because of bladder atony. Atonic bladder may require prolonged catheterization(4-6 wks).

In non specific urethritis or urethral syndrome, the patient has urinary symptoms but no organism can be isolated.

The suspect organisms are: Chlamydia, ureaplasma, HSV and trichomonas. The patients respond well to empirical treatment with tetracyclines.

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* Dr.A.Bhupathy, MD , Prof. & Head, Dept. of OBGY, SMVMC&H, Puducherry

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Antibiotics in Community Acquired Pneumonia K. Abdul Ghafur * Community acquired pneumonia is one of the very common clinical scenarios where rational usage of antibiotic is extremely important to achieve good clinical outcome and to avoid inappropriate antibiotic use.

May I scribble down a few important points I gathered while reading 2009 BTS (British Thoracic society) guidelines. I have made some modifications to suit Indian clinical scenario.

1.CURB 65 score is a useful tool in assessing the severity of pneumonia.

2.Patients with CURB 65 score of 0 or 1 do not require hospitalisation, while patients with score of 2 need to be hospitalised, possibly in a short stay unit (Emergency room observation unit in Indian scenario and can be discharged home while stable,on oral antibiotics), score of 3 require urgent hospitalisation, score of 4 or 5 usually require ICU admission.

CURB65 score

Confusion: New mental confusion Urea: Raised Urea >7 mmol/l (for patients being seen in hospital).

Respiratory rate: Raised >30/min.

Blood pressure: Low blood pressure (systolic ,90 mm Hg and/or diastolic (60 mm Hg).

Age >65 years

Empirical antibiotic choice for adults treated in the community

Amoxicillin is the ideal agent for treating patients with pneumonia who do not require hospitalisation. Clarithromycin or Doxycyclin are the alternative options especially in patients with penicillin allergy.

Empirical in- hospital antibiotic therapy for treating pneumonia

Most of these patients can be managed with oral antibiotics. Oral Amoxicillin and a macrolide is the ideal choice in this scenario. Alternative options are oral levofloxacin or moxifloxacin or doxycycline.

When oral therapy is contraindicated, intravenous crystalline penicillin or ampicillin along with intravenous clarithromycin is a good combination. In penicillin allergic individuals who require IV antibiotics, IV levofloxacin alone or a second generation cephalosporin (eg.cefuroxime) or third generation cephalosporin (eg.cefotaxime or ceftriaxone) along with intravenous clarithromycin can be used.

In patients with high severity pneumonia intravenous co-amoxiclav along with clarithromycin can be given.

Alternative options are second or third generation cephalosporins with a macrolide.When clinical improvement occurs , afebrile for more than 24 hours and no contraindication for oral therapy; those patients on IV therapy can be switched to oral. Those patients managed in the community or for most of the patients managed in the hospital with low or moderate severity uncomplicated pneumonia, 7 days of antibiotics is usually effective.

May I encourage the readers to go through the BTS guideline 2009 for a very interesting and thorough discussion on the subject.

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* Dr.Abdul Ghafur.K , Consultant in Infectious Diseases and Clinical Mycology

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Reading in between the lines in a Susceptibility Test report Iyer N Ranganathan * Susceptibility test results for bacteria conventionally are recorded and categorized individually and expressed as susceptibility, intermediate susceptibility or resistance of an organism to an antimicrobial agent. This is a direct approach which understates the fact that a single mechanism may be responsible for resistance to an antibiotic. Interpretative reading aims to analyse the overall susceptibility pattern, not just the results of individual antibiotics and so to predict the underlying mechanisms. Based on this type of interpretation susceptibilities that appear doubtful in the light of the inferred mechanism can be identified and reviewed and furthur drugs that merit testing can be identified.

There are some pre- requisites for an interpretative reading to gain in significance in the laboratory as well as for infection control and to direct antibiotic therapy in an individual patient. Recognising unusual resistances, detecting antibiotics that are likely to select for resistance and to use indicator drugs to pick out difficult to detect resistance mechanisms are important not only from the point of view of therapy of individual patients but also from an infection control perspective.

Some of the resistance mechanisms are easy to detect, some require special tests to be set up that may place additional demands on the laboratory, nevertheless this has to be done as it is important to segregate infected or colonized patients and institute appropriate isolation precautions. Patients infected with or colonized with ESBL producing gram negative organisms, methicillin resistant staphylococci, vancomycin resistant enterococci, metallobeta-lactamase producing Carbapenem-Resistant gram-negative organisms must be detected, extended colonization to other patients in the unit or the ICU worked out so that all patients colonized with the same organism are cohorted and managed with contact isolation precautions.

Detection of this resistance depends on the ability of the laboratory to screen for certain resistance patterns irrespective of a special request from clinical colleagues. A classic example of this are faeces cultures that are accepted by the laboratory for C. difficile toxin detection. It is important to remember that such patients, suspected to be colonized or infected with C. difficile may also harbor VRE ( Vancomycin resistant enterococci). Screening of such patients for VRE gives additional and valuable information regarding the colonization status. If this patient is admitted to an unit or the ICU, other patients in the same facility also need to be screened for the same pattern of resistance and all of the will need cohorting and isolation precautions.

The same principle holds good for Carbapenem resistant enterobacteriaceae and Non fermenters. Cleaning protocols need to be stepped up and enhanced if colonization or infection with such organisms are detected in an unit or the intensive care unit. Hence lateral reading of susceptibility tests and institution of additional and supplemental tests becomes necessary in many situations, many of which may be of importance in the sphere of infection control.

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* Dr. Iyer N Ranganathan , Senior Consultant, Dept. of Microbiology and Infectiuos Diseases, Global Hospital , Hyderabad

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Surgical Site Infections – Strategies for Prevention K.V.Rajan * Introduction

The term ‘surgical site infection’ (SSI) was introduced in 1992 to replace the previous term ‘surgical wound infection’. Surgical site infection accounts for 10 to 20% of Health Care Associated Infections (HCAI) in the UK. About 20 million surgical procedures are carried out in the US annually, out of which 600, 000 develop SSI. The delay in post-operative recovery due to SSI has economic consequences, leading to an additional cost about £3000 for each patient. It has been estimated that it requires an average additional hospital stay of 6.5 days in patients who develop SSI.

Definitions Of Surgical Site Infection (Ssi)

The Centre for Disease Prevention and Control (CDC) and the National Nosocomial Surveillance System in the US has developed standardised surveillance criteria for defining SSI. The US Centre for Disease Control and National Nosocomial Infections Surveillance risk index is the method of risk adjustment most widely used internationally to assess the risk of developing SSI. Risk adjustment is based on three major factors: • ASA score, reflecting the patient’s state of health before surgery • wound class, reflecting the state of contamination of the wound duration of operation, reflecting technical aspects of the surgery

Strategies To Minimise The Occurrence Of Surgical Site Infections

The interventions adopted to prevent the incidence of wound infections should be based on sound knowledge of various risk factors and the microbial flora relevant to the particular hospital setting. This includes optimisation of co-existing morbid conditions (diabetes, ischemic heart disease), cessation of smoking, judicious usage of prophylactic antibiotics and adopting guidelines for maintaining high level of asepsis during the preoperative, intra and postoperative phases.

Rational Antimicrobial Prophylaxis For Preventing SSI

Antibiotics play an important role in reducing the incidence of SSI and have the strongest evidence (level I) to support its use in surgical practice. On the other hand, antibiotic prophylaxis is never a substitute for asepsis and good surgical technique.

The antibiotic chosen should be directed against the most likely infecting organism in the particular patient, relevant to the type of surgery as well as the hospital setting.

Aims of Rational Antimicrobial therapy: • Reduce the incidence of surgical site infection (SSI) • Minimize the effect on the patient’s normal bacterial flora.

• Minimize adverse side effects of antibiotics.

• Minimize the emergence of antibiotics resistant strains of bacteria.

• Cost effectiveness.

Principles Of Prescribing Prophylactic Antibiotics 1.Indication The current recommendations are: • Clean surgery without implants

* Dr.K.V.Rajan, Ms, FRCS, Asst.Prof, Dept of Surgery MGMCRI, Puducherry Page 9

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*

No antibiotics

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• Clean surgery with implants • Clean contaminated • Contaminated surgery • Dirty

- - - -

Prophylactic Prophylactic Therapeutic Therapeutic

2. Choice of agent • Use narrow spectrum agent(s) when possible.

• Avoid cephalosporins, clindamycin, quinolones and co-amoxiclav whenever possible.

• Use appropriate alternatives for patients with penicillin/ beta-lactam allergy.

The antibiotics selected for prophylaxis must cover the expected pathogens for that operative site. Local antibiotic policy makers have the experience and information required to make recommendations about specific drug regimens based on an assessment of evidence, local information about resistance and drug costs.

3. Timing of antibiotic The time taken for an antibiotic to reach an effective concentration in any particular tissue reflects its pharmacokinetic profile and the route of administration. Optimum timing is 30 minutes prior to skin incision. Antimicrobial cover may be sub-optimal if given >1 hour prior to skin incision or post-skin incision. Antibiotics should be administered in Theatre at induction of anaesthesia and given as a bolus injection where possible. Antibiotic prophylaxis in caesarean section is delayed until clamping of the cord in order to prevent the drug reaching the neonate. Prophylactic antibiotics should be administered at least 10 minutes before the application of a tourniquet to achieve appropriate tissue concentrations.

4. Recording of antibiotic details The agent used and its dose should be recorded on the Anaesthetic Record Sheet or in the surgeon’s Operation Record.

Specific instructions are written to stop antibiotics in the postoperative period to avoid multi-dosing.

5. Frequency of administration Single dose is indicated for majority of procedures. Additional dosage may be indicated in the following: • if shorter-acting antibiotics are used • >1.5 litre intra-operative blood loss (re-dose following fluid replacement).

• Prolonged procedure (> 4 hours) • Primary arthroplasty (up to 24 hours prophylaxis used) Post-operative doses of antibiotic for prophylaxis are routinely avoided in majority of the surgical procedures.

Hospital acquired infection with pseudomonas and staphylococcus (including MRSA) are increasingly a problem worldwide. The other major problem is rapidly evolving anti-microbial drug resistance that can limit the number of effective anti-microbial agents. In this context, it would be prudent to take advice from the Institute microbiologist about the prevalent antibiotic resistance and the appropriate antibiotics to use in order to be both effective and to minimise the development of resistant strains. A local guideline outlining the rational use of antibiotics in the prevention of SSI should be formulated and this should be strictly followed by all the surgical specialities attached to the Institute.

In addition to the efforts of individual surgeons, an effective infection control program is essential in reducing Hospital-wide rates of SSI. Components of a successful program include adequate surveillance, data collection for SSI and feedback to individual surgeons to modify their current practices. Effective teamwork between anaesthetists, surgeons, nursing personnel and local microbiology department is of paramount importance to lower the impact on healthcare by SSI.

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Activities of the Hospital Infection Control Committee (HICC) WHO’s theme for World Health Day 2011 : “No action today - No Cure tomorrow” M.Varadarajan *

Millennium Development Goals set by United Nations for 2015 will get derailed due to the ‘abuse’ of antimicrobials.

A plethora of microbes resistant to available classes of antimicrobials are emerging which will naturally lead to increased mortality and healthcare expenses in these tough economic times. An earnest attempt is being made by the Hospital Infection Control Committee (HICC) of MGMCRI to address these issues, particularly by creating awareness among healthcare professionals.

The members of HICC meet bimonthly and the minutes of the meet are circulated to all concerned for necessary action. Irrespective of the regular meet, we also gather on a need basis, particularly when there is a breach in the protocols described in our infection control manual. An outbreak of Chicken pox among the patients and healthcare workers in the month of January was detected early by the team and thwarted in its early stages thanks to the vigilance shown by our HICC team. HICC, MGMCRI conducts regular monthly training activities for our nursing staff and other healthcare workers.

The Microbiology Department has played a crucial role in the execution of the Infection Control activities. A thorough surveillance of critical care areas is done on a weekly basis by them and appropriate measures are taken as and when needed. Through a decision taken by the HICC, a database of all the culture and sensitivity reports is being maintained I am glad to inform that the Department of Microbiology has been upgraded with state of the art equipments such as Vitek 2 Compact - an automated machine capable of identifying, measuring MIC’s and extremely useful in predicting and investigating nosocomial outbreaks by ascertaining the resistance mechanism(s) based on phenotypic characteristics of the bacterial isolates, which will further be characterized by molecular techniques. This certainly enhances our capacity to monitor emergence of MDR strains and implementation of antibiotic cycling particularly in critical care areas.

By our activities we wish to address the problems of today and ensure that we have systems that deal with the challenges of tomorrow.

* Prof. M.Varadarajan, Dept of CTVS, The Chairman HICC, MGMCRI Page 11

*

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Communication – the Key Factor in Preventing Nosocomial Resistant Infections K.R. Sethuraman *

The hospital infection committee has the main responsibility to try and control nosocomial infections and antimicrobial resistance in the hospital. For curbing hospital-acquired infections, the committee needs effective communication with all the key players responsible.

Key-stakeholders

Coalitions and networking are important in uniting stakeholders with shared interests, combining their knowledge and resources for advocating increased awareness and effective response to nosocomial infections and antimicrobial resistance.

Key Stakeholders include the following:

i. Public health practitioners ii. Healthcare providers iii. Infection Control Professionals iv. Microbiology Laboratory Directors v. Professional and voluntary organizations vi. Policymakers (from executive and legislative wings of the government) vii. Media viii. The public ix. Educators

By conducting an assessment of health bulletins, newsletters, electronic communication updates, minutes of association meetings etc., the hospital infection committee can identify opportunities to collaborate with existing stakeholder networks that share a common interest on the problems of nosocomial infections and antimicrobial resistance.

Categories of misunderstanding among the stakeholders

Awareness of common reasons for misunderstanding may help the hospital infection committee to nip the problem in the bud.

• End user information unknown to the provider • Provider information unknown to end user • Conflicting information given (verbal/non-verbal mismatch; doctor to doctor variations) • Disagreement about nature of the problem or its causation (knowledge gap) • Failure of communication about doctor’s decision • Dysfunctional relationship among various stakeholders

Ten Attributes of Effective Communication

The following are ten attributes of generic nature which are important factors in effective communication. The hospital infection committee should ensure that these attributes are embedded in all the communication strategies adopted to combat nosocomial infections and antimicrobial resistance.

These attribute are: i.Accuracy: Valid content presented accurately. ii.Availability: The message is available to the end user at the time of its need.

*

* Dr K.R. Sethuraman. MD, PGDHE, , Dean, Faculty of Medicine, and Deputy VC (International and Academic Affairs) AIMST University, 08100, Malaysia e-mail: sethuraman@aimst.edu.my & sethuramankr@hotmail.com Annals of SBV

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iii.Timeliness: The message is conveyed when the end user is in need of and most receptive to it. iv.Understandable: Follows the norms of clarity, choice of words appropriate for the end user. v.Culturally competent: The message, the medium and the mode of delivery are appropriate for the culture of the end user. vi. Reliability: The end users can rely on the source, and the message. vii. Evidence based: The message as well as the communication method is evidence based. viii.Balance: Presentation is balanced, e.g., felt need vs. real need, benefit and risk, cost and benefit, natural history and outlook etc. ix.Consistency: The message is internally consistent over time and externally consistent with other sources of unbiased information. x.Repetition: Repeated delivery to reinforce the message.

Meticulous planning by the hospital infection committee is essential to ensure that the message presented is effective and accurately conveys the facts. For instance, if surveillance programmes on nosocomial infections and antimicrobial resistance have to be effective and useful, the communications plan should raise awareness and increase key-stakeholder participation in the surveillance. Later, effective communication is critical for disseminating results, maintaining interest in the process, and for disseminating prevention messages to the providers and the public.

Effective Modes of Communication

For decades, health professionals have relied upon peer-reviewed journals, newsletters and surveillance reports as the modes of choice for timely dissemination of news and updates. With the telecommunication capabilities today, a coalition network can access a variety of timely, effective and inexpensive modes of effective electronic telecommunication.

Various electronic means that remain relatively cost effective and have a broad reach include: batch e-mail/fax, audio conference, and video conference. Targeted list serves can reach potentially large audiences. List serves have a flexible design and may be used as an alternate form of electronic updating (i.e., scheduled emails) or as a more interactive social media network (Linked-In, Face Book etc) resource that provides all the users access to message boards and chat rooms.

Traditional public relations tools such as press releases, news conferences, press fact sheets, and media-briefings are primary resources that deliver a message to the public and local community. Local-level communication infrastructures should incorporate community TV network to disseminate messages of antibiotic resistance or vaccine efficacy to costeffectively reach the general public. Learning to utilize these channels of communication is a very effective way to reduce direct personnel effort while the message is delivered to a wide audience.

For areas with rich ethnic or racial diversity, it is important build partnerships with community organizations and with credible media, which are familiar with cultural preferences of the community for accessing and receiving information. Otherwise the campaign may fail badly. We must carefully tailor information so that the content is presented at the appropriate literacy level, packaged in an attractive manner and disseminated through accepted channels of communication.

Developing Effective Communications Strategies

When developing a clear and effective communication plan, consider the following steps: Step 1: Plan and Select Communications Strategy • What is the message and image you want to create?

• Who are key audiences you want to target?

• What are the challenges to accurately conveying this message to your target audiences?

• How will you seek funding to continue this activity?

Step 2: Select Communication Channels and Materials • Are there established communication channels to target audiences that are open to partnership opportunities?

• Where is there a need to develop communications channels to reach target audiences?

• What are the most effective tools of communicating with target audience members? (i.e., brochures, PSAs, posters, face-to face consultation, hotline)

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Step 3: Develop Materials and Pre-Test for Acceptance • How do focus groups comprised of target audience members evaluate the materials?

• Are focus groups representative of the target audience?

• Are the materials understood, convey the appropriate message, considered useful by the target audiences?

Step 4: Implement Communication Plan • Which staff member will manage the communication plan?

• Should coalition members consider pilot testing prior to full rollout of message?

Step 5: Evaluate Communication Plan and Use Feedback for Program Improvements • What types of survey instruments should be developed to test effectiveness?

• How will these tools be evaluated?

• Who will oversee the evaluation process?

• Is there a need to contract outside evaluation assistance?

• How is the communication received and understood by target audience?

• Are there opportunities to refine the message and improve effectiveness?

Summary

Developing effective communications strategies is crucial to help form a coalition among stakeholders and to promote effective response to combat nosocomial infections and antimicrobial resistance.

Bibliography 1. “Building Partnerships” – a downloadable document from CDC, Atlanta URL: http://www.cdc.gov/abcs/reports-findings/downloads/bldg-partnerships-to-mkt-msg.pdf 2. K.R. Sethuraman. Communication skills in clinical practice. New Delhi, Jaypee Brothers Medical Publishers, 2001: 7-9

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Infection Control Is Everyone’s Business – Get Involved V.N. Mahalakshmi *

Introduction

Infection control is one of the most challenging issues facing health care organizations from a quality, safety and financial prospective.

The Complexity of Hospital Acquired Infections (HAIs)

The centres for disease control and prevention (CDC) estimates that approximately 1.7 million new cases of infections are acquired by patients during their stay in a hospital. Of these, approximately 99,000 results in death, making health care acquired infections (HAIs) one of the top ten causes of death in united states1.This translates in to approximately cost of $4.5 to 6.5 billion a year.

At any given time, 1.4 million people in the world are suffering from a HAI2.Available data suggest that developing countries experience HAIs more frequently than developed countries3.Developing countries experience HAIs more frequently than developed countries i.e. 5 – 19%.The number of critically ill patients is twice as higher – up to 51% in some ICUs. Also patients from developing countries experience more SSIs and Neonatal HAIs. HAIs represent more than just numbers. Infections results in increased in increased length of stay, longer recovery time, and increased treatment costs. The human dimension of this problem is that people suffer needlessly, experience diminished quality of life and sometimes must contend with lasting damage.

Infection control in Hospitals

30% to 35% of most HAIs are preventable by appropriate infection control measures.

Infection Control Program

Each hospital needs to develop a program for the implementation of good infection control practices and to ensure the well being of both patients and staff by preventing and controlling Hospital Acquired Infection (HAI). This overview has been abbreviated from WHO guidelines for hospital infection control.

Objectives of the infection control program • • • • • • • •

Monitoring of hospital-associated infections; Training of staff in prevention and control of HAI; Investigation of outbreaks; Controlling the outbreak by rectification of technical lapses, if any; Monitoring of staff health to prevent staff to patient and patient to staff spread of infection; Advice on isolation procedures and infection control measures; Infection control audit including inspection of waste disposal, laundry and kitchen, and Monitoring and advice on the safe use of antibiotics.

Infection control organizations in a hospital

Infection control organizations are essential features of an infection control program. These organizations are:

1.Infection Control Committee (ICC) Representatives of medical, nursing, engineering, administrative, pharmacy, CSSD and microbiology departments are the members. The committee formulates the policies for the prevention and control of infection. One

*

* Dr. V.N. Mahalakshmi , Professor Of Pediatric Surgery MGMC&RI, Puducherry e-mail: sethuraman@aimst.edu.my & sethuramankr@hotmail.com Page 15

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member of the committee is elected chairperson and has direct access to the head of the hospital administration. The infection control officer is the member secretary. The committee meets regularly and not less than three times a year.

2.Infection Control Team (ICT) Members are the people who undertake the day to day measures for the control of infection. One team is formed for each location with Clinician, Nursing supervisor and housekeeping staff.

3.Infection Control Officer (ICO) The Infection Control Officer is usually a medical microbiologist or any other physician with an interest in hospital associated infections.

Functions • Secretary of Infection Control Committee and responsible for recording minutes and arranging meetings; • Consultant member of ICC and leader of ICT; • Identification and reporting of pathogens and their antibiotic sensitivity; • Regular analysis and dissemination of antibiotic resistance data, emerging pathogens and unusual laboratory findings; • Initiating surveillance of hospital infections and detection of outbreaks; • Investigation of outbreaks, and • Training and education in infection control procedures and practice.

4.Infection Control Nurse (ICN) A senior nursing sister should be appointed full-time for this position. Adequate full-time or part-time nursing staff should be provided to support the program. The ICNs should be trained in basic microbiologic techniques.

Functions • To liaise between microbiology department and clinical departments for detection and control of HAI; • To collaborate with the ICO on surveillance of infection and detection of outbreaks; • To collect specimens and preliminary processing; • Training and education of other health care personal under the supervision of ICO, and • To increase awareness among patients and visitors about infection control.

• To maintain a database of all infections in the hospital.

5.Infection Control Manual (ICM) It is recommended that each hospital develops its own infection control manual based upon existing documents but modified, for local circumstances and risks.

Problems in the Implementation of Infection Control Programs

If 30% to 35% of most HAIs are preventable and such detailed guidelines are available, then why urinary tract infections, surgical site infections, pneumonia, and blood stream infections are common?

The simple answer is not as simple as patients are weak or already sick, or that microorganisms have become resistance to drugs.Those are significant factors but issues such as hand hygiene, effective cleaning and disinfection of the equipment and the areas where patients receive care, appropriate staffing, and use of personal protecting equipment (PPE).

Crux: halting infections requires identifying and tackling risks on many fronts.

The broad scope of infection prevention programs are complex by their very natures and must involve staff in virtually every department and service of an organization. Practices that can lead to infections are diverse, each with their own set of issues. Everyone in an organization should work together to protect patients.

What Needs To Be Done?

Clinicians have to take charge. They need to get involved; take initiatives; follow standard guidelines and protocols.

They need to follow rational prescription practices and take initiatives to educate the nursing and support staff and the patients.

Nurses need to follow guidelines regarding Hand hygiene, PPE use and adhere to safe injection practices. They also should educate the patients, their relatives and the support staff.

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Role of Structural departments

Architects and designers should design buildings in a way to give due consideration to infection control practices.

The Maintenance team should take structural defects /faults in a war footing and should allow repairs to go on without compromising infection control guidelines and patient safety.

House keeping Department needs to keep the premises efficiently clean and adhere to hospital guidelines regarding cleaning schedules.

Administration & Management

Should make prevention of HAIs, one of the primary goals of hospitals. They need to provide adequate resources for infection control activities in the form of budgetary allocations, materials and equipments for cleaning, disinfection and sterilization and adequate manpower for these activities in a sufficient space.

Patients and Attenders

Need to realize that infection control is also their primary responsibility. They need to follow hand hygiene and instructions regarding medication use and isolation procedures and PPE.

Infection Control is an Ongoing, Complex Process

Preventing and controlling infection is at heart of patient safety, and health care facilities must thrive for reducing risks. To be effective, an effective, ongoing program with adequate surveillance is required.

Infection control is everyone’s business - Get involved ; Contribute; Innovate; Follow guidelines.

References

1.Centre for disease control and prevention : health care associated infections (HAIs). www.cdc.gov/ncidod/dhqp/ healthDis.html (accessed january 4, 2010).

2. World Alliance for Patient Safety, Global Patient Safety Challenge 2005-2006 :Clean Care is Safer Care.

Geneva:World Health Organisation, 2005.

3. World Health Organisation :The burden of health care- association infection worldwide.http://www.who.int/ gpsc/country_work/burden_hcai/en/index/html (accessed may 24, 2010)

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Effective Surveillance in Practice – Specific Role of the Microbiology Laboratory in Infection Control Ranganathan Iyer * Surveillance is defined as an ongoing systematic collection, analysis and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know and the ongoing dissemination of information to those who need to know. The utility of surveillance in any infection control programme can be brought out with the following: • It can indicate when there is a change in the pattern of disease, giving an alert to all personnel in a hospital as to an impending outbreak of an infection • The spread and containment measures can be monitored through a data base created as part of the surveillance process.

• The efficiency of all routine infection prevention measures can be judged .

• The planning process can be supported.

• It does help reduce nosocomial infection rates in a hospital.

The type of surveillance activities will be influenced by the following: • Organisational demographics • Community demographics ( urban or rural population served) • Types of procedures and services offered.

• Infection prevention risk assessment • Annual evaluation of infection prevention plan and goals.

Many hospitals in India have an underdeveloped and underutilised infection surveillance facility. This program has four essential components namely: 1. Surveillance with feedback to clinical and surgical colleagues 2. Control/ monitoring and auditing of practice 3. having adequate staff with ICN’s in place to control and carry out surveillance activities.

4./ Having proper personnel involved in the program

Types of surveillance :-

A. Laboratory Based surveillance : This is usually a straightforward process where by the lab gives out alerts on organisms that can be a cause of serious concerns as they have the potential to cause outbreaks. A lab system though wonderful, must be clinically correlated with all information from the clinical side. Some examples of alert organisms are as follows: • Positive clinical isolates from sterile body sites and f luids.

• Positive organisms from high risk areas such as intensive care unit and the nursery.

• Positive clinical isolates from sites of interest such as surgical wound sites, intravascular catheter sites, Foley catheter sites and endotracheal secretions from ventilated patients.

B. Post discharge Surveillance :This describes the methodologies that are taken to follow up patients discharged from the hospital and in the community. This may be different for different surgical procedures. The surgical procedures with implants and prostheses may require longer periods of post discharge surveillance ( upt one year ) while those with no implants or prostheses

*

* Dr. Ranganathan Iyer , Senior Consultant – Microbiology and Infectious Disease, Global Hospital, Hyderabad.

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require a month’s follow up. This is done either via telephonic calls, E mails, letters or physical follow up. However the surveillance is easier said than done and is usually difficult to achieve success.

C. Targeted Surveillance : This is a method where a particular area of the hospital such as an unit , a ward or an ICU are targeted for surveillance. The beginning point for this may be through a well done point prevalence audit.

D. Sentinel Surveillance : A surveillance carried out by a small group of people which captures enough data for a meaningful collection of data.

The pharmacy may be linked with the surveillance system . This helps stem the prescribing of high on end antibiotics if there is considerable resistance or if that is not consonant with the local antibiotic policy.

Regular surveillance carried out also helps in picking out organisms with an identical antibiotic susceptibility pattern in times of an impending outbreak.

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Standard Precautions / Universal precautions Robinson Smiles * Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic.

Key components and their use.

Hand Hygiene

Hand hygiene refers to both washing with plain or anti-bacterial soap and water and to the use of alcohol gel to decontaminate hands. When hands are not visibly soiled, alcohol gel is the preferred method of hand hygiene when providing health care to clients.

Hand hygiene should be performed before and after contact with a client, immediately after touching blood, body fluids, non-intact skin, mucous membranes, or contaminated items (even when gloves are worn during contact), immediately after removing gloves, when moving from contaminated body sites to clean body sites during client care, after touching objects and medical equipment in the immediate client-care vicinity, before eating, after using the restroom, and after coughing or sneezing into a tissue as part of respiratory hygiene.

Needle stick and Sharps Injury Prevention

Safe handling of needles and other sharp devices are components of standard precautions that are implemented to prevent health care worker exposure to blood borne pathogens.

Used needles should be discarded immediately after use and not recapped, bent, cut, removed from the syringe or tube holder, or otherwise manipulated.

Any used needles, lancets, or other contaminated sharps should be placed in a leak-proof, puncture-resistant sharps container that is either red in color or labeled with a biohazard label.

Do not overfill sharps containers. Discard after 2/3 full or when contents are at the “full� line indicated on the containers.

Used sharps containers may be taken to a collection facility such as an area pharmacy, hospital, or clinic that provides this service.

Cleaning and Disinfection

Client care areas, common waiting areas, and other areas where clients may have potentially contaminated surfaces or objects that are frequently touched by staff and clients (doorknobs, sinks, toilets, other surfaces and items in close proximity to clients) should be cleaned routinely with disinfectants.

Housekeeping surfaces such as floors and walls do not need to be disinfected unless visibly soiled with blood or body fluids. They may be routinely cleaned with a detergent only or a detergent/disinfectant product.

Most disinfectants are not effective in the presence of dirt and organic matter, therefore cleaning must occur first before disinfection. Wet a cloth with the disinfectant, wipe away dirt and organic material, then with a clean cloth apply * Prof. Robinson Smiles , HOD, General Surgery, MGMCRI, Puducherry

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the disinfectant to the item and allow to air dry for the time specified by the product manufacturer.

Some pathogens such as norovirus and Clostridium difficile are not inactivated by commercial disinfectants routinely used in local public health settings. In situations where contamination with these pathogens is suspected, a bleach solution (1:10) is recommended for disinfecting contaminated surfaces and items.

Respiratory Hygiene.

Clients in waiting rooms or other common areas can spread infections to others in the same area or to local public health agency staff. Measures to avoid spread of respiratory secretions should be promoted to help prevent respiratory disease transmission. Elements of respiratory hygiene and cough etiquette include:

• Covering the nose/mouth with a tissue when coughing or sneezing or using the crook of the elbow to contain respiratory droplets.

• Using tissues to contain respiratory secretions and discarding in the nearest waste receptacle after use.

• Performing hand hygiene (hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) immediately after contact with respiratory secretions and contaminated objects/materials.

• Asking clients with signs and symptoms of respiratory illness to wear a surgical mask while waiting common areas or placing them immediately in examination rooms or areas away from others. Provide tissues and no-touch receptacles for used tissue disposal.

• Spacing seating in waiting areas at least three feet apart to minimize close contact among persons in those areas.

• Supplies such as tissues, waste baskets, alcohol gel, and surgical masks should be provided in waiting and other common areas in local public health agencies.

Waste Disposal

Sharp items should be disposed of in containers that are puncture resistant, leak-proof, closable, and labeled with the biohazard symbol or are red in color.. Items generated by local public health agencies that should be discarded into sharps containers include contaminated items that may easily cause cuts or punctures in the skin (used needles, lancets, broken glass or rigid plastic vials) and unused needles and lancets that are being discarded. Syringes or blood collection tube holders attached to needles must also be discarded still attached to the needles.

Non-sharp disposable items saturated with blood or body fluids (i.e. fluid can be poured or squeezed from the item or fluid is flaking or dripping from the item) should be discarded into biohazard bags that are puncture resistant, leak-proof, and labeled with a biohazard symbol or red in color. Such items may include used PPE and disposable rags or cloths.

Safe injection practices include:

• Use of a new needle and syringe every time a medication vial or IV bag is accessed • Use of a new needle and syringe with each injection of a client • Using medication vials for one client only, whenever possible

Personal Protective Equipment (PPE)

PPE includes items such as gloves, gowns, masks, respirators, and eyewear used to create barriers that protect skin, clothing, mucous membranes, and the respiratory tract from infectious agents. The items selected for use depend on the type of interaction a public health worker will have with a client and the likely modes of disease transmission.

Wear gloves when touching blood, body fluids, non-intact skin, mucous membranes, and contaminated items.

Gloves must always be worn during activities involving vascular access, such as performing phlebotomies.

Wear a surgical mask and goggles or face shield if there is a reasonable chance that a splash or spray of blood or body fluids may occur to the eyes, mouth, or nose.

Wear a gown if skin or clothing is likely to be exposed to blood or body fluids.

Remove PPE immediately after use and wash hands. It is important to remove PPE in the proper order to prevent Page 21

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contamination of skin or clothing.

If PPE or other disposable items are saturated with blood or body fluids such that fluid may be poured, squeezed, or dripped from the item, discard into a biohazard bag. PPE that is not saturated may be placed directly in the trash.

Saturated waste generated from the home should be placed in sealable leak-proof plastic bags before placing in regular trash bags for disposa The following table gives guidance for PPE in general.

NO risk of exposure LOW risk of contact Contact with blood and/or body fluids PROBABLE, splashing to face unlikely Contact with blood PROBABLE: potential for uncontrolled bleeding or splattering to the face

Hygiene precautions essential e.g. handwashing Gloves must be available Gloves to be worn, apron/safety spectacles/masks to be available Gloves and apron to be worn, water repellent gown, safety spectacles or face visor and masks to be available

Disadvantages of standard precaution.

Added cost of protective barrier equipment, particularly gloves, difficulty in maintaining routine use of the protocol for all patients, uncertainty about precautions for patients in isolation rooms and the overuse of gloves to protect staff at the expense of patients. The other draw back is, compliance by the healthcare workers. The administrators and staff will need to carefully review the recommendations contained in the Standard Precautions and modify them according to what is possible and practical within their resource setting.

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Antimicrobial Resistance - Causes, Implications and Strategies M. Ravishankar * Introduction

Antimicrobial agents represent one of the main therapeutic tools both in human and veterinary medicine to control and treat a variety of bacterial infectious diseases. Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it waspreviously sensitive. During the past five decades, the use and sometimes misuse of antimicrobials in both human and veterinary medicine has resulted in the emergence of strains of organisms,which includes bacteria, viruses and some parasitesthat no longer respond to antimicrobial therapy. Not only do antimicrobialresistant bacterial pathogens in animals pose a risk in terms of animal health, they also affect public health when transmitted to humans as foodborne contaminants. Thus, addressing the issue of antimicrobial resistance is one of the most urgent priorities in the fields of public health today.

There are several mechanisms by which bacteria develop resistance to antimicrobial agents and then transfer this resistance to susceptible bacterial strains.

Natural Mechanisms of Antimicrobial Resistance Darwinian principle

The increased prevalence and dissemination of resistance is an outcome of natural selection and should be viewed as an expected phenomenon of the Darwinian biological principle of “survival of the fittest.�

In any large population of bacteria, a few cells will be present which possess traits that enable them to survive in the presence of a noxious substance, in this case the ability to fend off the action of the antimicrobial. Susceptible organisms, those lacking the advantageous trait, will be eliminated, leaving the remaining resistant populations behind.With longterm antimicrobial use in a given environment / community, the bacterial strains will change dramatically, with more resistant organisms increasing in proportion.

Susceptible bacteria can acquire resistance to antimicrobials by either genetic mutation or by accepting antimicrobial resistant genes from other bacteria.This usually occurs through one of several biochemical mechanisms or by genetic transfer.

The biochemical mechanisms include Mutation, Destruction or Inactivation and Efflux.

Mutation

Mutation is a change in the DNA that can sometimes cause a change in the gene product, which is the target of the antimicrobial.

Destruction or Inactivation

Many bacteria possess genes which produce enzymes that chemically degrade or deactivate the antimicrobial, rendering them ineffective against the bacterium. Here the antimicrobial is either degraded or modified by enzymatic activity before it can reach the target site and damage the bacterial cell.

Efflux

Certain bacteria can often become resistant to antimicrobials through a mechanism known as Efflux. An efflux pump is essentially a channel that actively exports antimicrobial and other compounds out of the cell.The antimicrobial enters the bacterium through a channel termed a porin, and then is pumped back out of the bacterium by the efflux pump. By actively pumping out antimicrobials, the efflux pumps prevent the intracellular accumulation necessary to exert their lethal activity inside the cell.

The Genetic Transfer is the other mechanism of developing resistance. Genetic material can be transferred between bacteria by several means, most often by Conjugation, Transformation andTransduction. * Dr. M. Ravishankar, Professor and Head, Anaesthesiology and Critical Care, MGMC&RI, Puducherry Page 23

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Conjugation

Conjugation is mediated by a particular kind of circular DNA called a plasmid, which replicates independently of the chromosome.Many plasmids carry genes that confer resistance to antimicrobials.When two cells are in close proximity to each other, a hollow bridge-like structure, known as a pilus, forms between two cells.This allows a copy of the plasmid, as it is duplicated, to be transferred from one bacterium to another.This enables a susceptible bacteria to acquire resistance to a particular antimicrobial agent.

Transformation

During this process, genes are transferred from one bacterium to another as “naked” DNA.When cells die and break apart, DNA can be released into the surrounding environment. Other bacteria in close proximity can scavenge this free-floating DNA, and incorporate it into their own DNA. This DNA may contain advantageous genes, such as antimicrobial resistant genes and benefit the recipient cell.

Transduction

In this process, bacterial DNA is transferred from one bacterium to another inside a virus that infects bacteria.

These viruses are called bacteriophages or phage.When a phage infects a bacterium, it essentially takes over the bacteria’s genetic processes to produce more phage. During this process, bacterial DNA may inadvertently be incorporated into the new phage DNA. Upon bacterial death and lysis (or breaking apart), these new phage go on to infect other bacteria.

This brings along genes from the previously infected bacterium.

Unnatural / man made mechanisms

Inappropriate and irrational use of medicines provides favourable conditions for resistant microorganisms to emerge and spread.For example, when patients do not take the full course of aprescribed antimicrobial or when poor quality antimicrobialsare used, resistant microorganisms can emerge and spread.

Implictions

About 440 000 new cases of multidrug-resistant tuberculosis (MDR-TB) emerge annually, causing at least 150 000 deaths. Extensively drug-resistant tuberculosis (XDR-TB) has been reported in 64 countries to date.

Resistance to earlier generation antimalarial medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries. Falciparum malaria parasites resistant to artemisinins are emerging in South-East Asia; infections show delayed clearance after the start of treatment (indicating resistance).

A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci.

Resistance is an emerging concern for treatment of HIV infection, following the rapid expansion in access to antiretroviral medicines in recent years; national surveys are underway to detect and monitor resistance.

Ciprofloxacin is the only antibiotic currently recommended by WHO for the management of bloody diarrhoea due to Shigella organisms, now that widespread resistance has developed to other previously effective antibiotics. But rapidly increasing prevalence of resistance to ciprofloxacin is reducing the options for safe and efficacious treatment of shigellosis, particularly for children. New antibiotics suitable for oral use are badly needed.

AMR has become a serious problem for treatment of gonorrhoea (caused by Neisseria gonorrhoeae), involving even “last-line” oral cephalosporins, and is increasing in prevalence worldwide. Untreatable gonococcal infections would result in increased rates of illness and death, thus reversing the gains made in the control of this sexually transmitted infection.

New resistance mechanisms, such as the beta-lactamase NDM-1, have emerged among several gram-negative bacilli. This can render powerful antibiotics, which are often the last defense against multi-resistant strains of bacteria, ineffective.

Underlying factors that drive AMR include:

Inadequate national commitment to a  comprehensive and coordinatedresponse, ill-defined accountability and insufficientengagement of communities.  Weak or absent surveillance and monitoring systems.  Inadequate systems to ensure quality and uninterrupted supplyof medicines.  Inappropriate and irrational use of medicines, including inanimal husbandry.

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 Poor infection prevention and control practices.  Depleted arsenals of diagnostics, medicines and vaccines as well as insufficient research and development on new products.

The emergence of AMR is a complex problem driven by many interconnected factors; single, isolated interventions have little impact. A global and national multi-sectoral response is urgently needed to combat the growing threat of AMR.

Challenges To Overcome

> Limited public awareness and government commitment: media attention focuses on individual outbreaks but gives little attention to the wider threat of AMR. It is therefore not a priority of national governments or linked to the achievement of the health related Millennium Development Goals. Despite their potential to influence policy too few nongovernmental, donor and health advocacy agencies have recognized the threat of AMR. > Fragmentation of effort: specific activities to combat AMR are taken forward by individual programs, institutions and regulatory bodies, but too often in the absence of an overall strategy; without an adequate budget; and with no accountability for results. > Perverse incentives contribute to AMR, through the unregulated marketing of antimicrobials, their use for growth promotion in livestock, or profit-seeking prescribing of antibiotics in human health care. Where legal frameworks exist they are rarely accompanied by effective sanctions. > The voiceless are the worst affected: poor people are among those who are at greatest risk of infections and those most likely to lack access to quality services and suffer severe illness. They usually lack information or opportunity to demand or become involved in actions to combat AMR.

Strategies To Combat Amr

1. Commit to a Comprehensive, financed National plan with accountability and Civil Society engagement.

2. Strengthen surveillance And laboratory capacity 3. Ensure uninterrupted access to essential Medicines of assured quality.

4. Regulate and promote rational use of Medicines, including in animal husbandry, And ensure proper patient care.

5. Reduce use of antimicrobials in food-producing animals 6. Enhance infection prevention and control 7. Foster innovations and research and development for new tools

Why Is A Comprehensive National Plan Essential For Combating Antimicrobial Resistance?

The factors which favour the emergence and spread of resistant microbes, and the measures needed to combat antimicrobial resistance (AMR), are well known. A comprehensive plan brings all the elements together so that everyone can do more to make a difference: Policy-makers and planners in government ¾¾ must provide the legal framework and strategy that people need to work together effectively to combat AMR and its public health consequences. ¾¾ Civil society and patients’ groups can raise awareness of the issues, and demand action by policy-makers and all stakeholders. Everyone can play a part by using prescribed medicines correctly. ¾¾ Practitioners and prescribers need to combine appropriate prescription of antimicrobials with clear, accurate and understandable advice to patients. Veterinarians should resist pressures to use antibiotics as growth promoters and for disease prevention in livestock. ¾¾ Pharmacists and dispensers must ensure that antimicrobials are safe: obtained from an approved source and stored properly, and supplied in line with prescriptions. ¾¾ Providers, institution managers, and communities should apply infection control measures to prevent the emergence and spread of AMR. ¾¾ The diagnostic and pharmaceutical industry, through research and development, will need to produce the tools needed to better prevent and detect disease, identify AMR earlier, and develop new antimicrobials needed to replace those that have become ineffective.

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Multi - Drug Resistant Typhoid P. Ramachandran * Enteric fever (Typhoid or paratyphoid fever) is a potentially serious systemic infection. Typhoid fever is caused by Salmonella enterica serovar Typhi (S typhi) and paratyphoid fever is caused by Salmonella enterica serovar Paratyphi (S paratyphi) A, B or C. These organisms cause disease specifically in humans. Paratyphoid fever is usually a less serious infection. An estimated 21.6 million new cases of typhoid fever with about 2,16,150 deaths and about 5.4 million cases of paratyphoid fever occurred globally in 2000 (1). Endemic enteric fever is common in the Indian subcontinent, SouthEast Asia, Africa, Central and South America and the Mediterranean region. Reported incidence rates in the country vary. 980 per 100,000 population was the incidence reported from Delhi(2). Another study reported an annual incidence rate of 493.5 cases per 100,000 person years in the country(3). Contrary to earlier belief, typhoid fever is widely prevalent among young children under five years of age with higher morbidity and hospitalisation rates(4).

The mortality rate is 10 to 15% if untreated and is highest among children less than one year of age and the elderly(5).

Emergence of drug resistance

Multi-drug resistant (MDR) S typhi denotes those strains which are resistant to all the three first line antibiotics (Chloramphenicol, ampicillin and co-trimaxazole). For many decades, antibiotics such as chloramphenicol, ampicillin and co-trimaxazole were the drugs of choice for treating enteric fever. With effective treatment, the duration of disease was reduced and mortality rates fell from more than 10% to less than 1%. Chloramphenicol was widely used throughout the world from 1940s till mid-1970s. Major resistance to chloramphenicol with outbreaks were reported in 1972. From 1980s, multi-drug resistant (MDR) Salmonella strains have been reported from all parts of the world(1). Outbreaks of MDR typhoid have been reported from the Indian sub-continent since 1983(4) and also from South-East Asia and Africa(6).

Magnitude of the problem of MDR Enteric fever

Emergence of MDR strains of S typhi began from mid-eighties in the Indian sub-continent. These strains rapidly assumed epidemic proportions accounting for 60% to 90% of all cases of typhoid in certain reports (7). In Quetta, Pakistan, 69% of isolates of S typhi were MDR (8). The incidence of MDR S typhi in the UK was reported as over 50% in 1999, up from 34% in 1995 and 1.5% six years earlier (1) and chloramphenicol resistance was 100% in 1995.

MDR typhoid has become endemic in many developing countries from 1990s and these strains were also isolated from returning travellers in developed countries. In a study from Singapore in 1990 to 1992, all the MDR typhoid cases had a recent travel history to the Indian sub-continent(9).

From 1991, use of ciprofloxacin was recommended in the UK for treating enteric fever, particularly for those returning from areas where MDR strains were endemic. Extensive use of ciprofloxacin began for the treatment of typhoid, both in developing and developed countries (10). It was initially thought that quinolones have an inherent advantage due to low risk of plasmid mediated resistance. But chromosomally encoded ciprofloxacin resistance in strains of S typhi has been observed in the UK since 1991, majority of which were also MDR (11). Patients infected with such strains had recently returned from several countries in the Indian sub-continent.

Salmonella typhi isolates from Calcutta School of Tropical Medicine from 1991 to 2001 have shown fluctuating levels of multi-drug resistance. Changing pattern of sensitivity has been reported with re-emergence of sensitivity to chloramphenicol, ampicillin and co-trimaxazole due to the withdrawal of selection pressure (4). Some other recent reports also suggest a fall in proportion of MDR typhoid (12, 13). * Dr. P. Ramachandran , Former Director, Institute Of Child Health & Hospital for Children, Chennai Annals of SBV

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Factors responsible for emergence of MDR Salmonella

Numerous factors are responsible for the emergence of MDR Salmonella strains, namely the administration of antibiotics to farm animals and antibiotic treatment to animals and humans with Salmonella gastroenteritis(14). The contributing factors for drug resistance are the overuse, misuse and inappropriate prescribing practices of physicians, along with the intrinsic microbiological plasmid mediated factors. Large scale irrational use of anti-typhoid antibiotics such as chloramphenicol, co-trimaxazole and furazolidine for common diarrhoeal illnesses prepared fertile grounds for multi-drug resistance. The other contributing factor is the fact that most physicians in India are used to diagnosing infection without bacteriological proof which evolved from lack of bacteriological facilities, compounded by lack of initiative to pursue proof of infection (15). Compared to the earlier days of chloramphenicol therapy when defervescence was noted in 3-4 days, it takes several days for defervescence to occur with currently used drugs such as quinolone or third generation cephalosporins. The way is paved for various drug combinations, frequent change of antibiotics and irrationality in treatment protocols, leading onto drug resistance with newer drugs as well. Despite the sensitivity, minimum inhibitory concentration (MIC) levels of drugs has gone up considerably. Conventional doses have led to a poor response even when the strain was sensitive to the drug (15).

Clinical aspects of MDR typhoid

MDR typhoid appears to be a more severe illness with a larger duration of fever in comparison to drug susceptible typhoid fever (9). Many patients take more than 10-14 days to become afebrile even when a sensitive drug is used in adequate doses (15). The persistence of fever in most patients is maintained by the release of pyrogenic cytokines from macrophages and necrotic tissue. MDR typhoid infections have been documented to be associated with significantly higher case fatality rates, approaching 4-10%, similar to ‘pre-antibiotic era’(4). Besides delay in treatment, the increased toxicity may be due to greater virulence of MDR Salmonella typhi (7). Significantly higher rates of quantitative bacteremia have been observed among patients with MDR typhoid in Vietnam (16).

Diagnosis of MDR typhoid

The definitive diagnosis of enteric fever is the isolation of organisms from the blood or bone marrow. Cultures of bone marrow aspirate are reported to be positive in 60% to 90% of the cases and the organisms can be cultured from bone marrow even after exposure to antibiotics for some days.

Infections with strains susceptible to nalidixic acid (NA) respond extremely well to other fluoroquinolones used for treatment such as ciprofloxacin. There have been several reports of fluoroquinolone resistant S typhi. Progressive rise in MIC to ciprofloxacin has been observed in the past two decades. S typhi resistant to NA may not respond to ciprofloxacin despite having MIC values within the current NCCLS (National Committee for Clinical Laboratory Standards) susceptibility break point. Laboratories will continue to report these S typhi / paratyphi as sensitive to ciprofloxacin. But there is a high incidence of treatment failures in such situations and the in-vitro susceptibility may not always translate to in-vivo efficacy(1, 17). Resistance to NA is a surrogate marker of reduced susceptibility to ciprofloxacin with higher MICs and predicts treatment failure. If the culture shows resistance to NA, irrespective of the results of ciprofloxacin / ofloxacin sensitivity, quinolones should not be used for the treatment, or if used, high doses should be given (17). Essentially, there are three categories of susceptibility to fluoroquinolones (1) : a) Fully susceptible (sensitive to NA and ciprofloxacin) b) Reduced susceptibility (NA resistant but sensitive to ciprofloxacin) c) Resistant (NA and ciprofloxacin resistant) It is of some concern that isolates fully resistant to fluoroquinolones and extended spectrum cephalosporins are being reported (18, 19).

Treatment of MDR typhoid

A good clinical evaluation is essential in any child suspected to have typhoid fever. Complicated typhoid fever refers to the presence of complications including intestinal perforation, intestinal bleeding, shock, pancreatitis, pneumonia, myocarditis, meningitis and psychosis (1). Blood culture should be sent in any child suspected to have enteric fever before starting empirical antibiotics. Though there are some reports of the re-emergence of fully susceptible strains of Page 27

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S typhi / paratyphi to first line drugs (chloramphenicol, ampicillin, co-trimaxazole), they are few and unless antibiotic sensitivity testing shows the organisms to be fully susceptible to first line drugs, they are not advocated for empirical therapy in typhoid (17). In areas with a high prevalence of MDR S typhi infection like the Indian sub-continent, all patients suspected of typhoid fever should be treated with fluoroquinolones or a third generation cephalosporin until the results of culture and sensitivity studies become available. Recently, azithromycin is being used as an alternative agent for uncomplicated MDR typhoid (17). Aztreonam and imipenem are also potential third line drugs used recently.

Quinolones

Ciprofloxacin has been found to be highly effective for infections due to MDR S typhi and S paratyphi. But resistance of these organisms to ciprofloxacin seems to be increasing, especially in the Indian sub-continent (11, 20).

The minimum inhibitory concentration to ciprofloxacin was reported to steadily increase from 0.025 to 0.5 mcg/ml (21).

Patients infected with relatively quinolone-resistant S typhi strains (resistant to NA and an MIC of 0.125 to 1.5 mcg/ dl) may not demonstrate clinical recovery. High NA resistance, a surrogate marker of relative quinolone resistance, has been reported in more than 80% in some Indian studies (12, 13). Patients with NA-resistant strains should be treated with a higher dose of ciprofloxacin or ofloxacin.

Cephalosporins

Third generation cephalosporin is now considered the first drug of choice for MDR enteric fever, in view of increasing fluoroquinolone resistance. Of the third generation cephalosporins, oral cefixime has been widely used in children, in a dose of 15-20 mg/kg/day in two divided doses for uncomplicated MDR typhoid (17). Injectable forms of cephalosporins are the drugs of choice for complicated MDR typhoid. Ceftriaxone, cefotaxime and cefoperazone are used, of which ceftriaxone is the most convenient, administered in a dose of 50-75 mg/kg/day in one or two divided doses. It must be remembered that resolution of fever and symptoms is slow.

Azithromycin

Sporadic reports of resistance to third generation cephalosporins have followed. Azithromycin, a macrolide, has been used as an alternative drug for uncomplicated MDR typhoid fever. It is given as once daily dose and is well tolerated when used orally. There are no reports of resistance of S typhi to azithromycin (23). In a systematic review of seven trials conducted in Egypt, Vietnam and India, azithromycin was compared to ceftriaxone, ciprofloxacin, gatifloxacin and chloramphenicol (1). Azithromycin reduced the clinical failure rate and the duration of hospital stay in comparison to fluoroquinolones, and reduced the relapse rate in comparison to ceftriaxone, when used in typhoid fever in populations with MDR typhoid. Azithromycin is given in a dose of 20mg/kg/day for upto 7 days. IAP Task Force recommends azithromycin as the second line drug in uncomplicated MDR typhoid fever (17).

Treatment guidelines according to IAP Task Force (17)

MDR Typhoid – Uncomplicated :

I Line : Oral cefixime, 15-20 mg/kg/day for 14 days II Line : Oral azithromycin, 10-20 mg/kg/day for 7 days

MDR Typhoid – Complicated :

I Line : Ceftriaxone or Cefotaxime, 50-75 mg/kg/day for 14 days II Line : Aztreonam, 50-100 mg/kg/day for 14 days

Imipenem is a potential second line drug. Fluoroquinolones can be used in life threatening infections resistant to other recommended antibiotics.

Prevention of MDR Typhoid

Emergence and spread of MDR Salmonella typhi has made effective treatment of typhoid increasingly difficult and expensive. Emphasis must be placed on prevention with the provision of safe drinking water, proper sanitation and public health education. Rational choice of drugs to treat bacteriologically proven infections and vaccine coverage of susceptible population will help in averting such epidemics in future.

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References 1. Effa EE, Bukirwa H, Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever) (Review). Cochrane Database of Systematic Reviews 2008, Issue 4, Art No : CD006083. DOI : 10.1002/14651858 CD006083.pub 2

2. Sinha A, Saizawal AK, Kumar R, Sood S, Reddaiah VP, Singh B, et al. Typhoid fever in children less than 5 years. Lancet 1999; 354 : 734-737.

3. Ochiai RL, Acosta CJ, Danovara – Holliday MC, Baiqing D, Bhattacharya SK, Agtini MD, et al. Domi typhoid study group. A study of typhoid fever in five Asian countries : disease burden and implications for controls. Bull World Health Organ 2008; 86 : 260-268.

4. Srivatsava SP, Singh UK, Jaiswal BP. Emergence of multi-drug resistant (MDR) enteric fever : an alarming threat to health of Indian children. 5th National CME of IAP Chapter on Pediatric Infectious Diseases, 23-24 June, 2007, Patna.

5. Bhutta ZA. Impact of age and drug resistance on mortality in typhoid fever. Arch Dis Child 1996; 75 : 214-217.

6. Rowe B, Ward LR, Threlfall EJ. Multi-drug resistant Salmonella typhi : A world wide epidemic. Clinical Infectious Diseases 1997; 24 : S106-109.

7. Bhutta ZA. The Challenge of Multi-drug Resistant Typhoid in Childhood : Current Status and Prospects for the future. Indian Pediatr 1999; 36 : 129- 131.

8. Mirza SH, Bleeching NG, Hart CA. Multi-drug resistant typhoid : a global problem. Journal of Med Microbiol 1996; 44 : 317-319.

9. Oh HML, Chew SK, Monteiro EH. Multi-drug resistant typhoid fever in Singapore. Singapore Med J 1994; 35 : 599-601.

10. Mandal BK. Modern treatment of typhoid fever. J Infect 1991; 22 : 1-4.

11. Rowe B, Threlfall EJ, Ward LR. Ciprofloxacin resistant Salmonella typhi in the UK. Lancet 1995; 346 : 1302

12. Madhulika U, Harish BN, Parija SC. Current pattern in antimicrobial susceptibility of Salmonella typhi isolates in Pondicherry. Indian Journal Of Medical Research 2004; 120(2) : 111-114.

13. Lakshmi V, Ashok R, Susmita J, Shailaja VV. Changing trends in the antibiograms of Salmonella isolates at a tertiary care hospital in Hyderabad.

Indian J of Med Microbiol 2006; 24(1) : 45-48.

14. Cohen ML, Tauxe RV. Drug resistant Salmonella typhi in the United States : an epidemiologic perspective.Science 1986; 234 : 964-969.

15.Amdekar YK. Multi-drug resistant typhoid fever in children. Indian J of Med Ethics 2000; 8(2).

16. Wain I, Diep TS, Ho VA, Walsh AM, Hoa NT, Parry CM et al. Quantification of bacteria in blood of typhoid fever patients and relationship between counts and clinical features, transmissibility and antibiotic resistance. Clin Microbiol 1998; 36 : 1683-1687.

17. IAP Task Force Report on Guidelines and Management of Enteric fever in children. Bulletin Infectious Diseases Chapter of IAP 2007; 7 : 4-22.

18. Renuka K, Sood S, Das BK, Kapil A. High level ciprofloxacin resistance in Salmonella enterica serotype Typhi in India. J of Med Mircobiol 2005; 54 : 999-1000.

19. Mushtaq MA. What after ciprofloxacin and ceftriaxone in the treatment of Salmonella typhi? Pakistan J of Med Sciences 2006; 22(1) : 51-54.

20. Gupta A, Swankar NK, Choudhary SP. Changing antibiotic sensitivity in enteric fever. J Trop Ped 2001; 47 : 369-371.

21. Mandal S, Mandal MD, Kumar NP. Reduced minimum inhibitory concentration of chloramphenicol for Salmonella enterica serovar Typhi. Indian J Med Sci 2004; 58 : 16-28.

22. Girgis NI, Tribble DR, Sultan Y, Farid Z. Short course chemotherapy with cefixime in children with multi-drug resistant Salmonella typhi septicemia. J Trop Ped 1995; 41 : 364-365.

23. Girgis NI, Butler T, Frenck RW, Sultan Y, Brown FM, Tribble D, et al. Azithromycin versus ciprofloxacin for treatment of uncomplicated typhoid fever in a randomized trial in Egypt that included patients with MDR. Antimicrobial Agents and Chemotherapy 1999; 43(6) : 1441-1444.

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Perioperative Nursing Care Renuka Gugan * Introduction:

The total surgical episode is called the Perioperative period. This period in the health care continuum includes the Pre Operative period, Intra Operative period and Post Operative period.

Perioperative nursing care can range from home through surgery and recovery and back to home again.

The perioperative nurse is the member of the surgical team to whom clients are most likely to look for advocacy. The perioperative nurse must be a delegator and supervisor to ensure that the needs of the client are being met throughout the surgical experience.

Definition:

Perioperative Nursing: - Nursing care of the perioperative client taken place immediately before during and immediately after a surgical procedure.

Goals: • To assist clients and their signif icant others through the surgical episode.

• To promote positive outcomes.

• To help clients to achieve their optimal level of function and wellness after surgery.

Categories of surgical procedures – A review Category Aesthetic Constructive Curative Diagnostic Exploratory Emergent Palliative Reconstructive Urgent

Purpose Improvement of physical features that are with in the “normal range Repair of a congenitally defective body part Removal or repair of damaged or diseased tissue or organs Discovery or confirmation of a diagnosis Estimation of the extent of disease or confirmation of a diagnosis Life saving Relief or symptoms but without cure of underlying disease Partial or complete restoration of a body part Performed as soon as client is stable and infection is under control

Example Breast augmentation Cleft palate and cleft lip repair Hysterectomy Breast biopsy Exploratory laparotomy Repair of traumatic punctured lung Colostomy Total joint replacement Appendectomy

*

* Ms. Renuka Gugan, Professor of Medical & Surgical Nursing, Kasturba Gandhi Nursing College, Pondicherry.

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Preoperative Nursing Care:  Preoperative Assessment

1. History collection     

Medical / Health history Previous surgery & experience with Anesthesia Psychosocial history Cognitive Assessment Serious illness or treasure

o o o o o o o o o o o o o

A – Allergy to drugs, chemicals, Latex B – Bleeding tendencies/ use of medication like Heparin, aspirin C – Cortisone or steroid use D – Diabetes mellitus, a condition requires strict control E – Emboli Alcohol, Recreational Drug or Nicotine use Current Discomforts – like Headaches, pain Chronic illness – Arthritis of neck / back Advanced age - Plan the care accordingly Medication History – Over the counter drugs has operative risks Ability to tolerate perioperative stress Lifestyle habits Social history

           

Examine the part of the body that will be operated on first Complete general system assessment preoperative Head to Toe assessment Specific body system assessment Cardiovascular Assessment Respiratory Assessment Musculoskeletal Assessment Gastrointestinal Assessment Skin Integrity Assessment Renal Assessment Liver function Assessment Cognitive & Neurologic Assessment Endocrine Assessment

    

Age Pain Nutritional status Fluid & Electrolyte balance Infection & Immunity Hematologic functioning

2. Ask about ABCDE

3. Physical Examination

4. Additional Assessments

5. Estimating medical risk for surgery 6. Obtaining medical fitness for surgery 7. Obtaining Anesthetist’s opinion for fitness for surgery 8. Obtaining laboratory & diagnostic tests results for review prior to surgery.

9. Assessing the areas and educational need.

Preoperative Teaching • • • • o

Sensory information Psychological information Procedural information Preoperative exercises Deep breathing exercises

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o o o o

Coughing exercises Turning exercises Extremity exercises Early Ambulation

Immediate Preoperative Activities: • Record allergies • Check vital signs • Tie identif ication wrist band • Get consent signed • Start IV line • NPO • Empty bladder – Measures & record urine output • Complete oral hygiene & other physical care • Note for prostheses & notify. Remove dentures • Remove Jewels • Hand over valuables to relatives • Bath thoroughly • Change hospital gown & protective cap • Don’t remove hearing aid for communication. But notify it • Pre operative medication as prescribed. Eg. Atropine, Diazepam etc • Transporting the patient for surgery • Preparing the patient’s room for post operative care • Caring & support the relatives

Intra Operative Nursing Care:

• • • • • • • • • •

Nursing care during the intra operative phase focuses on the client‘s emotional well being as well as on physical factors such as Safety Positioning Maintaining asepsis Controlling surgical environment Coordinate with surgical team members Assisting in surgery as scrub Nurse Care during administering anesthesia and prevention of complication Active care during emergencies Documentation Moving & Transporting the clients

Post Operative Nursing Care:

o Close & constant observation is essential o Prepares & checks the function of all the equipment in PACU o Monitor vital physiologic function o Positioning o Ensure airway patency o Perform immediate assessment like Airway, breathing, circulation, LOC, muscle strength, skin / wound condition, drain, output, IV fluids & site o Care of wound – dressing & drain o Promote comfort o Promote nutritional status o Post operative exercises o Early ambulation o Reduce complications

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Roles of the Perioperative Nurse: o o o o o o o o

Circulating Nurse Scrub Nurse Registered Nurse First Assistant Certified Registered Nurse Anesthetist Nurse Manager Nurse Educator Care Manage Clinical Nurse specialist

Conclusion:

The nurse plays a critical role in the perioperative care of the client. Today surgery ranges from outpatient procedures to complex in patient procedures. No Matter what type of surgery is performed, however the client needs expect nursing car. The quality of nursing care can determine whether the client has a successful preoperative experience.

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Sterile Processing Unit – A Critical Partner in Infection Prevention Joy Kezia *

Governed by soundly designed principles, quality systems, and attributing to one’s dedication to deliver an infection free unit that is consistently superior to any other, in terms of function, reliability, cost effectiveness, ergonomics, environmental considerations and customer satisfaction, is the need to prevent infection in a health care setting. Time has now come to form strong local support gaining momentum with people who can think globally, yet act locally. We stand at an era where infection control is the key philosophy at work.

Fighting the power of microbial disease

Hospital acquired infection/nosocomial infection is the spread of pathogenic micro organisms to patients as a result of treatment or care given to them. These organisms develop during the time the patient is in the hospital or afterwards, or may be transmitted during treatment or may come from the patient himself. This infectious disease that the hospital staff may acquire as a consequence of their work is not limited to hospitals. Medical and dental clinics also serve as potential reservoirs.

Patients in the hospital are particularly vulnerable to infection, having lowered resistance, adding to the weakness caused by disease or injury. Adding to this infectious load, the increase in antibiotic-resistant bacteria, food preparation unit, and the difficulty of cleaning complex modern equipment pose serious threat to the development and spread of infection in hospitals. This makes the sterile processing unit/central sterile supply department [CSSD] a risky place – unless standard methods are implemented to sever the infectious cycle.

Good hygiene cuts cost!

Good infection control and cleaning equipment costs money. The lack of good equipments, costs even more. In addition to the unnecessary suffering, there are huge costs for extra hospitalization and lost working hours. A well – functioning hygiene system is crucial to minimizing the enormous costs involved with treating these infections. Hence an investment in the right direction in terms of a sterile supply unit, not only makes sense medically, it is a sound fiscal policy as well.

Disinfection:

Process that inactivates [kills] nearly all recognized pathogenic microorganisms but not all microbial forms such as bacterial endoscopes or inanimate objects. Hot water and steam are the most commonly employed agents that have proven efficient in the healthcare environment. A cleaning and disinfection unit, where thorough cleaning is performed by flushing with cold and warm water, followed by disinfection at a minimum temperature of 80 0C [1760F] for ten minutes or at 90 0C [194 0F] for one minute [Ao=600], is a good solution.

Sterilization:

Process that kills all microorganisms, including the non-sporiferous varieties that are fairly insensitive to heat.

The safest and the most economical method is treatment with heat, i.e. steam under pressure in a sterilizer, achieving sterilization within a minimum of 15 minutes at 1210C [250 0F] or 3 minutes at 134 0C [2720F]. However, it should be noted that an item is either sterile or not sterile – it can never be “nearly sterile”.

The word “sterile” is defined as the condition of a medical device that is free from viable microorganisms. [European Norm 556]. The measure of the microbial status [bioburden] of the medical device is also used as a definition: the item * Joy Kezia, MSc [N], RN, RM, Nurse Educator, Global Hospitals and Health City, Chennai

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shall have a Sterility Assurance Level [SAL] = 10-6, or among a million items there must not be more than one living microorganism.

Recommendation: The chain is only as strong as its weakest link.

Recognizing that an effective and efficient system for disinfection and sterilization takes more than equipment alone, it is appropriate to apply expertise in infection prevention and infection control, to the planning and the design of the entire system.

Maximum reliability at the Central Sterile Supply Department [CSSD]:

used for disinfection and sterilization; offers a number of advantages - cleaning, disinfection, inspection, packing, sterilization, storing, and distribution which are carried out by specialized experienced personnel.

Point-of-use Sterile Processing/Theatre Sterile Supply Department [TSSU]:

could be a decentralized sterilization facility, or sub sterile department, a relatively small unit usually located close to where the sterilized equipments are used. The main advantage of this being, shorter instrument circulating time, and lesser or nil transport time.

Zone 1: Reception of soiled goods: Unclean items from the Operating Theatres, Wards, Out-patient and other departments arrive at the reception area for soiled goods by covered trolleys or by lift - in the same instrument trays, baskets or containers as they were delivered in.

Barrier 1: The fight against pathogenic microorganisms starts right here between the reception area for soiled goods and the clean zone where sorting, inspection and packing take place. The barrier itself must consist of high capacity, pass-through washer-disinfectors.

Zone 2: Clean zone: Sorting, inspection and packing: On leaving the washer - disinfector, the clean [but not sterile] goods enter the area for sorting, inspection and packing. After packing the instrument trays are placed in the pass - through sterilizers. Fabric are sorted, inspected, packed and labeled in a separate area before moving along for sterilization.

Barrier 2: The second barrier, between the clean zone and the sterile store, consists of pass-through sterilizers.

Staff must be separated, one group working in the clean zone, the other working in the sterile zone.

Zone 3: Sterile storage: Over - pressure is maintanied in the sterile storage to keep the goods free from dust.

The room must be dry to prevent moisture from penetrating the packages, which might lead to recolonization of microorganisms.

Service excellence skills are essential for the sterile processing unit to support a healthcare facility’s infection control department and various infection control initiatives. Therefore, assessing and meeting the needs of the user – end customers are of prime importance. It is not enough to have the knowledge, tasks and processes in place to provide quality products. Unparalleled, innovative ability and secure controls are also required, along with quality services and products.

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An Overview of Hospital Infection Control Program Each hospital needs to develop a program for the implementation of good infection control practices and to ensure the well being of both patients and staff by preventing and controlling Hospital Acquired Infection (HAI). This overview has been abbreviated from WHO guidelines for hospital infection control.

Aim

Prevention and Control of Hospital Acquired Infections

Objectives of the infection control program

Monitoring of hospital-associated infections; Training of staff in prevention and control of HAI; Investigation of outbreaks; Controlling the outbreak by rectification of technical lapses, if any; Monitoring of staff health to prevent staff to patient and patient to staff spread of infection; Advice on isolation procedures and infection control measures; Infection control audit including inspection of waste disposal, laundry and kitchen, and Monitoring and advice on the safe use of antibiotics.

Responsibility of hospital administrator / Management The hospital administrator/head of hospital should: Provide the funds and resources for infection control program; Ensure a safe and clean environment; Ensure the availability of safe food and drinking water; Ensure the availability of sterile supplies and material, and Establish infection control organizations for the hospital.

Infection control organizations in a hospital

Infection control organizations are essential features of an infection control program. These organizations are: 1. Infection Control Committee (ICC) Representatives of medical, nursing, engineering, administrative, pharmacy, CSSD and microbiology departments are the members. The committee formulates the policies for the prevention and control of infection. One member of the committee is elected chairperson and has direct access to the head of the hospital administration. The infection control officer is the member secretary. The committee meets regularly and not less than three times a year.

2. Infection Control Team (ICT) Members are the people who undertake the day to day measures for the control of infection. One team is formed for each location with Clinician, Nursing supervisor and housekeeping staff.

3. Infection Control Officer (ICO) The Infection Control Officer is usually a medical microbiologist or any other physician with an interest in hospital associated infections.

Functions 1. Secretary of Infection Control Committee and responsible for recording minutes and arranging meetings; 2. Consultant member of ICC and leader of ICT; 3. Identification and reporting of pathogens and their antibiotic sensitivity; 4. Regular analysis and dissemination of antibiotic resistance data, emerging pathogens and unusual laboratory findings; 5. Initiating surveillance of hospital infections and detection of outbreaks; 6. Investigation of outbreaks, and 7. Training and education in infection control procedures and practice.

4. Infection Control Nurse (ICN) A senior nursing sister should be appointed full-time for this position. Adequate full-time or part-time nursing staff should be provided to support the program. The ICNs should be trained in basic microbiologic techniques.

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Functions 1. To liaise between microbiology department and clinical departments for detection and control of HAI; 2. To collaborate with the ICO on surveillance of infection and detection of outbreaks; 3. To collect specimens and preliminary processing; 4. Training and education of other health care personal under the supervision of ICO, and 5. To increase awareness among patients and visitors about infection control.

6. To maintain a database of all infections in the hospital.

5. Infection Control Manual (ICM) It is recommended that each hospital develops its own infection control manual based upon existing documents but modified, for local circumstances and risks.

Role of the microbiology laboratory

The microbiology laboratory has a pivotal role in the control of hospital associated infections. The microbiologist is usually the Infection Control Officer. The role of the department in the HAI control program includes: I. Identification of pathogens - the laboratory should be capable of identifying the common bacteria to the species level; II. Provision of advice on antimicrobial therapy; III. Provision of advice on specimen collection and transport; IV. Provision of information on antimicrobial susceptibility of common pathogens, and V. Periodic reporting of hospital infection data and antimicrobial resistance pattern - The periodic reporting of such data is an important service provided by the microbiology department. The frequency of this should be as determined by the ICC. VI.Identification of sources and mode of transmission of infection - Culture of carriers and environment for identifying the source of the organism causing infection (outbreak organism). The selection of sites for culture depends upon the known epidemiology and survival characteristics of the organism; VII.Epidemiological typing of the isolates from cases, carriers and environment; VIII.Microbiological testing of hospital personnel and / or environment - Testing for potential carriers of epidemiologically significant organisms. As a part of the infection control program, the microbiology laboratory at times may need to culture potential environmental and personnel sources of nosocomial infections. Usually this is limited to outbreak situation when the source and method of transmission needs to be identified. Routine microbiological sampling and testing is not recommended; IX.Provide support for sterilization and disinfection in the hospital including biological monitoring of sterilization.

X. Provide facilities for microbiological testing of hospital materials when considered necessary. These may include: sampling of infant feeds; monitoring of blood products and dialysis fluids; quality control sampling of disinfected equipment; additional sterility testing of commercially sterilized equipment is not recommended;

Infection Control Training Program

Provide training for personnel involved in infection control -This forms an important part of the Infection Control Program. Each hospital should develop an employee training program.

Different categories of staff should be targeted through this program training relevant to their functions.

The Infection Control Nurse plays a major part in training and education.

The aim of the training program is to thoroughly orient all hospital personnel to the nature of HAI and to ways of prevention and treatment.

As the various hospital employees have different functions and their level of education is different, the training program needs to be altered to suit the functional requirements of each category of staff and should be adapted accordingly.

Training should be preceded by a needs assessment survey. The training program should include the following: ¾¾ Basic concepts of infection; ¾¾ Hazards associated with their particular category of work.; ¾¾ Acceptance of their personal responsibility and role in the control of hospital infection; ¾¾ Methods to prevent the transmission of infection in the hospital, and ¾¾ Safe work practice.

Training should provide the information needed to modify staff behaviour. Innovative techniques such as role-play, problem solving, quiz competitions and poster making etc should be employed.

The ICC should agree to the level and frequency of training.

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Infection Control Practices & Policies for Nursing Professionals Policy - Hand hygiene Points to Remember

Learn how to clean your hands effectively Wash your hands with soap and water: • When starting a shift • When visibly soiled • Before drug rounds • When serving food

Introduction

Hand hygiene is the single most important way of reducing cross-infection in the hospitals.

The purpose 1. To remove microbial contamination that has occurred by recent contact with patient / environment.

2. To prevent cross infection.

The general guidelines • During clinical work, wear sleeves above the elbows.

• DO NOT WEAR a wristwatch or costume jewellery.

Hand washing should be carried out using either liquid soap (social hand washing) or using an approved skin disinfectant before a clinical procedure.

Alcohol rub (Sterilium) is to be used in high dependency areas as an alternative to hand washing to reduce bacterial load on clean hands.

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• Roll up sleeves and take off wristwatch and other jewellery.

• If unable to remove wedding ring, wash and dry thoroughly around and under it.

• Use running water, wet your hands and dispense one squirt of the recommended liquid soap or antiseptic into the palm of the hand.

• Hold hands down below elbow height to prevent water running onto forearms.

• Rub hands together vigorously to lather all surfaces of hands and wrists, paying particular attention to thumbs, finger tips and finger webs.

• Rinse hands thoroughly.

• Turn off water using elbows or wrists on elbow taps, then dry hands thoroughly on a paper towel; If elbow taps are not present, first dry hands thoroughly, then turn off the taps using a fresh paper towel.

• Dispose of towels into domestic waste (black) bag (do not contaminate your hands by touching the bin lid) • Use exactly the same technique for applying alcohol rub.

How long to wash • Two minutes at the beginning of each duty.

• Two minutes before high risk procedures eg. Catheter care, IV insertion.

• Two minutes after heavy contamination eg. Dressing change.

• Ten to fifteen seconds in between seeing patients.

• Five minutes scrub before operative procedures.

Skin lesions: If any member of staff has a hand lesion, or experiences skin problems associated with hand washing, he or she should consult the Occupational Health Department. If skin problems such as eczema are present, then staff should report to the Occupational Health Department or ICN or manager for advice. Staff with eczema, are at high risk of acquiring resistant hospital-associated staphylococci.

Cuts and abrasions on the hands must be adequately covered with an impermeable dressing when starting duty.

Policy - Glove usage General comments Note that non-sterile gloves protect the worker not the patient. If you employ good hygiene practices and clean your hands properly, you do not need gloves for most clinical purposes. When gloves are put on, they acquire your hand flora, so if you want gloved hands to be properly decontaminated, first, clean your hands properly before putting them on and secondly, rub the gloved hands with alcohol gel.

Gloves have a dual role: 1. To provide a barrier for personal protection* (use non-sterile gloves) 2. To reduce the risk of transmission to patients (use surgical gloves) *(and thus form part of the Personal Protective Equipment) Gloves should be worn when dealing with body fluids, secretions and excretions, and for nursing patients in source isolation. Gloves must be changed after nursing patients in source isolation or when they have been contaminated.

They should be removed immediately and discarded into yellow plastic waste bags and hands should be washed and dried thoroughly to remove allergenic components of the glove material before the next task.

If, in special instances, gloves need to be worn for long periods of duty, then gloved hands must be washed and dried, or rubbed with alcohol gel with the same frequency as un-gloved hands.

Important: Make a risk assessment of the procedure and decide whether to wear gloves. Choose your gloves according to the procedure to be carried out.

SUMMARY

• In order to reduce exposure to NRL, wear gloves only when necessary.

• Wearing gloves is not a substitute for hand hygiene.

• Cornstarch powdered gloves must not be used .

• Vinyl gloves are not a satisfactory substitute for NRL for protection against blood borne viruses .

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• Polythene gloves must not be used .

• Wash hands after taking gloves off

Standard Precautions Points To Remember

Assume all patients are potentially infectious Use Standard Precautions to prevent contact with bodily fluids Know how infections spread

Introduction

All blood and body fluids are potentially infectious and it is not always known whether a patient has a disease that can be transmitted via blood (WHO 2003). Body fluids which contain large numbers of micro-organisms are a major source of pathogens. Therefore, Universal Blood and Body Fluid Precautions, as well as protecting Health Care Workers from infection and blood borne viruses, could prevent transmission of many other pathogens, and make a contribution to the reduction of Hospital Acquired Infection.

General Principles

• Prevent blood / body substance contact with non-intact skin and mucous membranes • Minimise blood / body substance contact with intact skin • Prevent sharps injuries .

• Immunise staff against hepatitis B virus.

• Prevent contaminated items being used between patients.

All precautions should be allied to good skin care and safe Infection Control practices at all times in order to protect both staff and patients

Guidelines:

• Cover any cuts and grazes with an impermeable dressing • Wash hands or use an alcohol hand rub before and after contact with each patient, and before putting on and removing gloves • Change gloves between patients • Assess risk of accidental contamination with blood and body fluids • Wear appropriate protective clothing where contact with blood can be anticipated.

• Avoid contamination of clothing and skin with blood • Avoid sharps injuries • Clear up spillages properly (see policy for Spillages) • Follow safe procedures for the disposal of contaminated waste.

Gloves Use appropriate gloves when in contact with patients, waste, etc. Gloves used in patient’s care should be worn only for contact with the patient. Once used, gloves must be discarded before leaving the patient’s room in the appropriate containers (see waste disposal policy).

Gowns Gowns should be worn: • During activities that involve the management of large amounts of blood or body substances that may be difficult to contain properly.

• During procedures that may result in the splashing or splattering of blood or body substances.

Gowns should be: 1. Large enough to cover the clothing which is likely to be contaminated.

2. Made of a moisture-resistant material that provides an effective barrier to body substances.

3. Sterile gowns should be worn for procedures that require a sterile field.

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Gowns should be changed: 1. A fter giving care to an individual patient.

2. A fter performing any procedure involving instruments, equipment, or surfaces contaminated by blood or body substances.

3. W henever gross soiling occurs.

Discard used gowns in the patient care area or in the other areas in which they were used in the appropriate containers (see policies on waste disposal and disinfection).

Protective Eyewear Protective eyewear is worn to prevent blood and body substances from contaminating the mucous membranes of the eyes. Use recommended during procedures that may result in the splashing or splattering of blood or body substances. Use Goggles/ visors covering the eyes.

Face Shields Face shields are worn to prevent blood and body substances from contaminating the mucous membranes of the eyes, nose, and mouth during procedures which may cause splashing or splattering.

Masks Standard surgical masks are to be used: • When splashing, splattering, or spraying of blood or body fluids is likely in order to prevent exposure to the mucous membranes of the nose/mouth. Additionally, eye protection is warranted in such situations as well.

• When within 3 feet of a patient on Droplet Precautions.

• When working in a sterile field to prevent droplets from contaminating the field.

For suspected or confirmed patients with pulmonary TB, a N-95/HEPA respirator must be worn.

Universal precautions

Universal precautions should not be confused with Standard Precautions which goes beyond universal precautions.

Universal precautions refers to the practice, in medicine, of avoiding contact with patients’ bodily fluids, by means of the wearing of nonporous articles such as medical gloves, goggles, and face shields.

Under universal precautions all patients are considered to be possible carriers of blood-borne pathogens. The guideline recommends wearing gloves when collecting or handling blood and body fluids contaminated with blood and wearing face shields when there is danger of blood splashing on mucous membranes and when disposing of all needles and sharp objects in puncture-resistant containers.

Universal precautions are recommended for doctors, nurses, patients, and health care support workers who are required to come into contact with patients or bodily fluids. This includes staff and others who may not come into direct contact with patients.

Pathogens fall into two broad categories, bloodborne (carried in the body fluids) and airborne.

Universal precautions should be practiced in any environment where workers are exposed to bodily fluids, such as: • Blood • Semen • Vaginal secretions • Synovial fluid • Amniotic fluid • Cerebrospinal fluid • Pleural fluid • Peritoneal fluid • Pericardial fluid

Bodily fluids that do not require such precautions include: • Feces • Nasal secretions • Urine

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• Vomitus • Perspiration • Sputum • Saliva Universal precautions are the infection control techniques that were recommended following the AIDS outbreak in the 1980s. Every patient is treated as if infected and therefore precautions are taken to minimize risk. Essentially, universal precautions are good hygiene habits, such as hand washing and the use of gloves and other barriers, correct sharps handling, and aseptic techniques.

Policy: Specimens for Clinical Laboratories Points To Remember

Ensure all specimens are labeled correctly.

All specimens are potentially dangerous so should be bagged and must be transferred to laboratories in proper rigid containers.

Contaminated and unlabelled specimens will be discarded.

Label specimens as “HIGH RISK” when appropriate Serum should be saved for those having major cardiac, cranial, or abdominal surgery.

Management Of Specimens Microbiology

Objectives a. To collect an adequate amount of fluid un-contaminated from any other source. To preserve any organisms that are present. b. To ensure that the specimen is correctly labelled and despatched to laboratory with complete request information. c. To transport the specimen (and request form) to the laboratory safely with the minimum of delay or d. To store specimen in suitable conditions if delivery is delayed.

Guidelines For Appropriate Specimen Collection

• As a general rule, the more material sent for examination, the greater the chance of isolating significant bacteria.

A few ml of pus is much better than a swab. If in doubt send the pus in a sterile universal container plus a swab in transport medium.

• Use a syringe and needle to collect specimen and transfer into a sterile container eg Universal or plain sterile blood collection tube. Be very careful to avoid “Sharps” injury.

• Plain vacutainer tubes are good, as anaerobic conditions are maintained.

Specimens Must Be Transported To The Laboratory Without Delay.

If there is likely to be a delay in transporting to the laboratory, a specimen in transport medium (eg Transwab) is preferred.

Summary

• Always get specimens to the laboratory as soon as possible after collection.

• When delay is unavoidable, urine and sputum specimens must be refrigerated at 4o C. • Swabs for gonorrhoea must NOT be refrigerated.

• Always use the correct transport medium.

• Never use a swab when faeces, fluids or pus is available.

• Use only the correct request forms with an integral specimen bag or place the specimen in a separate plastic bag. Place only one specimen in each, and please complete the request form or computer entry fully.

• Never send leaking specimens anywhere. Discard them.

• Never wipe clinical material from the outside of a specimen container and then send it to the laboratory.

• Whenever you wish to collect an unusual specimen, or you have a query about safety or you need advice, please consult the laboratory staff.

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Specimen Collection

Swabs general: • From dry areas moisten swab with sterile transport medium.

• Rotate swab. No dabbing.

• Do not break swabs unless designed for this purpose.

Nose swab: • If purulent discharge the area at the back of the nose should be sampled.

• For carriers, (MRSA screening), the moistened swab should be directed away from the turbinates just within the anterior nares. The swab should be rotated five times (clockwise for R and counter-clockwise for L nostril) to obtain sufficient material. A single swab may be used for both nostrils.

Throat swab: • Avoid mouth and tongue.

• Sample any lesion, exudate, areas of inflammation.

Ear swab: • Fine wire swab is required under direct vision, a normal swab will only sample the external ear.

Eye swab: • Transport swabs should not be used, (lysozyme present). Direct culture onto culture medium preferred. Discuss with Medical Laboratory Scientists.

• Chlamydia/trachoma: Special swabs required.

Genital tract: • To take an HVS or Cervical swab, a speculum must be used, as faecal contamination must be avoided.

• Transport medium is essential. Charcoal transport medium for gonorrhoea

Specimen Transport To The Laboratory Urgent

Send To The Laboratory Without Delay: • Blood cultures, to 37°C incubator. (ARD Bottles to technician if used) • Cerebro-spinal fluid.

• Aspirates and tissue from normally sterile sites.

• Specimens where delicate bacteria such as Neisseria, Haemophilus are sought.

Routine Specimens

• Within 1-2 hours.

• Urines kept at room temperature for more than two hours have been shown to be useless. After two hours, contaminants have increased to significant numbers. This is the single most common reason for the report “Mixed growth of doubtful significance”. or • Missed infection due to overgrowth by contaminants.

• If delay is unavoidable, store routine specimens at 4°C (refrigerator).

• Specimens in transport medium should be kept at room temperature.

Health And Safety

• Do not overfill containers • Throw out contaminated containers.

• Transport in plastic bags • NO NEEDLES OR SYRINGES PLEASE

Ensure “High Risk Specimens” Are Labelled As Such

• In the case of pneumonia the laboratory will report significant numbers.

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• Delay in transport to the laboratory may increase the number of bacteria present and reduce the numbers of some relevant pathogens.

Urine: • Wash genital area with soap and water and dry thorooughly. (Some studies have shown that this is not necessary provided the urine is collected using good technique and processed immediately).

• The use of antiseptic may contaminate the specimen and confound the findings.

Male: • Retract foreskin.

Female: • Outer and inner labia cleaned in a front to back direction. (Reduces perineal contamination).

• Patient micturates with labia separated.

• The urine collected from the middle portion of the urine stream (MSU) is least contaminated.

• Container should be 4/5 full. This gives the laboratory ample urine for testing and allows the MLSO to remove the lid without spillage.

• If the container has a paper funnel, please remove it completely before putting lid on container, pushing the funnel into the container makes testing virtually impossible, and also makes the urine leak in transit.

• The laboratory should be specifically requested to rule out gonorrhoea, Chlamydia, or herpes. Special swabs are required for the latter two. Best to do a cervical swab as these organisms not reliably obtained from HVS. HVS only useful for Candida, Trichomonas and Mycoplasma hominis.

Catheter specimens of urine: • NOT from bag (Contains stagnant, almost certainly contaminated, urine).

• NOT from catheter drainage bag junction (High risk of contaminating system).

• Collect from self sealing sleeve of the drainage tubing using a fine bore needle and syringe (take care and do not place a finger behind the catheter!).

• Urinary catheter tips are inappropriate specimens and will not be processed.

• Urine samples should be transported to the laboratory within one hour of collection or held at 4°C and then transported to the laboratory without delay.

Wound swabs: • Pus preferred.

• Take swab before cleaning local area.

• Take from affected site, NOT surrounding tissue.

• The swab should be rotated gently to collect as much pus or exudate as possible.

• Transfer without delay into transport medium. Anaerobic bacteria may die in minutes.

• Preferably send 1-2 ml of pus in a sterile container (Universal or plain vacutainer) dispatch to laboratory without delay.

• Amoebic pus should not be refrigerated, but examined immediately for trophozoites.

Sputum: • Send sputum, not saliva.

• Early morning specimens after brushing teeth preferred as this is the most productive time.

• Quality not quantity. 2 ml is ample.

• Physiotherapy may be required.

• Avoid mouth contamination. (A mouth full of bacteria that may confuse culture interpretation).

Faeces: • May be examined for enteropathogenic bacteria, viruses, ova, cysts, parasites and toxins.

• May be collected into bedpan, or clean plastic bag draped over toilet (do not flush the plastic down the toilet). – Avoid bedpan for cholera stool • 5-10 ml of faeces is ample Over filled containers have been known to explode on warm days.

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o Take sample with a spatula or “tongue depressor” from mucoid and blood stained areas if present.

• If normally formed, samples from middle and both ends of the formed stool are very important for ova, cysts and parasites.

• “Hot” stools not necessary, but all stool samples should be reasonably fresh, and very fresh to see amoebic trophozoites.

• Solid faeces will not be processed unless justified (eg looking for continuing carriage of Salmonella sp.)

Summary Of Specimen Collection Guidelines

• Always get specimens to the laboratory as soon as possible after collection. Refrigerate urine and sputum specimens if delay is unavoidable.

• Do not refrigerate CSF or specimens for gonorrhoea.

• Always use the appropriate transport medium.

• Do not use a swab if faeces, fluid, or pus is available.

• Complete request form.

Histopathology & Cytology

A. BIOPSY: Specimens, organs removed at autopsy or amputated specimens should be transported to the Histopathology laboratory immersed in 10% formalin atleast 5 – 10 times the volume in a tight sealed and lid covered plastic leak proof container.

B. Body fluids : (Ascitic, Pleural, pericardial Synovial, CSF), should be sent in sterile containers (leak proof0.

These will be immediately centrifuged, and the deposit fixed with alcohol ether and the rest discarded following universal safely precautions.

C. All laboratory personnel handling the clinical samples shall follow universal precautions and shall be immunized for Hep. B. D. All unused blood, serum, plate, body fluids and used syringes and needles shall be disinfected in Hypochlorite solution before discarding as per the statuary regulations.

E. All cytologic aspirates (FNAC) shall be immediately fixed in methanol and the used syringe and needles dealt with as in (D) F. Specimens for frozen section / cryostat shall be fixed after sectioning in 10% formalin and processed as per the procedure for Histopathology. The microtome blade, knife and brushes will be cleaned and sterilized in hypochlorite solution before reuse.

Operation Theatres Dress Code

Personnel wishing to enter the theatre suite must report to reception.

The “operating room” (OR) includes the lay-up area but not the anaesthetic room.

Nurses, relatives, interpreters and designated visitors accompanying the patient to the pre-op holding room need not change. Similarly nurses collecting patients from recovery need not change.

Those not entering an operating room need not change into theatre dress.

Those passing through corridors within the theatre suite on business (e.g. to rest or conference rooms or offices) must not loiter in these corridors.

The Clothing To Be Worn By All Staff Working In The Operating Theatre Complex And All Those Entering The Operating Rooms Is As Follows: 1. Approved theatre suit.

2. Disposable cap to completely enclose the hair.

3. Jewellery: The wearing of jewellery is a hazard in theatres. Jewellery of any kind (dress rings, bangles) must not be worn.

Note: Earrings(clip on’s) are dangerous in that they may fall into a wound. Finger rings harbour bacteria so should be removed when scrubbing. They may be kept on a simple chain necklace, worn under the dress.

4. Masks: The scrubbed personnel should wear surgical masks to completely obscure the mouth and nose. The mask should be removed by the tapes and discarded in the OR at the end of a case. The mask must not be touched other

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than by the tapes.

Note: Surgeons performing certain operations (endoscopies) need not wear a mask. This is at the discretion of the surgeon. Visors can be worn to prevent splashing blood into the eyes and mouth.

5. Protective goggles/glasses will be available and should be worn for all infected operative procedures & HIV/ HBsAg positive cases.

6. Scrub gowns: Sterile gowns will be of a non-woven water-repellent material. Disposable gowns may also be worn.

Plastic aprons may be worn under these gowns for additional protection in urology & Obstetrics.

7. 7 Footwear: Dedicated personalised footwear is available for all regular staff in the theatre complex. Boots should be available and worn if there is a high risk of contamination of the feet with body fluids. Overshoes will not be available.

Note: Theatre staff are responsible for keeping their footwear clean.

Exceptions To These Rules

1. For short urgent visits to OR during an operation, maintenance staff, medical photographer and others must wear a jumpsuit over outdoor clothing with mask, hat or change fully.

2. In an emergency. For urgent immediate attendance to a sick patient, crash staff need not change, but should put on disposable gowns or aprons as soon as conveniently possible.

When Leaving Operating Theatre

Staff must not leave the operating theatre without changing into ordinary clothes or uniform, except: • Theatre personnel who collect patients for operations, collect blood, deliver urgent pathology specimens (etc), must wear a buttoned white coat over the theatre suit, with hat, but no mask. Outside shoes should be worn.

• CRASH CALLS and supervised transfer of ill patients to ICUs: Theatre staff who have to leave the theatres under these circumstances should change their theatre clothing on return.

Theatre Suits In Other Areas (To be introduced)

• Personnel who wear OT style uniforms at work (eg in ICU or A/E) should wear a suit of a different colour to that used in the operating theatres.

Infected Cases In Operating Theatres

• Assuming that any patient may unknowingly have a blood-borne virus infection or be colonised with any communicable pathogen (such as MRSA), STANDARD PRECAUTIONS will be taken to prevent the transmission of infection in operating theatres.

• This policy relates to those patients prior to surgery who are known to be infected with multiple drug-resistant bacteria (eg MRSA) and those in whom there is an accumulation of pus, even though the patient has been on antibiotics. In practice, it refers to anyone in Source Isolation on the ward.

• Ward staff will inform theatre staff about the infectious risk before the patient is considered for surgery.

As far as possible, infected cases should be placed at the end of the operating list.

• A special designated theatre in casuality may be used for heavily infected & gas gangrene cases

Theatre Procedure

• In addition to STANDARD PRECAUTIONS, • Unnecessary equipment should be removed from the operating room (OR) • The minimum necessary number of people should be in the OR. The operating (scrub) team • Should wear water repellent/proof gowns • Eye protection (visors and goggles) must be available for scrub personnel and should be worn for any operation by all those in the vicinity of the operating table.

The circulating nurse, anaesthetist and anaesthetic nurse/ODA • should wear plastic aprons and disposable gloves and should use eye protection.

Other personnel • It is not necessary for anyone entering the OR, who does not go to the immediate vicinity of the operating table, to take any special precautions.

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Anaesthetic Equipment

• Disposable or fully-autoclavable anaesthetic machine circuits must be used.

Equipment Disposal

• All linen from theatres is separated as soiled and non-soiled. The soiled lined is washed with water, wearing personal protection gear, to separate the debris and then disinfected using chlorine releasing solution before sending to central laundry covered with plastic bags.

• Instruments must be returned to CSSD in the normal way, or decontaminated using local procedures.

Cleaning of Instruments • Staff must be protected when performing these activities. Personal protective equipment such as face protection, gloves and gowns are recommended.

• Instruments should be cleaned as soon as possible after use so that organic material will not dry. Organic material must be removed before disinfection or sterilization procedures are initiated as it interferes with these processes.

• Placing the instrument in a pre-soak of water or a solution of instrument detergent/enzymatic will help prevent drying of secretions and help facilitate the cleaning process.

• Instruments should be cleaned with an instrument detergent / enzymatic diluted in water according to the manufacturer’s directions or alternatively, by ultrasonic machines also using instrument detergents.

• Careful attention must be paid to delicate or lumened instruments. Appropriate cleaning tools must be employed and care used to clean every surface. The cleaning tools must also be appropriately cleaned and disinfected.

• One designated staff person should be assigned the responsibility for cleaning and disinfection of equipment.

Appropriate education or continuing education is strongly recommended for this person with regard to all equipment and when new equipment is purchased.

• The manufacturer’s instructions should be followed and documented for each instrument reprocessed.

Thorough cleaning of instruments to mechanically remove all organic material is of the utmost importance prior to either sterilization or disinfection. Organic matter, if present, will inactivate or interfere with the sterilization or disinfection process. Do not use hand soap to clean instruments as emollients in soap could remain on the surface of the instrument and interfere with the disinfection or sterilization process.

Theatre Cleaning

• After the operation, all surfaces which may have become contaminated should be cleaned with General Purpose detergent. Surfaces which are known to have become contaminated with infected material should be cleaned promptly with fresh chlorine-releasing agent or Phenolic . Proper protective clothing must be worn (Plastic apron, domestic quality rubber gloves and visor). Equipment in the immediate vicinity of the operating table which is to be used again should also be wiped over with detergent and then with disinfectant if contaminated during the procedure.

• Protective clothing should be removed before leaving the OR. • As soon as theatre cleaning is complete, it will be ready for use again.

Staff Dress

• If the case is known to be colonised with multiply resistant bacteria, and is not at the end of the operating list, theatre dress should be completely changed by all members of the operating team and anaesthetists and hands properly cleansed before proceeding to the next operation.

Recovery

• Patients who are in Source Isolation on the ward (ie those who may be infectious to other patients) should be recovered in the OR and then sent straight back to the ward. If general condition of the patient does not permit for ward transfer, the patient isolation should be done in post operative ward. All other patients may be sent to the recovery room.

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Management of Percutaneous Devices Introduction

Any catheter or device which penetrates the skin allows the opportunity for invasion by saprophytic and pathogenic bacteria and fungi. The longer a device is in situ, and the more lumens and stopcocks involved, the graver this risk.

Tunnelled long intravenous lines (eg Hickman, Broviac), large bore lines for renal dialysis (eg Permacath) are often a patient’s “life-line” and need to be kept free of infection as far as possible. Skin commensals such as Staphylococcus epidermidis have a tendency to stick to prosthetic material and are then very difficult to remove. Invasion by virulent strains of Staphylococcus aureus may cause septicaemia. Colonisation of any device may lead to chronic blood stream spread which may predispose to endocarditis and endo-luminal arterial colonisation. Invasive organisms may be delivered in infusion fluids and via breaks in the system, such as three-way taps. Therefore strategies for reducing risks to patients and managing infections must be adopted.

Aims

• Not to contaminate the device on insertion with patient’s or staff members bacterial flora.

• To keep infection of percutaneous lines and devices to a minimum

Responsibilities

Those inserting and managing percutaneous devices are accountable for their practice and are responsible for updating their knowledge and maintaining the highest standards of practice. Inserters must not take on this role unless they have been appropriately trained to do so.

No member of staff should handle any percutaneous device (ie flushing, dressing, administering drugs etc) without having been properly trained to do so The named nurse for a patient with an existing percutaneous device is responsible for: • Educating the patient as to optimal care of his/her device • Assessing the patient for any signs of infection on each shift. This may or may not include visualisation of the exit site, depending on the device used.

Inflammation is characterised by: • Pain/discomfort (initially on movement, or when drip used and then at rest) • Local swelling and redness • Pus from around the insertion site • Phlebitis proximal to the device • Distal purpurae or vasculitis • Signs of general infection (eg fever, neutrophil leucocytosis, raised CRP and positive blood cultures) Inflammation of a line site demands removal unless the risks of changing a line (eg in the case of a Permacath or Broviac line) are greater than treating expectantly with antibiotics.

Inflammation at a line site or evidence of line-associated sepsis must be reported immediately to a member of the medical team. A senior qualified nurse may take the responsibility of removing a line if there is clear inflammation, the patient is in pain and a doctor is not available. Bacteriological cultures of line sites, line tips and blood cultures should be done when line infection is suspected.

General Guidelines for all Percutaneous Lines Insertion

• A percutaneous device should only be used if absolutely necessary.

• The lumen diameter, the number of lumens and stopcocks should be kept to the minimum consistent with clinical need.

• Use a Teflon or polyurethane catheter where possible.

• Equipment must be kept in a clean storage area.

• Staff inserting percutaneous devices must be appropriately trained.

• It is good practice to use a properly cleaned and fitted trolley with a Sharps Bin at the bedside rather than carrying individual items and placing them on the patient’s bed.

• Effective handwashing and a meticulous no-touch aseptic technique is vital when inserting percutaneous devices • Insertion of a line must be recorded in the patient’s and/or nursing notes.

• Lines must be dated.

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Management Of Established Lines

• Staff managing percutaneous devices must be appropriately trained.

• Effective handwashing and a meticulous no-touch aseptic technique is vital when handling percutaneous devices. Gloves should be worn but these need not be sterile except where intra-arterial or intra-thecal devices are concerned. Non-sterile gloves can be decontaminated by alcohol gel before touching a site.

• Interruptions to the closed system should be kept to a minimum.

• Use membranes to deliver injections if possible rather than stopcocks.

• Clean membranes, stopcocks and taps with alcohol (eg Sterets) before breaking a connection. (Aqueous or alcoholic chlorhexidine or alcoholic betadine may also be used.)

Change administration sets as follows: • Blood products: immediately on completion of each transfusion or every 24 hours, whichever is the sooner.

• TPN: immediately on completion of each bag of infusion or every 24 hours, Whichever is the sooner.

• Clear IV fluids/drugs: no more frequently than every 72 hours unless clinically indicated. o Consider the use of filters in regularly accessed lines. o If an administration set is disconnected it must always be replaced with a new line and never re-connected. o Percutaneous sites must be inspected regularly – see below for frequency. o Signs of local infection at exit sites as well as systemic infection must be taken seriously and referred to medical staff. Management depends on the device used: see below.

Blood Products

• Use a separate, dedicated administration set and do not use this for anything other than the blood product in question.

• Change administration set on completion of each transfusion or every 24 hours, whichever is the sooner.

Total Parenteral Nutrition (TPN)

• Use a dedicated lumen and do not use this lumen to give anything other than TPN. • Do not attach three-way taps.

• Change administration set immediately on completion of each bag of infusion or every 24 hours, whichever is the sooner.

• Type of device depends on the duration of therapy and the concentration of TPN given. Peripheral cannulas may be used for short term nutritional support but the cannula must be changed every 24 hours. A midline catheter may be used for up to 4 weeks. Longer periods of nutritional support require a central venous catheter.

Periphera Intravenous Cannulae

Insertion • Choose a site where patient’s movement will not cause movement of device at the entry site. The forearm provides an ideal site where veins tend to be straight and where the arm provides a natural splint. Avoid the antecubital fossa and the hand unless there are no other options.

• Do not shave the site.

• Clean the skin with alcoholic chlorhexidine or alcoholic povidone iodine (check patient is not allergic to iodine), twice, allowing the solution to evaporate to dryness on each occasion.

• Clean hands or put on sterile gloves after preparation of the materials and the skin before inserting the device.

Only repalpate the vein if wearing uncontaminated sterile gloves.

Fixing and Dressings • The catheter must be secured properly to ensure minimal movement of the cannula.

• Always anchor the flexible end of any administration set to the skin so that tension and movement is not applied to the entry site.

Ongoing Management • Lines should be assessed for signs of inflammation each nursing shift. A line dressing may be left if the patient has no discomfort and the drip is flowing freely. If there are any problems, the insertion site must be inspected.

• A peripheral iv cannula used for TPN must be changed every 24 hours.

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• A peripheral iv cannula used for other drugs and infusions should normally be changed routinely every 72 hours or immediately if any of the following occur: • Pain on administration of fluids • Inflammation at insertion site • Phlebitis • Leakage of infusion fluids / drugs from exit site • Extravasation of fluids / drugs inot tissues

Central Venous Catheters

Insertion • Must be carried out using strict aseptic technique. Operator must use sterile gown, drapes and gloves.

• Do not shave the site.

• Clean the skin with alcoholic chlorhexidine [or alcoholic povidone iodine (check patient is not allergic to iodine)] twice, allowing the solution to evaporate to dryness on each occasion.

• Unless medically contra-indicated choose the subclavian vein in preference to the jugular or femoral veins for nontunnelled catheters as there is less risk of infection.

Fixing and Dressings • Central venous catheters must be anchored so as to prevent “to and fro”motion which increases the risk of infection. Different types of central venous catheters are fixed in different ways but, as a general rule, any “dangling” lines must be anchored so that tension and movement is not applied to the line at the entry site. The type of dressing depends on the device used.

Cleaning of exit sites at dressing change • Routine cleaning of the exit site and surrounding skin at dressing changes may be justified as part of the general hygiene of the patient to avoid odours and discomfort, and to aid dressing adherence.

• Cleaning, when it occurs, should be carried out using sterile gauze and sterile 0.9% saline using an outward “single-swipe” motion to avoid transferring bacteria to the exit site.

• The exit site should be allowed to air dry or may be dried gently using sterile gauze before applying a fresh dressing.

Other ongoing management • Do not routinely replace centrally-inserted central venous catheters over a guidewire as an infection control precaution (Pratt et al 2001)

Intra-Arterial Lines

• Proper aseptic precautions should be used as for insertion of central intravenous lines. The notes above on care apply but transparent film dressings should not be used on arterial line sites.

Hospital Policy on HIV Infected Patients Admission

• No patient is to be denied hospital admission on account of his or her HIV positivity.

• Patient with HIV infection to be admitted for treatment if his or her health condition warrants it.

Confidentiality

• HIV positivity of the patient should not be revealed to anyone else without the consent of the patient.

• HIV positivity should not be displayed on the case sheets by writing or colour coding.

• Accessibility to medical records should be restricted.

• Disease classification should be as per ICD 10.

Exceptions

1. To spouse or fiancé (e)- patient should be persuaded by the treating physician to reveal HIV positivity. If persuasion fails, notify authorities, and if the authorities take no action, notify the endangered third party.

2. In the interest of the patient, HIV positivity may be revealed to other physicians

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3. If demanded by the court of law

Management Of Patients With Hiv Infection

A) Testing for HIV • HIV testing should not be done routinely.

• Testing should always be accompanied with counseling.

Exceptions: same as that for informed consent • Any clinician who decides to request for the HIV testing of the patient should do so after appropriate pre test counseling (can be done by a trained counselor, social worker or the clinician himself / herself) • Post test counseling should be done (by the same person who has given the pre test counseling) before revealing the result of HIV test to the patient.

• HIV testing should be done only after taking real written informed consent from the patient (not implied consent) ie, full disclosure of the nature of HIV disease, nature of the proposed test, implications of a positive and a negative test result and the consequences of treatment must be made prior to taking consent. The consent must be voluntary and patient must be able to understand and competent to refuse.

Specified exceptions to the need for informed consent for HIV testing include HIV testing that is not linked to identity (e.g. sentinel surveillance, research), blood banks and organ procurement.

HIV testing in a minor and an incompetent patient can be undertaken with a guardian’s consent.

(A form may be generated in the language the patient understands to record the process of pre and post test counseling administered to patients with HIV infection. It should clearly show the date and time of counseling & the name and signature of the person who counseled) B) Treatment • Treatment should be instituted for the condition for which the patient has been admitted / examined in the OPD (example, diarrhoea, meningitis, intestinal obstruction, pulmonary tuberculosis, furunculosis etc).

• Steps to be taken to detect and treat tuberculosis (pulmonary / extra pulmonary).

• Patients may be referred to General hospital for ART (admitted patients may be referred only after they are fit to be discharged).

Infection Control In Hiv

A) Prevention of Patient-to-patient transmission All equipments and devices used in percutaneous procedures to be disinfected and sterilized (see policy on Disinfection Guidelines).

B) Prevention of occupational hazard All health care personnel should strictly adhere to universal precautions when handling sharps, blood& body fluids (directly / indirectly).

Used needles to be destroyed immediately (Needle destroyers to be provided in casualty, injection rooms, procedure rooms of OPDs, operation theatres & wards).

Post Exposure Prophylaxis (PEP)

• Health care personnel with occupational exposure to HIV should receive follow up counseling, post exposure testing & medical evaluation regardless of whether they receive PEP. • If appropriate PEP should be initiated as soon as possible preferably within two hours of exposure.

Labour and Delivery in HIV Infected Mothers All HIV positive mothers should deliver in the hospital for proper management.

Elective Caesarean section to be opted for all pregnant women who are, if there are no other contraindications to surgery .

The Paediatrician should be informed of the impending delivery.

Foetal blood sampling and foetal scalp electrodes must not be used.

If the patient undergoes spontaneous vaginal delivery, the following protocol should be followed.

Once labour is established: During procedures where there is a risk of splashing e.g. vaginal examination, delivery, episiotomy, suturing, manual removal of placenta, staff should wear full protective clothing i.e.

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• Water repellent gown and apron • Gloves • Headwear • Mask • Protective eyewear • Protective footwear Spillage of blood should be handled wearing gloves. Sprinkle sodium hypochlorite solution 1:10, over spillage. Wait for 2 minutes. Wipe clean using a disposable cloth. Rinse disinfected area thoroughly. Wipe dry.

Episiotomy is not contra-indicated. Full protective clothing must be worn during episiotomy and suturing.

Clinical waste: After delivery all bio-hazardous wastes generated should be segregated & disposed in appropriate colour coded plastic bags.

The following infection control procedures are recommended for health personals attached at labour rooms in hospitals a) Health care workers who perform vaginal deliveries and manual removal of placenta should wear elbow- length latex gloves and long-sleeved disposable plastic gown. For Caesarean section, wear a plastic apron beneath the sterile surgical gown. b) Disposable latex / rubber gloves to be worn when handling placenta, the newborn and the umbilical cord. c) Placenta to be handled as follows: For Health Care Worker • Plastic apron and double gloves to be worn when examining placenta.

• Avoid splashes Placenta The placenta must be examined in the delivery room, still wearing full protective clothing. No part of the cord, placenta or membranes should be retained unless on specific medical instructions. The placenta should be disposed of, in a placenta box, as infected material by incineration. If cord blood is required full precautions must be taken.

Waste disposal of placenta • Placenta should be placed in sodium hypochlorite solution 1: 10, for 10 minutes.

• It is then drained out and carefully sealed in yellow plastic bags& discarded as clinical waste.

The mother should sit or lie on disposable incontinence pad on the wheel chair or stretcher during transfer to the postnatal wards.

Disposable latex / rubber gloves and plastic aprons should be worn when handling baby and umbilical cord after initial handling and examination.

Stillbirth In the event of a stillbirth, the baby should be washed in the delivery room as above. The parents may hold the baby if they wish to do so.

The baby should have an identification bracelet attached to the wrist and ankle indicating mother’s name, case sheet number, ward and date. The baby should be dressed in a clean baby sheet and transferred to mortuary.

Disinfection procedure outlined in section on “Disinfection Policy after handling Hepatitis B and HIV positive patients in OT or Labour Room” should be followed.

Post-natal infection control measures • Gloves and plastic aprons should be worn for any procedures involving or vaginal secretions.

• Minimal handling of contaminated materials such as under wear and sanitary towels should be ensured.

• Hands should be thoroughly washed after examination.

• All linen that is stained with blood or liquor should be discarded into appropriate linen bags before sending to laundry.

• All used sanitary towels and disposable items should be discarded into waste bags for incineration.

• Educate Patient should be educated on good hand and personal hygiene.

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Antenatal mothers with HIV No special precautions are required unless there is potential or actual bleeding or rupture of membranes. The patient should be cared for in a single room.

Antiretroviral treatment Guidelines for the Management of HIV infection in Pregnant Women and for the Prevention of Mother-to-Child Transmission of HIV Treatment of the mother HIV positive women already on combination antiretroviral treatment during the second half of the pregnancy must continue the drugs during delivery.

Intravenous zidovudine starting 4 hours before anticipated delivery, 2 mg / Kg over 1 hour followed by 1 mg / Kg until cord is clamped, is currently recommended, . After delivery this is discontinued and the combination treatment will be continued.

HIV positive woman who is not on ARV drugs before delivery should be administered Tab Nevirapine 200mg (single dose) intra-partum.

Treatment of the infant

1.Low Risk:

Infant born to a mother who has received anti-retroviral therapy for at least 4 weeks leading up to delivery and has a viral load of <50 copies/ml. (The most common scenario).

Treatment: zidovudine monotherapy unless 1. Maternal zidovudine resistance and / or 2. Maternal stavudine treatment (this drug may theoretically cause competitive inhibition).

Use oral lamivudine.

Term infant (> 34 weeks gestation): Oral zidovudine 4 mg/kg twice daily from birth to 4 weeks of age. Pharmacy will order this in advance of delivery.

Baby born to HIV positive mother who has not received antenatal ART should be administered Nevirapine drops at the dose of 2 mg/kg (single oral dose) within 72 hrs of birth.

Preterm infant: • 30 - 34 weeks gestation - oral zidovudine 2 mg/kg twice daily for the first 2 weeks then 2 mg/kg three times daily for a further 2 weeks.

• < 30weeks gestation - oral zidovudine 2 mg/kg twice daily for four weeks.

Any infant who is sick or intolerant of oral medication: Intravenous zidovudine.

• Term infants (>34 weeks gestation) - zidovudine 1.5 mg/kg IV every 6 hours • Preterm infants - zidovudine 1.5 mg/kg IV every 12 hours.

2.Higher Risk:

Infant born to a mother who has received at least 4 weeks treatment but who still has a detectable viral load, or whose viral load is unknown and compliance is in doubt.

Infant born to a mother who has received less than 4 weeks anti- retroviral treatment prior to delivery and whose viral load is high or unknown.

• Triple antiretroviral therapy, then co-trimoxazole as PCP (pneumocystis pneumonia) prophylaxis given orally until the child is confirmed likely free of infection at three months.

3. Infant Born To A Mother Who Declines Any Interventions Prior To Delivery.

Triple antiretroviral therapy for 4 weeks then co-trimoxazole prophylaxis.

4. Late Diagnosis Of The Mother

If the mother’s HIV status only becomes apparent after delivery, it is still worth treating the infant (triple antiretroviral therapy for 4 weeks, then co-trimoxazole prophylaxis), but treatment is less likely to be effective if more than 48 hours have elapsed since delivery.

5. Infant Born To A Mother With A History Of Multiple Antiretroviral Therapy Exposure And Resistance.

Seek expert advice from Infectious Diseases Unit, (preferably before delivery). Therapy will require to be tailored according to maternal resistance pattern/ antiretroviral therapy exposure.

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Annals of SBV Sri Balaji Vidyapeeth

(D eemed

to be

U niversity , u / s 3, UGC A ct , 1956)