Serhat Ünal MD
Study Group on Nosocomial Infections
European Society of Clinical Microbiology and Infectious Diseases
Department of Internal Medicine Hacettepe
Infection control (IC) is a quality standard and is essential for the wellbeing and safety of patients, staff and visitors. An IC programme with a firm structure should be in existence in all institutions that provide healthcare in order to establish a managed environment that secures the lowest possible rate of hospital-acquired infection (HAI) and protects staff and visitors from unnecessary risks. The hospital manager or medical director is ultimately responsible for safety and quality within the hospital. He or she must ensure that appropriate arrangements are in place for effective IC practices and that there is an Infection Control Team (ICT) and an Infection Control Committee (ICC).
Infection Control Team
The ICT should have a range of expertise covering knowledge of infection control, medical microbiology, infectious diseases and nursing procedures.(1) The team should have close links with the microbiology laboratory and ideally a microbiologist should be a member of the team. The team should consist of at least one physician, the infection control officer (ICO) and at least one nurse – the infection control nurse (ICN). One ICN for 250 acute beds on a fulltime basis was recommended in the US during the 1980s. A recent study in several different types of healthcare facilities reported 0.8–1.0 ICNs per hundred beds as adequate staffing.(2) The optimal number of ICNs cannot be calculated simply on the basis of the number of acute care beds but, rather, depends on the case mix and workload. The number of ICOs in a team is probably best related to the number of ICNs (eg, 1 to 5). The team is responsible for day-to-day decisions on IC as well as the long-term planning of IC policy. It should meet several times a week, or preferably daily. The team should be adequately funded to provide secretarial assistance, IT capabilities, facilities and training materials, and to allow members to attend educational courses and professional meetings.
ICO duties and responsibilities
The ICO should preferably be a senior member of the hospital staff with experience and training in IC, such as a medical microbiologist, epidemiologist or infectious diseases physician. In the absence of one of these, a surgeon, paediatrician or other appropriate physician with special interest in the field could act in this role. Whichever person is appointed must be guaranteed the extra time needed to fulfil the responsibility of an ICO. The ICO is usually the chairman of the ICC and is responsible to the hospital manager or medical director for infection control in the healthcare setting.
ICN duties and responsibilities
The ICN should be able to function as a clinical nurse specialist. The duties of the ICN are primarily associated with IC practices with special responsibility for nursing problems and education. In a large hospital the ICN can train “link” nurses. These individuals have special responsibility for maintaining good IC practices and education within their clinical departments. This person is the link between the ICN and the ward and helps identify problems, implement solutions and maintain communications.
Infection Control Committee
The ICC should act as a link between departments responsible for patient care and supportive departments (eg, pharmacy, maintenance). Its aim should be to improve hospital IC practice and recommend appropriate policies, which should be subject to frequent review. The committee should be responsible to the hospital CEO or medical director and should have a physician, preferably the ICO or hospital epidemiologist as a chairperson. The hospital CEO and the chief nursing officer, or their representatives, should attend meetings. It should produce an annual report and an annual business plan for IC. The following are the most important activities to ensure adequate IC practices where healthcare is provided:
- Provide facilities and equipment that make it possible for the staff to maintain good IC practices.
- Produce standards (ie, policies, guidelines) for procedures or systems used within the healthcare setting.
- Implement educational programmes for all personnel in the use of such standards.
- Establish surveillance systems that identify problem areas.
- Produce a policy for the prudent use of antibiotics and work to ensure adherence to the policy.
- Produce guidelines for cleaning, disinfection and decontamination and work to ensure adherence to those guidelines.
Surveillance for nosocomial infections
Hospital IC programmes should include surveillance to detect common source outbreaks, identify problem areas, help set priorities for IC activity, and meet national standards. Surveillance can also provide data to help convince clinicians and managers of the need for improvements in IC practices. Surveillance must be performed in a systematic way with the aim of reducing rates of hospital infection. Surveillance results should be fed back to clinical and managerial staff and should lead to action.
Cleaning, disinfection and sterilisation
Decontamination is a process that removes or destroys microorganisms to render an object safe for use. It includes cleaning, disinfection and sterilisation.
In hospitalised patients, the skin may become colonised with multidrug-resistant (MDR) pathogens and infected wounds and other lesions are also potential sources of cross-infecting organisms. Pathogenic organisms from colonised and infected patients (and sometimes from the environment) transiently contaminate the hands of staff during normal clinical activities and can then be transferred to other patients. Hand transmission is one of the most important methods of spread of infectious agents in healthcare facilities. Proper hand hygiene is an effective method for preventing the transfer of microbes between staff and patients.
Appropriate isolation precautions for all patients, including those who are infected and colonised reduce the risk of transmission.
Principles of antibiotic policy
Within hospitals, the unnecessary use or overuse of antibiotics encourages the selection and proliferation of resistant and multiply resistant strains of bacteria.(3) Once selected, resistant strains are favoured by antibiotic usage and spread by cross infection. Where resistance is encoded on transmissible plasmids, resistance can also spread between bacterial species. An antibiotic policy will:
- Improve patient care by promoting the best practice in antibiotic prophylaxis and therapy.
- Make better use of resources by using cheaper drugs where possible.
- Retard the emergence and spread of multiple-antibiotic-resistant bacteria.
- Improve education of junior doctors by providing guidelines for appropriate therapy.
- Eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones.
The medical director and/or hospital CEO should ensure that the hospital plan for prevention and control of nosocomial infection includes an official committee that has responsibility for the formulation and supervision of an antibiotic policy. An Antibiotic Committee should have the support of the medical director and the authority to ensure that its policies are implemented throughout the hospital. A major task of the Antibiotic Committee will be to establish guidelines for antibiotic use. This will lead to the production of a formulary that restricts agents available to the minimum number needed for most effective therapy.
- Standard principles for preventing hospital- acquired infections. J Hospit Infect 2001;47 Suppl: S21-37.
- O’ Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002;30:321-33.
- French G, Friedman C, editors. Infection control: basic concepts and practices. 2nd ed. Denmark: IFIC; 2005.