LEARNING OUTCOME AND OBJECTIVES:  Upon completion of this course, you will have increased your knowledge of current, evidence-based information on preventing and controlling the spread of infection. Specific learning objectives to address potential knowledge gaps include:

• Summarize the goals of infection prevention and control.
• Describe pathogenic organisms and the chain of infection.
• Explain methods to prevent the spread of infection.
• Discuss engineering, work practice, and environmental controls that protect against healthcare-associated infections.
• Identify barriers and personal protective equipment for protection from exposure to potentially infectious material.
• Discuss efforts designed to minimize the risk of occupational exposures to infectious diseases.
• Recognize suspected sepsis and methods to prevent it.

THE NEED FOR INFECTION PREVENTION AND CONTROL PRACTICES

Infection control was born in the mid-1800s when Ignaz Semmelweis, a Hungarian obstetrician, demonstrated that handwashing could prevent infection. Semmelweis was director of two obstetrical clinics, one staffed by medical students, the other by midwives. Disturbed by the fact that the maternal mortality rate from puerperal (postpartum) fever in the clinic staffed with medical students was almost six times greater than in the clinic staffed by midwives, he set about analyzing the difference and found that medical students often performed dissection prior to assisting with deliveries without washing their hands.

Semmelweis came to the conclusion that the medical students performing dissection (which midwives did not do) were carrying some invisible poisonous material on their hands to the women they were assisting in the delivery room, and he instituted a policy requiring medical students to wash their hands in a solution of chlorinated lime prior to assisting in any obstetrical procedure. As a result of this practice, the mortality rate dropped from 18.27% to 1.27% in the medical students’ clinic, and in a period of two months, the death rate dropped to zero (Zoltán, 2023).

Later in that same century, Florence Nightingale described the relationship between the diseases that were killing her patients during the Crimean War and the conditions in which they were cared for. Nightingale instituted ways to improve overall hygiene through clean clothing and dressings, bathing, and supplying adequate nutrition. These measures helped prevent contamination and led to reductions in infections and only a 2% mortality rate. Her greatest influence has been on hospital infection control, and many modern healthcare practices (e.g., isolation, ventilation, routine cleaning, and medical and human waste disposal) are attributed to her (Selanders, 2023).

Today, we know about pathogenic microorganisms and how they are transmitted, and we have a great deal of knowledge of the principles of infection control. Despite these advances, preventable infections continue to occur. Every year the five most common healthcare-associated infections (HAIs) in U.S. hospitals cost $9.8 billion, with surgical site infections the leader. Healthcare costs from HAIs occur in every medical department, including the intensive care unit (Monegro et al., 2023). Healthcare providers clean their hands less than they should, despite it being known that hand hygiene is the most effective way to prevent HAIs (CDC, 2023a).

This discussion indicates that infection control is not just a matter of knowing what is effective but that there is a strong behavioral element involved in the process of carrying out infection control practices. Both factors must be addressed if the absence of HAIs is the goal. To accomplish this, each healthcare worker should have the necessary knowledge, skills, and abilities to implement effective infection control practices, which then may influence their perceptions and provide motivation to change behavior.

Healthcare-Associated Infections (HAIs)

The rate of HAIs is 1 in 31 patients in acute care hospitals and 1 in 43 patients in long-term care facilities (CDC, 2022a). In the United States, the Centers for Disease Control and Prevention (CDC) estimates that HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year.

COMMON TYPES OF HAIs

• Catheter-associated urinary tract infections (CAUTIs). These infections involve any part of the urinary system, including urethra, bladder, ureters, and kidneys, and result from incorrect insertion, failure to maintain asepsis, and leaving a catheter in place for too long. These make up 32% of all HAIs.
• Surgical site infections (SSIs). These can involve the skin, tissues, and organs under the skin, or implants such as material inserted or grafted into the body (e.g., prosthetic joints). These constitute 22% of HAIs.
• Central line–associated bloodstream infections (CLABSIs). These are bloodstream infections unrelated to an infection at another site that develops within 48 hours of central line placement. Of all HAIs, these are associated with increased care costs and mortality. These and other bloodstream infections add up to 14% of HAIs.
• Ventilator-associated events (VAEs) or pneumonias (VAPs). These events or pneumonias are caused by a wide variety of pathogens, can be polymicrobial, and can be due to multidrug-resistant organisms. These are 15% of all HAIs in the United States.
  (Patient CareLink, 2023)

The impact of HAIs may be greater when they are due to drug-resistant organisms, which include:

• Methicillin-resistant Staphylococcus aureus (MRSA). This type of bacteria is resistant to many antibiotics.
• Clostridioides difficile (C. difficile) (formerly known as Clostridium difficile). When antibiotics are taken, “good” bacteria are destroyed for several months, during which time infection with C. difficile bacteria can cause life-threatening diarrhea.
• Carbapenem-resistant Enterobacteriaceae (CRE). This family of organisms, which includes Escherichia coli (E. coli) and Klebsiella pneumoniae, has a high level of antibiotic resistance.
  (Monegro et al., 2023)

The improvement in reducing HAIs is mixed, depending on the type of infection being measured. The United States has made significant progress toward the collective goal of eliminating some HAIs and is safer now than it was in years past.

Cases of C. difficile decreased by 50% between 2015 and 2021. Other HAIs saw a 7%–21% reduction in in the same time period (CDC, 2021a). However, increases were documented for MRSA at 14%, VAEs at 12%, SSI-hysterectomy at 11%, CLABSIs at 7%, and CAUTIs at 5% between 2020 and 2021 (CDC, 2022c).

The presence of the COVID-19 virus also contributed to an unusual increase in infection rates. This new virus brought patients with existing central lines and urinary catheters into the hospital and/or caused newly immunocompromised patients to acquire these tubes as well as endotracheal tubes while hospitalized.

HAIs IN OUTPATIENT SETTINGS

Increasingly, healthcare delivery, including complex procedures, is being shifted to outpatient (ambulatory) settings. These settings often have limited capacity for oversight and infection control compared to hospital-based settings. Because patients with HAIs, including those caused by antibiotic-resistant organisms, often move between various types of healthcare facilities, prevention efforts must expand across the continuum of care.

Examples of outpatient settings include:

• Medical group practices
• Clinics at hospitals or other facilities
• Surgery centers
• Imaging centers
• Mental health centers
• Lab centers
• Physical therapy and rehabilitation facilities
• Chemotherapy and radiation therapy centers
• Dialysis centers
• Birthing centers
• Hospice homes
• Home care

Surveillance for infection in outpatient or ambulatory settings is inherently difficult, as detecting infections among outpatients typically requires retrospective reviews of medical records and/or prospective audits. However, intelligent information technology may serve as a meaningful tool. Such automated systems can be used to perform prospective surveillance for infections following outpatient procedures, such as a reference database designed to document SSIs in ambulatory surgery and linking institutional databases to detect bloodstream infections (Anderson & Kanafani, 2020; AHRQ, 2023).

HAIs IN LONG-TERM CARE FACILITIES

Long-term care settings include nursing homes, skilled nursing facilities, and assisted living facilities. Over 4 million Americans are admitted to or live in nursing homes and skilled nursing facilities each year, and nearly 1 million live in assisted living facilities. While reporting is limited, the CDC (2020) provides the following data about infections in these facilities:

• 1 to 3 million serious infections occur each year.
• Infections include urinary tract infections, diarrheal diseases, antibiotic-resistant staph infections, and many others.
• Infections are a major cause of hospitalization and death.

As many as 380,000 people die of infections in long-term care facilities every year.

Development of Infection Control and Prevention Standards and Guidelines

Standards and guidelines are designed to proactively prevent the spread of infection in healthcare settings. The development of these standards and guidelines came about through the collaborative efforts of the Centers for Disease Control and Prevention, the Joint Commission, the World Health Organization, and the Occupational Safety and Health Administration.

Significant infection control challenges include:

• SARS-CoV-2 (COVID-19)
• SARS-CoV (severe acute respiratory syndrome)
• HIV infection
• Lyme disease
• Escherichia coli
• Hantavirus
• Dengue fever
• West Nile virus
• Zika virus

Reemerging infectious diseases include:

• Tuberculosis
• Pertussis
• Influenza
• Pneumococcal disease
• Malaria
• Cholera
• Gonorrhea

Standards and guidelines for these and other infectious diseases include vaccinations, emergency medications, preventive care, and information learned about the possible risks to avoid or to prepare for when traveling (Johns Hopkins, 2023).

Goals of Infection Control and Prevention

The goals of infection control and prevention training are to:

• Assure that health professionals understand how pathogens can be transmitted in the work environment from patient to healthcare worker, healthcare worker to patient, and patient to patient
• Apply current scientifically accepted infection prevention and control principles as appropriate for the specific work environment
• Minimize opportunity for transmission of pathogens to patients and healthcare workers
• Periodically reinforce knowledge through continued training to ensure high understanding of how to prevent infection transmission