Guidelines

Guidelines for prevention of hospital acquired

infections
Yatin Mehta, Abhinav Gupta1, Subhash Todi2, Myatra SN3, D. P. Samaddar4,
Vijaya Patil5, Pradip Kumar Bhattacharya6, Suresh Ramasubban7
Abstract

These guidelines, written for clinicians, contains evidence-based recommendations for Access this article online
Website: www.ijccm.org
the prevention of hospital acquired infections Hospital acquired infections are a major
DOI: 10.4103/0972-5229.128705
cause of mortality and morbidity and provide challenge to clinicians. Measures of infection
Quick Response Code:
control include identifying patients at risk of nosocomial infections, observing hand
hygiene, following standard precautions to reduce transmission and strategies to reduce
VAP, CR-BSI, CAUTI. Environmental factors and architectural lay out also need to be
emphasized upon. Infection prevention in special subsets of patients - burns patients, include
identifying sources of organism, identification of organisms, isolation if required, antibiotic
prophylaxis to be used selectively, early removal of necrotic tissue, prevention of tetanus,
early nutrition and surveillance. Immunodeficient and Transplant recipients are at a higher
risk of opportunistic infections. The post tranplant timetable is divided into three time
periods for determining risk of infections. Room ventilation, cleaning and decontamination,
protective clothing with care regarding food requires special consideration. Monitoring
and Surveillance are prioritized depending upon the needs. Designated infection control
teams should supervise the process and help in collection and compilation of data.
Antibiotic Stewardship Recommendations include constituting a team, close coordination
between teams, audit, formulary restriction, de-escalation, optimizing dosing, active use of
information technology among other measure.The recommendations in these guidelines
are intended to support, and not replace, good clinical judgment.The recommendations are
rated by a letter that indicates the strength of the recommendation and a Roman numeral
that indicates the quality of evidence supporting the recommendation, so that readers
can ascertain how best to apply the recommendations in their practice environments.
Keywords: Hospital Acquired Infection prevention, Standard Precautions, Burns,
Monitoring Surveillance, Antibiotic Stewardship,

Introduction Considering morbidity, mortality, increased length

of stay and the cost, efforts should be made to make
Hospital acquired infections (HAIs) is a major safety
the hospitals as safe as possible by preventing such
concern for both health care providers and the patients.
infections.[1,2]
From:
 Institute of Critical Care and Anesthesiology, Medanta- The Medicity,
Gurgaon, 1Critical Care,Medanta – The Medicity, Gurgaon, 2AMRI Group These guidelines have been developed for health care
of Hospitals, Kolkata, 3Department of Anaesthesia, Critical Care and Pain, personnel involved in patient care in wards and critical
Tata Memorial Hospital, Dr. E Borges Road, Parel, Mumbai, 4Department of
Anaesthesiology and Critical Care, Tata Main Hospital, Tata Steel Limited, care areas and for persons responsible for surveillance
Jamshedpur, Jharkhand, 5Department of Anaesthesia, Critical Care and Pain, and control of infections in hospital.
Tata Memorial Hospital, Dr. E Borges Road, Parel, 6Critical Care, Chirayu
Medical College and Hospital, Bhopal, Madhya Pradesh, 7Critical Care, Apollo
Gleneagles Hospital, Kolkata, West Bengal, India The principles of the grading of recommendations
Correspondence: assessment, development and evaluation (GRADE)
Dr. Yatin Mehta, Institute of Critical Care and Anesthesiology, Medanta ‑ system is used to guide assessment of quality of
The Medicity, Gurgaon ‑ 122 001, Haryana, India.
E‑mail: yatinmehta@hotmail.com evidence from high (A) to very low (C) and to

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determine the strength of recommendations. Each source isolation) and positive-pressure (for protective
recommendation is categorized on the basis of existing isolation) ventilations.
scientific data, theoretical rationale, applicability
and economic impact. The GRADE system classifies Patient at risk of nosocomial infections
recommendations as strong (grade 1) or weak (grade 2). There are patient, therapy and environment related risk
The assignment of strong or weak is considered of greater factors for the development of nosocomial infection.[3]
clinical importance than a difference in letter level of • Age more than 70 years
quality of evidence.
• Shock
• Major trauma
The system for categorizing recommendations in this
• Acute renal failure
guideline is as follows.
• Coma
• Prior antibiotics
Level of evidence
• Mechanical ventilation
 Evidence from at least one properly-designed
• Drugs affecting the immune system (steroids,
randomized, controlled trial
chemotherapy)
 Evidence from at least one well-designed clinical
• Indwelling catheters
controlled analytic studies (preferably from more
• Prolonged ICU stay (>3 days).
than one center), or from multiple time-series
studies, or dramatic results from uncontrolled
Observe hand hygiene
experiments
Hands are the most common vehicle for transmission
 Evidence from opinions of respected authorities
of organisms and “hand hygiene” is the single most
based on the clinical experience, descriptive studies, effective means of preventing the horizontal transmission
or reports of expert committees. of infections among hospital patients and health care
personnel.[4]
Strength of recommendation
 Strong (we recommend) When and why – follow World Health
 Weak (we suggest). Organizations (WHO’s) five moments for hand hygiene
[Figure 1]
General Measures of Infection Control • Before touching a patient (IB) – to protect the patient
Isolation from harmful germs carried on your hands
1. Assess the need for isolation.[3] Screen all intensive • Before aseptic procedures (IB) – to protect the patient
care unit (ICU) patients for the following: against harmful germs, including the patient’s own
• Neutropenia and immunological disorder germs
• Diarrhea • After body fluid exposure/risk (IA) – to protect
• Skin rashes
• Known communicable disease
• Known carriers of an epidemic strain of bacterium.

2. Identify the type of isolation needed.

There are two types of isolation in the ICU:
 Protective isolation for neutropenic or other
immunocompromised patients to reduce the chances
of acquiring opportunistic infections
 Source isolation of colonized or infected patients to
minimize potential transmission to other patients or
staff.

Isolation rooms should have tight-fitting doors, glass

partitions for observation and both negative-pressure (for Figure 1: World Health Organization's five moments for hand hygiene

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yourself and the health care environment from the  Change gloves between tasks and procedures in
harmful patient’s germs the same patient especially when moving from a
• After touching the patient (IB) – to protect yourself contaminated body area to a clean body area (1A)
and the health care environment from the harmful  Never wear the same pair of gloves for the care of
patient’s germs more than one patient (1A)
• After touching the patient’s surrounding (IB) – to  Remove gloves after caring for a patient
protect yourself and the health care environment  Practice hand hygiene whenever gloves are removed.
from the harmful patient’s germs.
Gown
(Remember there are two moments before and three  Wear a gown to prevent soiling of clothing and skin
moments after touching the patient). during procedures that are likely to generate splashes
of blood, body fluids, secretions or excretions (IB)
How  The sterile gown is required only for aseptic
• Wash hands with soap and water when they are procedures and for the rest, a clean, non-sterile gown
soiled or visibly dirty with blood or other body is sufficient (2A)
fluids (IB). Wet your hands, apply soap and then  Remove the soiled gown as soon as possible, with
scrub them vigorously for at least 15 s. Cover all care to avoid contamination.
surfaces of the hands and fingers, wash with water
and then dry thoroughly using a disposable towel Mask, eye protection/face shield
• Use an alcohol-based hand rub (IA) e.g. 0.5%  Wear a mask and adequate eye protection (eyeglasses
chlorhexidine with 70% w/v ethanol, if hands are are not enough), or a face shield to protect mucous
not visibly dirty. A combination of chlorhexidine membranes of the eyes, nose and mouth during
and alcohol is ideal as they cover Gram-positive and procedures and patient care activities that are likely
Gram-negative organisms, viruses, mycobacteria and to generate splashes/sprays of blood and body fluids,
fungi. Chlorhexidine also has residual activity. etc., (2B)
 During surgical hand preparation, all hand  Patients, relatives and health care workers (HCWs)
jewelries (e.g. rings, watches and bracelets) must presenting with respiratory symptoms should also
be removed (2A) use masks (e.g. cough) (2A).
 Finger nails should be trimmed to <0.5 cm (2A)
with no nail polish or artificial nails (2A) Shoe and head coverings
 Avoid wearing long sleeves, ties should be tucked  They are not required for routine care (2B).
in, house coats are discouraged and wearing
scrubs is encouraged. Patient-care equipment
 Used patient-care equipment soiled with blood, body
Follow standard precautions fluids, secretions, or excretions should be handled
Standard precautions include prudent preventive carefully to prevent skin and mucous membrane
measures to be used at all times, regardless of a patient’s
exposures, contamination of clothing and transfer
infection status.[4]
of microorganisms to HCWs, other patients or the
environment (1B)
Gloves
Sterile gloves should be worn after hand hygiene  Ensure that reusable equipment is not used for the
procedure while touching mucous membrane care of another patient until it has been cleaned and
and non-intact skin and performing sterile sterilized appropriately (2A)
procedures (2A) e.g. arterial, central line and Foley  Ensure that single use items and sharps are discarded
catheter insertion properly (1A).
 Clean, non-sterile gloves are safe for touching blood,
other body fluids, contaminated items and any other Follow transmission-based precautions
potentially infectious materials In addition to standard precautions, the following

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should be observed in those patients known or suspected protect against both large and small droplets. This
to have airborne, contact or droplet infections:[4] should be worn by all persons entering the room,
including visitors (1B)
Airborne precautions  Limit transport of the patient (2B).
 Disease-causing microorganisms may be suspended
in the air as small particles, aerosols, or dust Use specific strategies focused on prevention of
and remain infective over time and distance, for specific nosocomial infections
example, Mycobacterium tuberculosis (pulmonary/ In addition to the standard and transmission-based
laryngeal), varicella zoster virus (chickenpox), herpes precautions, there are several strategies focused on
zoster (shingles), rubella virus and measles prevention of specific nosocomial infections in critically ill
patients. Of these, ventilator-associated pneumonia (VAP),
 Isolate with negative-pressure ventilation (2B)
catheter-related bloodstream infection (CRBSI) and
 Respiratory protection must be employed when
urinary tract infection (UTI) are the most important.
entering the isolation room (1B)
 Use the disposable N-95 respirator mask, which fits Strategies to reduce VAP 
tightly around the nose and mouth to protect against  Avoid intubation whenever possible (2B)[5-7]
both large and small droplets. This should be worn by  Consider noninvasive ventilation whenever
all persons entering the room, including visitors (1B). possible (2B)
 P r e f e r o r a l i n t u b a t i o n s t o n a s a l u n l e s s
Contact precautions contraindicated (2B)
Infections can be spread by usual direct or indirect  Keep head elevated at 30-45° in the semi-recumbent
contact with an infected person, the surfaces or patient
body position (IA)
care items in the room, for example, parainfluenza
 Daily oral care with chlorhexidine solution of
virus infection, respiratory syncytial virus infection,
varicella (chickenpox), herpes zoster, hepatitis A and strength 0.12% (IA)
rotavirus infections.[4]  Daily sedation vacation if feasible and assessment of
 Isolation is required (1B) readiness to extubate (IA)
 Non-critical patient-care equipment should  Avoid re intubation whenever possible (2B)
preferably be of single use. If unavoidable, then  Routine change of ventilator circuits is not
clean and disinfect them adequately before using to required (2B)
another patient (2B)  Monitor endotracheal tube cuff pressure (keep
 Limit transport of the patient (2B). it >20 cm H2O) to avoid air leaks around the cuff,
which can allow entry of bacterial pathogens into
Droplet precautions the lower respiratory tract (2B)
 M i c r o o r g a n i s m s a r e a l s o t r a n s m i t t e d b y  Prefer endotracheal tubes with a subglottic suction
droplets (large particles >5 m in size) generated port to prevent pooling of secretions around the cuff
during coughing, sneezing and talking, or a leading to microaspiration (2A)
short-distance travelling, for example,  The heat moisture exchanger may be better than the
influenza virus, Bordetella pertussis, Hemophilus heated humidifier (2B)
influenzae (meningitis, pneumonia), Neisseria  Closed endotracheal suction systems may be better
meningitidis (meningitis, pneumonia and than the open suction (2B)
bacteremia), Mycoplasma pneumoniae, Severe acute  Periodically drain and discard any condensate that
respiratory syndrome-associated coronavirus, collects in the tubing of a mechanical ventilator (2B).
Group A Streptococcus, adenovirus and rhinovirus[4]
 Isolation is required (1A) Strategies to reduce CRBSI 
 Respiratory protection must be employed when  Prefer the upper extremity for catheter insertion.
entering the isolation room or within 6-10 ft of the Avoid femoral route for central venous
patient. Use the disposable N-95 respirator mask, cannulation (CVC) (IA) [8]
which fits tightly around the nose and mouth to  If the catheter is inserted in a lower extremity

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site, replace to an upper extremity site as soon as frequently (every 72 h) (2A)

possible (2A)  Replace disposable or reusable transducers at 96-h
 Use maximal sterile barrier precautions (cap, mask, intervals (2A).
sterile gown and sterile gloves) and a sterile full-body
drape while inserting CVCs, peripherally inserted Strategies to reduce UTI
central catheters, or guidewire exchange (IA)  Insert catheters only for appropriate indications (2A)
[9]
 Clean skin with more than 0.5% chlorhexidine
preparation with alcohol (usually 2% chlorhexidine  Follow aseptic insertion of the urinary catheter (IB)
with 70% w/v ethanol) before CVC, arterial catheter  Maintain a closed drainage system (IB)
insertion, etc., (IA)  Maintain unobstructed urine flow. At all times the
 Use chlorhexidine/silver sulfadiazine or urinary catheter should be placed and taped above
minocycline/rifampin-impregnated CVCs when the the thigh and the urinary bag should hang below the
catheter is expected to remain in place for more than level of the bladder (2B)
5 days and only if the bloodstream infection rates are  The urinary bag should never have floor contact (2B)
high in the unit despite successful implementation  Changing indwelling catheters or drainage bags at
of measures to reduce CRBSI (2A) fixed intervals is not recommended. Change only
 Use ultrasound-guided insertion if technology and if there are clinical indications such as infection
expertise are available (IB) or obstruction, or when the closed system is
 Use either sterile gauze or sterile, transparent, compromised (2B)
semipermeable dressing to cover the catheter site (IA).  Remove the catheter when it is no longer needed (2A).
Replace the catheter site dressing only when the
dressing becomes damp, loosened, or visibly soiled Consider environmental factors
Cleaning and disinfection
 Evaluate the catheter insertion site daily and check if
 High-quality cleaning and disinfection of all
a transparent dressing is present and palpate through
patient-care areas is important, especially surfaces
the dressing for any tenderness (1B)
close to the patient (e.g. bedrails, bedside tables,
 Insertion date should be put on all vascular access
doorknobs and equipment) [10]
devices (2B)
 Some pathogens can survive for long periods in
 Use 2% chlorhexidine wash daily for skin cleansing
the environment, particularly methicillin-resistant
to reduce CRBSI (2B)
Sataphylococcus aureus (MRSA), vancomycin-resistant
 Use needleless intravascular catheter access
Enterococcus (VRE), Acinetobacter species, Clostridium
systems (2B) and avoid stopcocks. Closed catheter
difficile and norovirus
access systems should be preferred to open
 EPA-registered disinfectants or detergents that best
systems (2A)
meet the overall needs of the ICU should be used for
 Clean injection ports with an appropriate routine cleaning and disinfection
antiseptic (chlorhexidine, povidone-iodine, an  Frequency of cleaning should be as follows: Surface
iodophor, or 70% alcohol), accessing the port only with cleaning (walls) twice weekly, floor cleaning
sterile devices. Cap stopcocks when not in use (2A) 2-3 times/day and terminal cleaning (patient bed
 Assess the need for the intravascular catheter daily area) after discharge or death (2B).
and remove when not required (IA)
 Peripheral lines should not be replaced more Architecture and layout, especially while designing
frequently than 72-96 h. Routine replacement of a new ICU
CVCs is not required (2A)  The unit may be situated close to the operating
 Replace administration sets, including secondary sets theater and emergency department for easy
and add-on devices, every day in patients receiving accessibility, but should be away from the main ward
blood, blood products, or fat emulsions (2A) areas (2B) [11]
 If other intravenous fluids are used, change no <96-h  Central air-conditioning systems are designed in
intervals and at least every 7 days (IA) such a way that recirculated air must pass through
 Needleless connectors should be changed appropriate filters (1B)[11]
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 It is recommended that all air should be filtered to infection acquired by burn patients is a frequent cause
99% efficiency down to 5 m (1A) [11] of morbidity and mortality.
 Suitable and safe air quality must be maintained at
all times. Air movement should always be from clean Epidemiology of infection
to dirty areas (1A) [11] The development of infection depends on the presence
 It is recommended to have a minimum of six total of three conditions, a source of organisms; a mode of
transmission; and the susceptibility of the patient.
air changes per room per hour, with two air changes
per hour composed of outside air (1B) [11]
Source of organisms
 Isolation facility should be with both negative- and
Sources of organisms are found in the patient’s
positive-pressure ventilations (2B) [11] own endogenous (normal) flora, from exogenous
 Clearly demarcated routes of traffic flow through the sources in the environment and from health care
ICU are required (2B) [11] personnel. Although burn wound surfaces are sterile
 Adequate space around beds is ideally 2.5-3 m (2B) immediately following thermal injury, these wounds
 Electricity, air, vacuum outlets/connections should eventually become colonized with microorganisms.[12]
not hamper access around the bed (2B) [11] Gram-positive bacteria that survive the thermal insult,
 Adequate number of washbasins should be such as staphylococci located deep within sweat
glands and hair follicles, heavily colonize the wound
installed (2B) [11]
surface within the first 48 h unless topical antimicrobial
 Alcohol gel dispensers are required at the
agents are used. [13] Eventually (after an average of
ICU entry, exits, every bed space and every 5-7 days), these wounds are subsequently colonized
workstation (1B) [11] with other microbes, including Gram-positive bacteria,
 There should be separate medication preparation Gram-negative bacteria and yeasts derived from the
area (1B) [11] host’s normal gastrointestinal and upper respiratory
 There should be separate areas for clean storage and flora and/or from the hospital environment or that are
soiled and waste storage and disposal (1B) [11] transferred via a HCW hands.[12,14]
 Adequate toilet facilities should be provided (1B) [11]
Mode of transmission
Organizational and administrative measures[4,11] In burn patients, the primary mode is direct or indirect
contact-either through the hands of the personnel caring
 Work with hospital administration for better patient
for the patient or from contact with inappropriately
to nurse ratio in the ICU (1B) [4,11] decontaminated equipment.[15] Burn patients are unique
 Policies for controlling traffic flow to and from the in their susceptibility to colonization from organisms in
unit to reduce sources of contamination from visitors, the environment as well as in their propensity to disperse
staff and equipment (1B) organisms into the surrounding environment. In general,
 Waste and sharp disposal policy (1A) the larger the burn injury, the greater the volume of
 Education and training for ICU staff about prevention organisms that will be dispersed into the environment
of nosocomial infections (1A) from the patient.
 ICU protocols for prevention of nosocomial  Hydrotherapy equipment is an important
infections (1A) environmental reservoir of Gram-negative
 Audit and surveillance of infections and infection organisms (2A).
control practices (IB)
 I n f e c t i o n c o n t r o l t e a m ( m u l t i d i s c i p l i n a r y Patient susceptibility
approach) (1B) The patient has three principal defense against
infection: Physical defenses, nonspecific immune
 Antibiotic stewardship (1B)
responses and specific immune responses. Changes in
 Vaccination of health care personnel (1A). these defenses determine the patient’s susceptibility to
infection. Invasive devices, such as endotracheal tubes,
Guidelines for Infection Prevention in Burns intravascular catheters and urinary catheters, bypass the
Patients body’s normal defense mechanisms.[16,17]
Burn wounds can provide optimal conditions for
colonization, infection and transmission of pathogens; Culturing and surveillance

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Burn wound flora and antibiotic susceptibility patterns  Routine environmental surveillance culturing is
change during the course of the patient’s hospitalization not generally recommended on units with burn
so that the purposes of obtaining routine surveillance patients[22] (2A).
cultures are:
 To provide early identification of organisms
Antibiotic prophylaxis
colonizing the wound
 Several studies have demonstrated the role of topical
 To monitor the effectiveness of current wound
antimicrobials in decreasing morbidity and mortality
treatment in patients with major burn injuries (partial-or
 To guide perioperative or empiric antibiotic therapy full-thickness skin involvement), particularly before
 To detect any cross-colonizations, which occur early excision[23] (1B)
quickly so that further transmission can be prevented Topical antibiotic agents should first be applied
 Routine surveillance wound cultures should be directly to the patient’s dressings before application
obtained when the patient is admitted and at least to the burn wound to prevent contamination of the
weekly until the wound is closed. Surveillance of agent’s container by burn wound flora
infection has been shown to diminish the rate of  Studies of the clinical benefit of prophylactic courses
nosocomial infection (2A).[18] of systemic antibiotics in burn patients in decreasing
the occurrence of burn wound infections have not
Isolation guidelines demonstrated improved outcome compared to the
 Standard precautions should be followed when use of topical therapy along with surgical excision
caring for all patients with burn injury. The  Systemic antibiotic administration in burn patients
effectiveness of simple protective barrier precautions should therefore only be used selectively and for a short
reduces nosocomial colonization and infection (1A)[19] period of time. Due to the secondary bacteremia, burn
 It is recommended that patients with larger burn injuries wound manipulation and/or excision, prophylactic
be isolated in private rooms or other enclosed bed systemic antibiotic therapy may be given immediately
spaces to ensure physical separation from other patients before, during and for one or two doses after the
on the unit. Such isolation has been associated with a procedure, particularly in burn patients with extensive
decrease in cross transmission of organisms (IB).[20,21] injury (e.g. 40% TBSA) (2A).[24,25]
Early burn wound excision now occurs within the
Patients with >30% TBSA burn injuries are more first few days after burn injury and has resulted
immunocompromised, due to the larger size of their in improved survival. The primary aims of early
injury. This, in combination with their loss of physical excision are removal of the dead tissue that
defenses and need for invasive devices, significantly stimulates an overwhelming systemic inflammatory
increases their risk of infection. These patients also response syndrome and prevention of infection
represent a significant risk for contamination of their by temporary or permanent closure of the burn
surrounding environment with organisms, which may wound. [25] Furthermore, shortening the period
then be spread to other patients on the unit. of wound inflammation, which in turn reduces
the development of hypertrophic scarring, may
Environmental issues optimize the outcome in terms of function and
 Plants and flowers should not be allowed in units with appearance.[25] This is achieved by early removal of
necrotic tissue (e.g. eschar) and wound closure with
burn patients because they harbor Gram-negative
autograft, allograft, or skin substitutes in selected
organisms, such as Pseudomonas species, other enteric patients.
Gram-negative organisms and fungi. Many of these
organisms are intrinsically resistant to multiple Early nutrition
antibiotics, which may serve as reservoirs to colonize  Early enteral feeding diminished the incidence of
the burn wound[22] (2A) wound colonization and infection by bowel flora and
 Routine cleaning, disposal of waste and gathering sepsis (IB).[26]
of soiled linen is required to reduce the bioload of Early enteral feeding is likely effective because it
organisms, which are present and ensure that the increases circulation to the bowel, thereby decreasing
unit is as clean as possible[22] (2A) ischemia post-injury and the translocation of bowel flora.

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Prevention of tetanus allogeneic HSCT patients and those who have received
 Burn centers routinely administer human tetanus the most intensive chemotherapy (e.g. childhood acute
immunoglobulin (250-500 IU) to provide immediate myelogenous leukemia patients).[30]
passive immunization regardless of the patient’s active
In general, opportunistic infections result from at least
immunization status. Active immunization with
1 of 3 basic mechanisms: (1) Exogenous acquisition of
tetanus toxoid is also given (0.5 ml intramuscularly)
a particularly virulent pathogen (e.g. meningococcal
to burn patients who have not received a complete meningitis or pneumococcal pneumonia), (2) reactivation
primary immunizing series or who have not of an endogenous latent organism (e.g. herpes simplex
received a tetanus toxoid booster within the past virus, herpes zoster virus [HZV or shingles], or
10 years[27] (2A). tuberculosis and (3) endogenous invasion of a normally
commensal or saprophytic organism (e.g. bacteria,
Bloodstream and intravascular catheter infection viruses, fungi, or protozoa/parasites).
 Whenever possible, catheters should be placed
The post-transplant timetable can be divided into three
through unburned skin, preferably at a sufficient
time periods:[31]
distance from the wound to prevent contamination
• During the 1st month after transplantation: >95% of the
of the insertion site. This is not always feasible in
infections are due to bacterial or candida infection of
patients with large burn injuries, requiring long-term
the surgical wound, vascular access, endotracheal tube,
vascular access[28] (2B).
or drainage catheters. These infections are comparable
to those observed in non-immunosuppressed patients
Pneumonia
undergoing similar surgery
Burn patients with severe inhalation injury requiring
prolonged intubation are also at risk for developing VAP. • During the period 1-6 months after transplantation:
 Prevention should also include vigorous chest Two classes of infection are observed: Infections
physiotherapy, turning, coughing, deep breathing caused by immunomodulatory viruses and
and suctioning[29] (2B). infections caused by opportunistic pathogens such
as Pneumocystis carinii, Listeria monocytogenes and
UTI Aspergillus species
 Patients usually develop significant bacteriuria after • In the late period: >6 months after transplantation,
72 h of urinary catheter insertion, so these devices the patient population can be divided into three
should be removed after the initial period of fluid subgroups: more than two-thirds of transplant
resuscitation and output monitoring[15] (2B). patients have had a good result from transplantation
and are primarily at risk from community-acquired
Guidelines for Infection Control in the respiratory viruses. On an average 10-15% of
Special Subsets - Immunocompromised and transplant patients suffer from chronic viral infection,
Transplant Patients such as infection with hepatitis B or C virus, which
Immunocompromised patients are those patients progresses inexorably to end-stage organ dysfunction
whose immune mechanisms are deficient because of and/or cancer unless effective antiviral therapy
immunologic disorders (e.g. human immunodeficiency can be administered. Finally, 5-10% are who have
virus (HIV) infection or congenital immune relatively poor allograft function and who have
deficiency syndrome), chronic diseases (e.g. diabetes, received excessive amounts of immunosuppression.
cancer, emphysema, or cardiac failure), or These patients are the subgroup at greatest risk
immunosuppressive therapy (e.g. radiation, cytotoxic of opportunistic infection, particularly with such
chemotherapy anti-rejection medication, or steroids). organisms as Cryptococcus neoformans, P. carinii and
Immunocompromised patients who are identified as
L. monocytogenes.
high-risk patients have the greatest risk of infection
caused by airborne or waterborne microorganisms.
Patients in this subset include persons who are severely Hand hygiene
neutropenic for prolonged periods of time (i.e. an  The most important intervention is hand hygiene.
absolute neutrophil count (ANC) of <500 cells/mL), When hands are visibly dirty, contaminated with

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proteinaceous material, or visibly soiled with  Exhaust vents, window sills and all horizontal
blood or body fluids, wash hands with either a surfaces should be cleaned with cloths and mop heads
non-antimicrobial soap and water or an antimicrobial that have been premoistened with disinfectant (2B).
soap and water[32] (IA)  Prohibit exposures of patients to such activities
 If hands are not visibly soiled, or after removing as vacuuming or other floor or carpet vacuuming
visible material with non-antimicrobial soap and that could cause aerosolization of fungal
water, the preferred method of hand decontamination spores (e.g. Aspergillus species) (1B)
is with an alcohol-based hand rub[32-35] (1B).  Moisture problems (i.e. rainwater or plumbing leaks)
should be promptly reported and repaired (1B)
Isolation  Organic materials that become moist must be
 Simple protective isolation offered no advantage dried or removed within 24-48 h to prevent fungal
over routine care for most immunocompromised growth (1B).
patients (2B)  Medical devices and other equipment should be
 Immunocompromised individuals should never be decontaminated according to existing guidance (2B).
placed in the same room or adjacent to people with The role of cleaning and decontamination should
a known infection (1A) not be underestimated. At times of local epidemics
 Isolation of potentially contagious patients within or outbreaks, the closure of part of or the whole unit
the ICU should be attempted if practical to reduce should be considered to allow thorough cleaning.
the chances of cross infection. Although isolation Hydrogen peroxide vapor decontamination has been
is recommended for control of airborne spread shown to be superior to conventional cleaning but
of pathogens, cross-colonization with organisms can only be used in enclosed rooms as it is toxic to
predominantly spread by contact (such as MRSA), humans. Interestingly, MRSA may not be completely
infection may only be reduced by changing behavior cleared with a conventional solution containing
of staff. In the absence of adequate isolation rooms, 5-15% non-ionic surfactant and 5-15% cationic
barrier precautions with gloves and gown combined surfactant, diluted 1:500.[11]
with good hand hygiene is paramount[36] (1B).
Guidelines exist for floor space in ICUs (ESICM and
SCCM references). The transmission of micro-organisms
Room ventilation will occur more readily in cramped conditions. There
 Patient should be placed in rooms with >12 air are recommendations for the number of isolation
exchanges/h and point-of-use HEPA filters that cubicles that should be available for patients with
are capable of removing particles >0.3 m in resistant organisms and for immunocompromised
diameter (2A) patients.[37,38]
 Inspection and preventive maintenance of duct and
filter systems should occur on a routine, scheduled Protective clothing
basis (2A)  P
 rotective clothing must, as a minimum, be used to
 Patient room should have positive room air pressure prevent contact with bodily fluids or other sources
when compared with any adjoining hallways, toilets of contamination and when in contact with broken
and anterooms, if present (2A) skin or mucous membranes. Any protective clothing
 The use of single rooms with HEPA filtration may should be removed promptly when no longer
reduce the risk of hospital-acquired infection by required and disposed of as clinical waste[3,39] (1B).
airborne fungi, in particular the Aspergillus genus.
This is especially true where refurbishment, building Food and drink
or demolition are in progress in the hospital or  Hospital food is normally very safe. However, the
nearby[37] (IA). immunocompromised patient is at increased risk
of food-borne illness and the acquisition of harmful
Cleaning micro-organisms from some food and drink.
 Rooms should be cleaned >1 times/day with special Therefore immunocompromised individuals are
attention to dust control (1A) advised to avoid certain high-risk foods, for example

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Table 1: Monitoring of Infection Control Monitoring of Infection Control

Areas of infection control Parameters What should be monitored? Monitoring includes various
Incidence of nosocomial VAP, CRBSI, UTI, SSI, etc. aspects of infection control practices [Table 1]. Simultaneous
infections monitoring of all the aspects might not be possible
Morbidities with potential Incidence of needle stick injury, occupational
to cause infection exposure to blood and body fluids therefore prioritization must be done by the infection
Organism prevalence and Antibiogram monitoring for different areas control team depending upon the need and situation.
antibiotic sensitivity pattern of hospital Monitoring of process compliance is most important to
Process compliance Hand washing, personal hygiene, waste
disposal, personal protective equipment reduce incidence of HAI, preventing multidrug resistance
use, reprocessing of reusable equipment to antimicrobials and protecting HCWs from getting
and instrument, environmental cleaning and infection. Methodology of monitoring should be adopted as
spills management, isolation, linen, laundry
and food services, blood and blood product per the institutional policy.[45-47] Environmental monitoring
transfusion and handling, care bundles, along with microbiological surveillance has been claimed
handling of therapeutic devices, antibiotic to reduce infection rate. Adherence to hand hygiene is
protocol, specimen collection etc.
Infrastructure Design and maintenance of health care being considered as one of the most important preventive
premises including hospital mortuaries, action.[47] Observed adherence to hand hygiene protocol
air-conditioning, ventilation, temperature ranges from 5% to 89% (38.7%) among the HCWs.
and water system monitoring. Monitoring of
construction and demolition work
Outbreak Surveillance and monitoring of outbreak Process related recommendations
Training Periodic evaluation of knowledge and skill
level, provision of training material • Hand washing: This is the single most effective
Protection of health care Monitoring of physical protection with hygiene practice for minimizing health care associated
worker equipment, immunization, health screening
etc. infections. HCWs must wash their hands before
Economic impact Monitoring of financial gain because of and after every significant patient contact. Hand
reduced HAI
basins with hot and cold water supplies, non-touch
VAP: Ventilator associated pneumonia; CRBSI: Catheter related blood stream
infection; UTI: Urinary tract infection; SSI: Surgical site infection; HAI: Hospital taps with antisplash devices, supplies of liquid
acquired infections
handwash (preferably in non-refillable disposable
soft cheeses and foods made with raw egg, such as containers) and disposable paper towels or single-use,
mayonnaise[3,39] (1B) clean, cloth towels are recommended to facilitate hand
 All drinking water for immunocompromised hygiene. CDC guidelines[48] and the WHO guidelines[4]
recommend that HCWs wash their hands with soap
patients (including bottled water) should be
and water when visibly soiled and exposure to potential
chemically sterilized or boiled (1B)
spore-forming pathogens is strongly suspected
 V i s i t o r s w h o m i g h t h a v e c o m m u n i c a b l e
or proven, including outbreaks of C. difficile (1B).
infectious diseases (e.g. upper respiratory tract Otherwise, hand rubbing with an alcohol based agent
infections (URTIs), flu-like illnesses, recent exposure is recommended (1A) for all other opportunities as it is
to communicable diseases, an active shingles rash faster, more effective and better tolerated by the skin.
whether covered or not, a VZV-like rash within Exposure of hands to body fluid in presence of intact
6 weeks of receiving a live-attenuated VZV vaccine, skin deserves decontamination (recommendation
or a history of receiving an oral polio vaccine within level 1B) but it is particularly vital when skin is
not intact or mucous membrane has been
the previous 3-6 weeks) should not be allowed to
exposed (recommendation level 1A).[5] Compliance
visit immunocompromised patients[40,41] (1B)
monitoring for hand hygiene among HCWs therefore
 Vaccination in Immunocompromised patients had been given a higher recommendation level (1A).[4,48,49]
should be done in accordance with the published • Recommendations for use of gloves:[50]
guidelines.[42,43] • Sterile gloves – for procedures requiring a sterile
field, involving normally sterile areas of the body
Pharmacological prophylaxis against diseases in • Non-sterile gloves – for procedures other than
transplant patients may be done as per recommendations the above
in the references mentioned.[40,43,44] • General purpose utility gloves – for housekeeping

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and cleaning 6. Compliance monitoring of care bundles should be

• Use of gloves had been advocated when it can done in a very stringent manner. Non-compliance to
be reasonably anticipated that contact of blood a single measure should be interpreted as failure to
or other potentially infectious materials with, comply with the whole bundle. Therefore, a higher
mucous membranes, or non-intact skin will target of > 95% compliance had been advocated[47]
occur (IC).[4] 7. Training: Effectiveness of staff education on
HAI prevention is controversial but as a part
• Recommendations for changing gloves:[50]
of comprehensive infection control program
• After contact with each patient and when
it’s value had been appreciated. [53] Designated
performing separate procedures on the same
infection control personnel can help in imparting
patient if cross-contamination is possible
prescheduled training, maintaining record,
• as soon as gloves are damaged (torn or punctured);
monitoring the knowledge base and bed side
• After completion of any task not involving
patients but requiring the use of gloves application of the knowledge. [54] Ongoing staff
• Before answering telephones or recording patient education is also a regulatory need.[53] Education
notes of HCW and periodic assessment of adherence
• Remove gloves after caring for a patient. Do not to insertion and maintenance of intravascular
wear the same pair of gloves for the care of more catheters protocol had been given higher level of
than one patient (IB).[4] recommendation (Category IA).[55] New employee
orientation to infection control program and
• Recommendations for eyewear or face-shields: making the employees responsible for infection
During procedures where there is potential for prevention had been recommended by Joint
splashing, splattering or spraying of blood or other Commission on Accreditation of Healthcare
body substances[50] Organizations (JCAHOs)[53]
• Waste disposal and spillage: Disposal protocol should 8. To prevent airborne transmission negative pressure
be followed differently for general waste (concern single rooms (1/100 beds) with anterooms and
is not more than household waste), cytotoxic fresh air at 100% (that is, no recirculating air) is
waste, pharmaceutical waste, chemical waste and recommended to achieve most effective dilution of
radioactive waste. For blood spillage in ward or airborne microorganisms[50]
operation theater, cleaning should be done at the 9. Periodic safety and operational inspection should
earliest with paper towels followed by water and be done by engineering and building services
detergents. Sodium hypochlorite is not necessary department
for such cleaning. Laboratory spillage should be 10. Mortuary guidelines:[50]
absorbed on to paper towels and disposed of as • Body storage at an internal temperature of 4°C
clinical waste. The contaminated surfaces should • Longer-term storage in a freezer maintained
be treated with 2.0-2.5% sodium hypochlorite, left at −20°C
for 1 h and cleaned again with paper towels that • Mortuary must not be used except storage of
are disposed of as clinical waste. In suspected bodies
creutzfeldt–jackob disease spillage of brain tissue or • All refrigerators/freezers should be monitored
spinal fluid is treated in the similar manner but the and fitted with alarms that operate 24 h a day
paper towels are incinerated.[50] It has been observed • Mortuary design should minimize manual
that HBV and HCV in dry blood remain infectious handling of bodies
even when exposed to external environment for • Where autopsies are performed, dedicated
up to a week and 16 h respectively. Implications room(s) should be used with negative air pressure
remain the same even if blood is invisible or not
ventilation.
present in sufficient quantity.[51] Considering this
glucometers should be cleaned and disinfected as Who should monitor: Designated infection control
per CDC recommendation after every use to avoid nurses should supervise the process and help in collection
contamination[11,52] and compilation of data. However, for case controlled

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study of an outbreak, the primary investigating team Automated monitoring

should include the hospital epidemiologist, the director Automated monitoring helps in avoiding errors
of employee health, the infection-control team and and variability related to manual collection of data.
microbiologist. External consultants might be necessary Hospitals with sophisticated information systems are
in some cases.[54] in a position to streamline surveillance process through
computer-based algorithms that identifies patients at
How to monitor: Following methods had been highest risk of HAI.[54] Computerized surveillance helps in
advocated for monitoring HAI data.[56] better implementation of preventive strategies, but lower
 Observations infection rates had not been proven conclusively.[62,63] The
use of sinks and hand rub dispensers had also been used
 Interviews
for electronic monitoring of hand hygiene practice.[4,57]
 Surveys and inspections
 Quality assurance activities.
Endemic rate of infection
Surveillance of endemic infection is the focal point of
Observation infection control activity. It helps in generating a data
Direct observation is the gold standard to monitor base and identifying epidemic when incidence crosses
compliance with optimal hand hygiene practice. Monthly the endemic threshold.[47] The first aim of surveillance is
monitoring of hand hygiene product consumption (Soap, to determine endemic rate of infection.[54] The base line
alcohol rub) had also been advocated as an indirect measure data of HAI helps in taking improvement initiatives. It
of hand hygiene but this needs further validation. Number has been claimed that infection rate can be reduced by
of dispenser filled with alcohol rub and number of dispenser 31-44% with the implementation of effective surveillance
working when compared to total number of dispensers system.[18,64]
available are also simple monitoring parameters.[57]
Outbreak investigation
Predesigned format for survey, inspection and Investigation for outbreak should be considered when
interview monthly incidence of a particular type of infection is more
Data collection and compliance monitoring are than 95% of the confidence interval of same infection in the
facilitated if a format is available for doing so.[58] For full, same month in the previous year.[54] Analysis of all isolates,
partial and minimal compliance >85%, 76-84% and <75% patients’ demographic data and exposure to potential risk
respective scores had been suggested.[59] factors (medication, procedure and contact) are necessary
for such investigation. This should be followed by analysis
of time interval between infection and exposure to potential
Surveillance
risk factors. Based on the generated data, case controlled
Surveillance is defined as ‘‘ongoing, systematic
study is recommended according to age, gender and
collection, analysis and interpretation of health data
exposure to potential risk factors. This exercise helps in
essential to the planning, implementation and evaluation
developing a hypothesis regarding source and transmission
of public health care practice. It is closely integrated with
of infection. Temporary infection control measures are
timely dissemination of these data to those who need to implemented based on the hypothesis formed. Molecular
know.’’[58,60] typing is advocated if such facilities are available.[54]

Periodicity of data collection Coding of clinical indicators, trend analysis and bench
Frequency of data collection, analysis and generation marking
of report for evaluation and taking corrective measures Use of ICD-10-AM codes for clinical indicators of
should also be predefined.[54] If data is being collected infection control is desirable as it helps in data collating
intermittently then, it should be done at least for and benchmarking between health care institutions.
four continuous weeks in each time period under However, all indicators do not have their ICD code.[58]
study.[58] Authenticity of data remains a matter of concern Interhospital comparison of HAI demands standardization
therefore source of data should always be mentioned of definitions, data collection and analysis.[65] Therefore
and its must be verified before relying on the same for comparison of data might not be justified always due
decision making. Data can be presented as pooled mean, to differences in the infrastructure, quantitative and
median and percentile manner. Team should further qualitative gap in human resource, compliance level,
analyze and investigate extremely higher or lower rate variation in the practices and case mix. Such exercise is
or ratio (>90th percentile, ≤10th percentile).[61] further constrained because tools needed to compare

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infection rates for a given case mix is provided by very requirements can lead to significant reductions in
few systems.[65] Trend monitoring of unit’s own data over antimicrobial use (1B)
a period of time therefore is more appropriate.[66] • Formulary restriction may also help in decreasing
nosocomial outbreak of resistant infection (2B)
Organism prevalence, sensitivity pattern and • Formulary restriction and preauthorization from
antimicrobial use a logistic point of view may not be universally
Tracking of organism prevalence, sensitivity pattern
applicable in an “open” prescription writing
and antimicrobial use should be part of epidemiology
prevalent health care delivery system as is existing
program. Community acquired and HAI should be
separated while analyzing the data. [54] Active and in India (1C)
aggressive surveillance of all isolates and patients has • Continuing education of all the stakeholders should
been advocated on admission and weekly basis provided be done to provide a foundation of knowledge
higher risk for carrying MRSA and VRE is anticipated. that will enhance and increase the acceptance of
More frequent culture had been advised if >50% isolates stewardship strategies (1C)
are MRSA positive. [67] But this approach has been • Education alone without active intervention like
challenged.[68] audit and feedback do not have a sustained impact
on prescribing behavior of physicians (2B)
Recommendations for Antimicrobial
• Guidelines and clinical pathways based on evidence
Stewardship
and incorporating local microbiology and resistance
• Core members of a multidisciplinary antimicrobial pattern can improve antibiotic utilization (1A)
stewardship program should include an infectious • Antimicrobial cycling to decrease antibiotic resistance
disease physician and a clinical pharmacist with has not been found to be useful and is logistically
infectious disease training (1B) [69-73] difficult in Indian setting (2B)
• Other members of the team may include clinical • Antimicrobial order form has been given a weak
microbiologist, an information system specialist, recommendation (2B) in IDSA guidelines of North
an infection control professional and hospital America, but this may be a readily implementable,
epidemiologist (1C) documentable and a useful tool for stewardship
• In resource limited setting a physician (hospital based program in India (1C)
practitioner preferable) with interest in infectious • There are insufficient data to recommend the routine
disease should lead the program along with the use of combination therapy to prevent the emergence
hospital microbiologist (1C) of resistance (2B)
• Close collaboration between the antimicrobial • De-escalation of antibiotic once culture results are
stewardship team, microbiology lab, hospital back is an essential ingredient of any stewardship
pharmacy and infection control team should be program and should be practiced (1B)
maintained (1C) • De-escalation is poorly practiced in India and an audit
• Involvement of the administration with their buy of de-escalation practices and education on its proper
in to the program is essential for the success of any implementation should be an important ingredient of
stewardship program (1C) any antibiotic stewardship program in India (1C)
• It is desirable that antimicrobial stewardship • Optimizing antibiotic dose taking into consideration
programs function under the auspices of quality pk/pd characteristic should be universally
assurance and patient safety department (1C) practiced (1B)
• Prospective audit of antimicrobial use with direct • As under dosing may be prevalent in resource limited
interaction and feedback to the prescriber by senior setting a close vigilance on the appropriate dosing
members of antimicrobial stewardship team can and a hospital information system and warning
result in reduced inappropriate use of antibiotics (1A) mechanism should be incorporated (1C)
• This is the preferable mode of antimicrobial • An early switch from parenteral to oral antibiotics is
stewardship in an “open” prescription writing setting highly desirable specially in resource limited setting
as prevalent in India (1C) to decrease cost of therapy and should be actively
• Formulary restriction and preauthorization implemented (1C)

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• Decreasing duration of antibiotic use as per clinical 16. Goldmann DA, Pier GB. Pathogenesis of infections related to
intravascular catheterization. Clin Microbiol Rev 1993;6:176-92.
guideline to decrease the cost of therapy, antibiotic 17. Becker WK, Cioffi WG Jr, McManus AT, Kim SH, McManus WF,
consumption and reduce side effects of drugs should Mason AD, et al. Fungal burn wound infection. A 10-year experience.
Arch Surg 1991;126:44-8.
be actively incorporated in the antibiotic stewardship 18. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP,
program (1C) et al. The efficacy of infection surveillance and control programs in
preventing nosocomial infections in US hospitals. Am J Epidemiol
• Active use of information technologies such as
1985;121:182-205.
electronic medical record, hospital information 19. Klein BS, Perloff WH, Maki DG. Reduction of nosocomial infection
system, computerized physician order entry and during pediatric intensive care by protective isolation. N Engl J Med
1989;320:1714-21.
clinical decision support facilitates delivery of the 20. Burke JF, Quinby WC, Bondoc CC, Sheehy EM, Moreno HC. The
stewardship program more effectively (1B) contribution of a bacterially isolated environment to the prevention of
infection in seriously burned patients. Ann Surg 1977;186:377-87.
• In resource limited setting an effort should be made 21. McManus AT, McManus WF, Mason AD Jr, Aitcheson AR, Pruitt BA Jr.
customizing use of existing information technology Microbial colonization in a new intensive care burn unit. A prospective
cohort study. Arch Surg 1985;120:217-23.
and using indigenous innovation to utilize the 22. Kates SG, McGinley KJ, Larson EL, Leyden JJ. Indigenous
existing resources to achieve similar objective (1C) multiresistant bacteria from flowers in hospital and nonhospital
environments. Am J Infect Control 1991;19:156-61.
• Optimal use of microbiology lab is an essential 23. Monafo WW, West MA. Current treatment recommendations for topical
ingredient of any stewardship program (1C). burn therapy. Drugs 1990;40:364-73.
24. Mozingo DW, McManus AT, Kim SH, Pruitt BA Jr. Incidence of
bacteremia after burn wound manipulation in the early postburn period.
References J Trauma 1997;42:1006-10.
25. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound
1. Plowman R; Graves N; Griffin M; Roberts JA; Swan AV; Cookson B;
infections. Clin Microbiol Rev 2006;19:403-34.
Taylor L. The socioeconomic burden of hospital acquired infection.
26. Hart DW, Wolf SE, Chinkes DL, Beauford RB, Mlcak RP, Heggers JP,
London Public health laboratory service and the London school of
et al. Effects of early excision and aggressive enteral feeding on
hygiene and tropical Medicine, 1999.
hypermetabolism, catabolism, and sepsis after severe burn. J Trauma
2. Wenzel RP. The Lowbury Lecture. The economics of nosocomial
2003;54:755-61.
infections. J Hosp Infect 1995;31:79-87.
27. Edlich RF, Hill LG, Mahler CA, Cox MJ, Becker DG, Horowitz JH,
3. Guideline for isolation precautions: Preventing transmission of
et al. Management and prevention of tetanus. J Long Term Eff Med
infectious agents in healthcare settings. Available from: http://www.
Implants 2003;13:139-54.
cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf. March 10, 2014
28. Lesseva M. Central venous catheter-related bacteraemia in burn
4. WHO guidelines on hand hygiene in health care: A summary. patients. Scand J Infect Dis 1998;30:585-9.
Available from: http://www.whqlibdoc.who.int/hq/2009/WHO_IER_ 29. Sheridan RL, Kacmarek RM, McEttrick MM, Weber JM, Ryan CM,
PSP_2009.07_eng.pdf. March 10, 2014 Doody DP, et al. Permissive hypercapnia as a ventilatory strategy in
5. Maselli DJ, Restrepo MI. Strategies in the prevention of burned children: Effect on barotrauma, pneumonia, and mortality.
ventilator-associated pneumonia. Ther Adv Respir Dis 2011;5:131-41. J Trauma 1995;39:854-9.
6. Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, 30. Linden PK. Approach to the immunocompromised host with infection
Anderson DJ, et al. Strategies to prevent ventilator-associated in the intensive care unit. Infect Dis Clin North Am 2009;23:535-56.
pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 31. Fishman JA, Issa NC. Infection in organ transplantation: Risk
2008;29 Suppl 1:S31-40. factors and evolving patterns of infection. Infect Dis Clin North Am
7. Lorente L, Blot S, Rello J. Evidence on measures for the prevention 2010;24:273-83.
of ventilator-associated pneumonia. Eur Respir J 2007;30:1193-207. 32. Dykewicz DA, Jaffe H, Spira T, et al. Guidelines for preventing
8. Guidelines for the prevention of intravascular catheter-related opportunistic infections among hematopoietic stem cell transplant
infections. Available from http://www.cdc.gov/hicpac/pdf/guidelines/ recipients: recommendations of CDC, the Infectious Disease
bsi-guidelines-2011.pdf Society of America, and the American Society of Blood and Marrow
9. Guidelines for prevention of catheter-associated urinary tract Transplantation. MMWR Morb Mortal Wkly Rep 2000;49:1-128. Last
infections. Available from http://www.cdc.gov/hicpac/pdf/CAUTI/ accessed date March 10, 2014
CAUTIguideline2009final.pdf. 33. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory
10. Circulation for disinfection and sterilization in healthcare facilities, Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force .
2008. Available from: http://www.cdc.gov/hicpac/pdf/guidelines/ Guideline for Hand Hygiene in Health-Care Settings. Recommendations
Disinfection_Nov_2008.pdf. of the Healthcare Infection Control Practices Advisory Committee and
11. Guidelines for environmental infection control in health care facilities. the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for
Available from: http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_ Healthcare Epidemiology of America/Association for Professionals in
HCF_03.pdf. Infection Control/Infectious Diseases Society of America. Available at
12. Wysocki AB. Evaluating and managing open skin wounds: Colonization http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf Last accessed date March
versus infection. AACN Clin Issues 2002;13:382-97. 10, 2014
13. Erol S, Altoparlak U, Akcay MN, Celebi F, Parlak M. Changes of 34. Nishimura S, Kagehira M, Kono F, Nishimura M, Taenaka N.
microbial flora and wound colonization in burned patients. Burns Handwashing before entering the intensive care unit: What we learned
2004;30:357-61. from continuous video-camera surveillance. Am J Infect Control
14. LeVoyer T, Cioffi WG Jr, Pratt L, Shippee R, McManus WF, Mason 1999;27:367-9. Last accessed date March 10, 2014
AD Jr, et al. Alterations in intestinal permeability after thermal injury. 35. Pittet D. Hand hygiene: Improved standards and practice for hospital
Arch Surg 1992;127:26-9. care. Curr Opin Infect Dis 2003;16:327-35.
15. Wurtz R, Karajovic M, Dacumos E, Jovanovic B, Hanumadass M. 36. French GL, Otter JA, Shannon KP, Adams NM, Watling D,
Nosocomial infections in a burn intensive care unit. Burns Parks MJ. Tackling contamination of the hospital environment by
1995;21:181-4. methicillin-resistant Staphylococcus aureus (MRSA): A comparison

162
 Indian Journal of Critical Care Medicine March 2014 Vol 18 Issue 3

between conventional terminal cleaning and hydrogen peroxide vapour 5th ed. Philadelphia; Churchill Livingston .2009; 2988-2995.
decontamination. J Hosp Infect 2004;57:31-7. 55. Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP,
37. Guidelines for intensive care unit design. Guidelines/Practice Parameters et al. Clinical practice guidelines for the diagnosis and management of
Committee of the American College of Critical Care Medicine, Society intravascular catheter-related infection: 2009 Update by the Infectious
of Critical Care Medicine. Crit Care Med 1995;23:582-8. Diseases Society of America. Clin Infect Dis 2009;49:1-45.
38. Ferdinande P. Recommendations on minimal requirements for Intensive 56. Review of outcomes data analysis HLTIN403B-Implement
Care Departments. Members of the Task Force of the European Society and monitor infection control policies and procedures.
of Intensive Care Medicine. Intensive Care Med 1997;23:226-32. Available from: http://www.riskresponse.com. au/training/
39. Centers for Disease Control and Prevention, Infectious Disease Society units-of-competency/hlt07-health/hltin403b-imple
of America, American Society of Blood and Marrow Transplantation. ment-and-monitor-infection-control-policies-and -procedures.
Guidelines for preventing opportunistic infections among hematopoietic 57. Hargreaves, S. UK team adopts unique approach to hospital infection
stem cell transplant recipients. MMWR Recomm Rep 2000;49:1-125, control. The Lancet. 2008; 8(12): 747
CE1. 58. 58. Infection control program quality monitoring indicators. Vs 2.
40. Green M, Avery R, Preiksaitis J. Guidelines for the prevention and NSW Department of Health 2005. Available at www0.health.nsw.gov.
management of infectious complications of solid organ transplantation. au/pubs/2005/pdf/infection_ctrl_manual.pdf
Am J Transplant 2004;4 Suppl 10:10-7, 57-109, 160-3. 59. ICNA Audit Tools for Monitoring ICNA Audit Tools for Monitoring
41. Recommendations for preventing transmission of infections among Infection Control Guidelines within the Community Setting 2005 pp1-
chronic hemodialysis patients. MMWR Recomm Rep 2001;50:1-43. 48 . Department of Health U.K Available at : http://www.ips.uk.net/
42. Advisory Committee on Immunization Practices. Recommended icna/Admin/uploads/AuditTools2005.pdf
adult immunization schedule: United States, 2010. Ann Intern Med 60. Do AN, Ray BJ, Banerjee SN, Illian AF, Barnett BJ, Pham MH,
2010;152:36-9. et al. Bloodstream infection associated with needleless device use and
43. Centers for Disease Control and Prevention. Guidelines for Prevention the importance of infection-control practices in the home health care
and Treatment of Opportunistic Infections in HIV-Infected Adults and setting. J Infect Dis 1999;179:442-8.
Adolescents: Recommendations from CDC, the National Institutes of 61. Edwards JR, Peterson KD, Mu Y, Banerjee S, Allen-Bridson K,
Health, and the HIV Medicine Association of the Infectious Diseases Morrell G, et al. National Healthcare Safety Network (NHSN) report:
Society of America. [2009 Apr 10]. Data summary for 2006 through 2008, issued December 2009. Am J
44. UTIs in renal insufficiency, transplant recipients, diabetes mellitus and Infect Control 2009;37:783-805.
immunosuppression. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, 62. Boughton B. Computerized infection monitoring and rapid control
Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner measures benefit patients and hospitals. From Medscape Medical News.
F. Guidelines on urological infections. Arnhem, The Netherlands: Available from: http://www.medscape.com/viewarticle/725013.
European Association of Urology (EAU); 2009 Mar. p. 52-63. Available 63. Pittet D, Allegranzi B, Sax H, Bertinato L, Concia E, Cookson B, et al.
at : http://www.guideline.gov/content.aspx?id=14806 Considerations for a WHO European strategy on health-care-associated
45. Yokoe,DS, Mermel LA, Deverick AJ, Kathleen AM, Burstin H, David infection, surveillance, and control. Lancet Infect Dis 2005;5:242-50.
CP, et al. Executive Summary: A Compendium of Strategies to Prevent 64. Centers for Disease Control and Prevention (CDC). Monitoring
Healthcare‐Associated Infections in Acute Care Hospitals . Infection hospital-acquired infections to promote patient safety – United States,
Control and Hospital Epidemiology 2008;29:S12-S21 1990-1999. MMWR Morb Mortal Wkly Rep 2000;49:149-53.
46. Starling B. Postnote July 2005 Number 247 Infection control in 65. Coffin SE, Zaoutis TE. Infection control, hospital epidemiology, and
healthcare settings. Available from: http://www.parliament.uk/ patient safety. Infect Dis Clin North Am 2005;19:647-65.
parliamentary_offices/post/pubs2005.cfm. Last accessed date March 66. B. Ray, D. P. Samaddar, S. K. Todi, N. Ramakrishnan, George John, and
10, 2014 Suresh Ramasubban. Quality indicators for ICU: ISCCM guidelines for
47. Chastre J, Luyt CE. Ventilator-associated pneumonia. In: Mason RJ, ICUs in India. Indian J Crit Care Med. 2009 Oct-Dec; 13(4): 173–206.
Broaddus VC, Martin TR, et al., eds. Murray& Nadel's Textbook of 67. Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR,
Respiratory Medicine. 5th ed. Philadelphia, PA: Elsevier Saunders; Boyce JM, et al. SHEA guideline for preventing nosocomial
2010:chap 33. transmission of multidrug-resistant strains of Staphylococcus aureus
48. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care and Enterococcus. Infect Control Hosp Epidemiol 2003;24:362-86.
Settings: Recommendations of the Healthcare Infection Control 68. Lautenbach E. Expanding the universe of methicillin-resistant
Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA staphylococcus aureus prevention. Ann Intern Med 2008;148:474-6.
Hand Hygiene Task Force. Morbid Mortal Wkly Rep. 2002;51:1-45 69. Fi s h m a n N . A n t i m i c r o b i a l s t e w a r d s h i p . A m J M e d
49. Mody L, McNeil SA, Sun R, Bradley SE, Kauffman CA. Introduction 2006;119 6 Suppl 1:S53-61.
of a waterless alcohol-based hand rub in a long-term-care facility. Infect 70. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA,
Control Hosp Epidemiol 2003;24:165-71. Burke JP, et al. Infectious Diseases Society of America and the Society
50. Infection control guidelines for the prevention of transmission of for Healthcare Epidemiology of America guidelines for developing an
infectious diseases in the health care setting, 2008. Australian institutional program to enhance antimicrobial stewardship. Clin Infect
Government Department of Health and ageing. Available from: http:// Dis 2007;44:159-77.
www.health.gov.au/internet/main/./icg-guidelines-index.htm. Last 71. Drew RH. Antimicrobial stewardship programs: How to start and steer
accessed date March 10, 2014 a successful program. J Manag Care Pharm 2009;15:S18-23.
51. Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak 72. Shah RC, Shah P. Antimicrobial stewardship in institutions and office
investigations highlight the need for safe injection practices and basic practices. Indian J Pediatr 2008;75:815-20.
infection control. Clin Liver Dis 2010;14:137-51. Last accessed date 73. Raghunath D. Emerging antibiotic resistance in bacteria with special
March 10, 2014 reference to India. J Biosci 2008;33:593-603.
52. Centers for Disease Control and Prevention (CDC). Transmission of
hepatitis B virus among persons undergoing blood glucose monitoring
in long-term-care facilities – Mississippi, North Carolina, and Los
Angeles County, California, 2003-2004. MMWR Morb Mortal Wkly
Rep 2005;54:220-3. How to cite this article: Mehta Y, Gupta A, Todi S, Myatra SN, Samaddar DP, Patil
53. Mody L. Infection control issues in older adults. Clin Geriatr Med
V, Bhattacharya PK, Ramasubban S. Guidelines for prevention of hospital acquired
2007;23:499-514, vi.
infections. Indian J Crit Care Med 2014;18:149-63.
54. Edmond MB, Wenzel RP. Organization for infection control. In: Mandel
GL, Bennet JE, Dolin R. Principles and practice of infectious diseases. Source of Support: Nil, Conflict of Interest: None declared.

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