Introduction

This lesson explores the importance of why nurses need to know and understand factors that
contribute to the spread of infection and their role in preventing the spread of potentially harmful
microorganisms. Learning about and understanding the chain of infection and its various
components assist the nurse in identifying and preventing infections, especially health care–
associated infections (HAIs).

Comprehension of this lesson will enable you to:

 Describe factors contributing to the spread of infection.

Overview
The infectious process begins with the chain of infection, which has six components:

 Infectious agent
 Source of infection
 Portal of exit
 Mode of transmission
 Portal of entry
 Susceptible host

It is important to understand how each of these contributes to the millions of infections that occur
in the United States and worldwide every year.
Infectious Agent
Infectious agents are the first link in the chain of infection. Any infectious agent that causes
disease is referred to as a pathogen. Pathogens have varying degrees of ability to cause disease.
This property is called pathogenicity or virulence. For example, when influenza causes severe
illness in adults and children, it is often considered a virulent strain of influenza. Pathogens
include bacteria, viruses, fungi, and parasites.

Bacteria
Viruses
Fungi
Reservoir
Animate (insects, family) and inanimate (water, kitchen platform) sources of infection.

The second link of the chain of infection is the source of infection, also known as the reservoir.
This is where the infectious agent lives, receives nourishment, and multiplies. Reservoirs can be
human, animal, or inanimate objects such as surfaces, equipment, medications, air, food, or water
on which microorganisms can survive.

Reservoi Description
r
Human  People transmit pathogens when: 
o They have active infectious diseases
o They are infected, but are asymptomatic carriers
 Patients, health care personnel, family, or friends can serve as
reservoirs for infectious agents

Animal  Insects
 Birds
 Animals such as mice, rats, pigs, cows

Portal of Exit
Infectious agents require a means by which to leave the reservoir so they can travel to the next
host. These pathways out of the host are called portals of exit.

Portals of exit can occur from several sources:

 Respiratory tract: Sputum, Cough, Sneezing

 Gastrointestinal tract: Emesis, Stool
 Genitourinary tract: Genital secretions
 Open lesions on the skin: Blood, Wound drainage
 Urinary tract: Urine
Mode of Transmission
Once the infectious agent finds a portal of exit and leaves the host, it must find a way to travel
from the source (reservoir) to the next susceptible host. The transportation process is called the
mode of transmission and occurs by three different methods: contact, vehicle,
and vector transmission.

Contact Transmission

Contact transmission occurs by three different methods. Transmission-based

precautions are required for these patients.

 Direct contact is the physical transfer of microorganism (pathogens)

from between hosts. For example, between the infected individual
directly to a susceptible host through kissing, touching, sexual contact,
or fecal-oral contact. 
 Indirect contact is the transfer of microorganisms between hosts by
means of an inanimate object, called a fomite. For example, a fomite
can be a dressing, medical equipment or supplies, clothing, toys,
diapers, money, dishes, contaminated needles, or air.
o Airborne transmission occurs when air serves as the transmission
vehicle. Microorganisms are dispersed by air currents that travel
greater than one meter and are inhaled or deposited on the skin of
a susceptible host. Tuberculosis, measles, and chickenpox can be
transmitted through air conditioning and cooling systems,
 forceful coughing, and pathogens attached to dust particles,
sweeping, and by changing bed linens.
o Droplets are infectious agents transferred by small respiratory
beads (droplets) from infected host to susceptible host through
coughing, sneezing, laughing, or simply by exhaling. Influenza
and respiratory syncytial virus (RSV) are transmitted via droplets
(CDC, 2018).

 Waterborne/foodborne transmission occurs when water or food serve as

the transmission vehicle. Pathogens are transmitted to the susceptible
host when water is contaminated by untreated sewage or food is
contaminated with feces. Salmonella, hepatitis A, and Escherichia coli
are examples of pathogens that are transmitted by contaminated food
and/or water. Depending on the pathogen, standard precautions, or
standard plus other specific transmission precautions may be required
for these patients.

Vehicle Transmission
Vectors carry pathogens from one host to the next susceptible host. Standard
precautions are used for patients infected with pathogens transmitted by
vectors.

 Biological vectors participate in the pathogen’s life cycle and transmit

disease. These vectors can be animals or insects. For example, ticks
carry Lyme disease. Mosquitoes carry West Nile, malaria, yellow fever,
and viral encephalitis. Lice carry epidemic typhus. Each of these passes
the pathogens along to susceptible hosts when they bite the host.
 Mechanical vectors passively pass the pathogen from host to the next
susceptible host. They do not participate in the pathogen’s life cycle,
but are capable of passing the pathogen passively along. Examples
include the common housefly contaminating food causing dysentery
and intestinal worms, and cockroaches causing the foodborne disease
giardiasis through food contamination.

Portal of Entry
The infectious agent must gain entry into the new host for successful transmission. A portal of
entry is the means by which the infectious agent achieves entry to a susceptible host. Portals of
entry are similar to portals of exit, including the respiratory tract, gastrointestinal tract,
genitourinary tract, blood, and breaks in the skin or mucous membranes. Portals of entry are
usually the first colonized by infectious agents.

Susceptible Host
Once an infectious agent gains entry into a host, it does not mean the
pathogen will cause infection. Several factors must be present, including:
a susceptible host, an adequate dose of infectious agent to ensure it will
multiply, and adequate virulence of the infectious agent. When the host’s
biological defenses are inadequate, or the host has more than one risk
factor for infection, the potential for developing infection is increased.

A susceptible host is a person who is likely to contract the disease after

transmission of an infectious agent. Many factors, including age, nutritional
status, chronic diseases, and trauma can contribute to a person being a
susceptible host.

Any time the chain of infection can be broken, it enhances the potential for
preventing the host from developing infections.

Overview
Health care–associated infections (HAIs) are infections acquired by patients while receiving
treatment for other conditions within the health care setting. These settings include inpatient
acute care hospitals, outpatient settings such as ambulatory surgical centers and end-stage renal
disease facilities, and long-term care facilities such as nursing homes and rehabilitation
centers. Many HAIs are preventable, yet they contribute to morbidity (infection and disease) and
mortality (death) every year (Magil, 2014).

Common hospital–associated infections are:

 Catheter–associated urinary tract infections (CAUTIs)

 Pneumonia and ventilator–associated pneumonia (VAP)
 Injection site infections
 Surgical site infections
 Central line–associated bloodstream infections (CLABSIs)
 Gastrointestinal infections from Clostridium difficile

Risk Factors
Many factors can contribute to the development of HAIs including:

Use of medical devices

  Indwelling urinary catheters
 Intravenous catheters
 Ventilators

Infective Cleaning

 Lax or ineffective use of handwashing or standard precautions

 Improper use or reuse of hospital equipment
 Improper cleaning or disinfecting of health care environment,
especially between patients

Transmission of contagious materials

 Contact by patient or health care workers with blood-borne pathogens

through contaminated blood or body fluids

Patient Vulnerability

 Complications after surgical procedures

 Overuse or incorrect use of antibiotics
 Patients with multiple comorbidities, such as diabetes mellitus, chronic
heart failure or other chronic illnesses, compromised immune system

Blood-Borne Pathogens
Blood-borne pathogens are infectious agents that are transmitted by blood
and body fluids. These pathogens place patients and health care providers at
risk for infection. Examples of blood-borne pathogens include:

 Hepatitis B virus (HBV)

 Hepatitis C virus (HCV)
 Human immunodeficiency virus (HIV)

These pathogens are important because the most common way health care
workers are exposed to them is through needlesticks and other sharps-related
injuries. There’s a difference between exposure to a blood-borne pathogen
and infection from a blood-borne pathogen. Exposure occurs through contact
with contaminated blood or body fluids but does not necessarily mean that
infection from the pathogen will follow. Infection can be significantly
decreased by following the correct precautions and barriers.

If exposure occurs, steps can be taken to decrease the risk of developing

infection:

 Wash exposed skin, cuts, and needlestick injuries thoroughly with soap
and water. 
 Flush splashes to the nose or mouth with water.
 Irrigate splashes to the eyes with clean water, saline, or sterile wash.
 Report all exposures promptly to ensure appropriate follow-up care
(NIOSH, 2007).

An individual who is exposed to a blood-borne pathogen should have

baseline laboratory work completed to check for HIV and hepatitis; however,
guidelines vary by institution. If the patient source is known, the patient is
tested. Subsequent testing and medical prophylaxis may also be warranted
(CDC, 2011).

Factors that Promote Drug Resistance

Antibiotics have saved millions of lives. The persistent use of antibiotics over
the years, however, has resulted in the development of antibiotic resistance,
which is now a global threat (CDC, 2018).

Over prescription of Antiobiotics: Antibiotics are often prescribed for

minor bacterial infections when they are not needed, or for viral infections
when they are not indicated.

Use of inappropriate antibiotics: Antibiotics only treat bacterial infections,

but it is often difficult to differentiate between bacterial and viral infections.
It is faster to prescribe an antibiotic rather than take the time to prescribe the
right antibiotic or not prescribe one at all.
Incomplete course of Antibiotics: Inability to monitor patient compliance
with antibiotic usage (e.g., failure to take the entire course of medication).

Antibioptics use in animals: Antibiotics are used to treat livestock and

fish to prevent infections, which creates a reservoir of potentially resistant
bacteria.

Infection Control: Even when antimicrobials are used correctly, societal

conditions accelerate pathogenic drug resistance, for example:

 Dense populations of people have greater exposure to pathogens.

 Hospitals and clinics are crowded, also providing exposure to
pathogens.
 Lack of hygiene and sanitation often occurs in urban centers,
contributing to the spread of microorganisms.

Overview
Drug resistance occurs when microorganisms such as bacteria, viruses, parasites, or fungi grow
in the presence of drugs that would normally kill them or limit their growth.

Overview: Microorganisms adapt to their environment to compete for

survival.

 As early as the 1940s, there were documented cases of microorganisms

developing resistance to medications that were previously effective at
treating the infection.
 The phenomenon of microorganisms adapting is known as drug
resistance or antimicrobial resistance.

Examples: A microorganism is considered resistant if replication cannot be

stopped by two or more antibiotics sequentially or simultaneously.

 Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium

that is resistant to many antibiotics and is mostly seen as skin infections
within the community.
  In the health care setting, MRSA can cause bloodstream infections
(septicemia), pneumonia, and surgical site infections (CDC, 2015).

Concerns: Until recently, new drugs were provided in time to treat bacteria
that had become resistant to older antibiotics. 

An unprecedented number of antibiotics were developed over the past 40

years, but the number of new antibiotics being developed has slumped to
an all-time low due to development costs.

Drug-Resistant Microorganisms
Resistant microorganisms are found in both community settings and health
care settings.

Community-acquired microorganisms that have developed drug resistance

include:

 Enterobacteriaceae (Salmonella and Shigella)

 Mycobacterium tuberculosis (TB)
 Staphylococcus aureus (staph infection)
 Streptococcus pneumoniae (pneumococcus)
 Haemophilus influenzae (pneumonia, bacteremia, meningitis)
 Neisseria gonorrhoeae (gonorrhea)

Microorganisms that have developed resistance within health care (hospital)

settings include:

 Methicillin-resistant Staphylococcus aureus (MRSA)
 Vancomycin-resistant Staphylococcus aureus (VRSA)
 Vancomycin-resistant enterococci (VRE)
 Clostridium difficile (C-Diff) (CDC, 2014)

Summary
 The chain of infection includes an infectious host, source of infection,
portal of exit, mode of transmission, portal of entry, and susceptible
host.
 Pathogens are the disease-producing microorganisms that cause
infection and can include bacteria, viruses, fungi, and parasites. When
these microorganisms develop resistance to medications that had been
previously successful at treating the infection, this is called drug
resistance. This can be seen in both community- and hospital-acquired
infections.
 HAIs are infections acquired in a health care facility. Exposure and
disease development can be decreased with the appropriate precautions
and barriers.