Lesson 1: Infection

Lesson 2: Chain of Infection

Lesson 3. Infection Process

Lesson 4: Personal Protective Equipment

Lesson 5. Hand Hygiene
Lesson 6. Gloving

MODULE 4: Medical Asepsis

Introduction
Health Workers are directly involved in providing a biologically safe environment.
Microorganisms exist everywhere: in water, in soil, and on body surfaces such as the skin,
intestinal tract, and other areas open to the outside (e.g., mouth, upper respiratory tract,
vagina, and lower urinary tract). Most microorganisms are harmless, and some are even
beneficial in that they perform essential functions in the body. Some microorganisms found in
the intestines (e.g., enterobacteria) produce substances called bacteriocins, which are lethal to
related strains of bacteria. Others produce substances that repress the growth of other
microorganisms.
Objectives:
After the lesson, you are expected to learn the following
1. Explain the concepts of medical asepsis
2. Identify signs of localized and systemic infections and
inflammation.
3. Identify risks for nosocomial and health care–associated
infections.
4. Identify factors influencing a microorganism’s ability to produce
an infectious process.
5. Identify interventions to reduce risks for infections.
6. Identify measures that break each link in the chain of infection.

Lesson 1: Infection
INFECTION
An infection is the growth of microorganisms in body tissue where they are not usually
found. Such a microorganism is called an infectious agent. If the microorganism produces no
clinical evidence of disease, the infection is called asymptomatic or subclinical. Some subclinical
infections can cause considerable damage. For example, cytomegalovirus (CMV) infection in a
pregnant woman can lead to significant disease in the unborn child. A detectable alteration in
normal tis sue function, however, is called disease.
Microorganisms vary in their virulence (i.e., their ability to produce disease).
Microorganisms also vary in the severity of the diseases they produce and their degree of
communicability.

PATHOGENICITY
Is the ability to produce disease; thus, a pathogen is a microorganism that causes
disease. Many microorganisms that are normally harmless can cause disease under certain
circumstances. A “true” pathogen causes disease or infection in a healthy individual. An
opportunistic pathogen causes disease only in a susceptible individual.
Infectious diseases are a major cause of death worldwide. The control of the spread of
microorganisms and the protection of people international, national, state, community, and
individual levels. The World Health Organization (WHO) is the major regulatory agency at the
international level. In the United States, the Centers for Disease Control and Prevention (CDC) is
the principal national public health agency concerned with disease prevention and control.
ASEPSIS
Is the freedom from disease-causing microorganisms. To decrease the possibility of
transferring microorganisms from one place to another, aseptic technique is used.

The two basic types of asepsis are:

1. medical asepsis
2. surgical asepsis

Medical Asepsis
Include all practices intended to confine a specific microorganism to a specific area,
limiting the number, growth, and transmission of microorganisms. Objects are referred to as
clean, which means the absence of almost all microorganisms, or dirty (soiled, contaminated),
which means likely to have microorganisms, some of which may be capable of causing
infection.

SURGICAL ASEPSIS OR STERILE TECHNIQUES

Refers to those practices that keep an area or object free of all microorganisms; it
includes practices that destroy all microorganisms and spores (microscopic dormant structures
formed by some pathogens that are very hardy and often survive common cleaning
techniques).

4 TYPES OF MICROORGANISMS THAT CAUSE INFECTIONS

1. Bacteria are by far the most common infection-causing microorganisms. Several
hundred species can cause disease in humans and can live and be transported through
air, water, food, soil, body tissues and fluids, and inanimate objects.

2. Viruses consist primarily of nucleic acid and therefore must enter living cells in order to
reproduce. Common virus families include the rhinovirus (causes the common cold),
hepatitis, herpes, and human immunodeficiency virus.

3. FUNGI include yeasts and molds. Candida albicans is a yeast considered to be normal
flora in the human vagina.

4. PARASITES live on other living organisms. They include protozoa such as the one that
causes malaria, helminths (worms), and arthropods (mites, fleas, ticks).

TYPES OF INFECTIONS

Colonization is the process by which strains of microorganisms become resident flora. In this
state, the microorganisms may grow and multiply but do not cause disease. Infection occurs
when newly introduced or resident microorganisms succeed in invading a part of the body
where the host’s defense mechanisms are ineffective, and the pathogen causes tissue damage.
The infection becomes a disease when the signs and symptoms of the infection are unique and
can be differentiated from other conditions.

Infections can be local or systemic

LOCAL INFECTION is limited to the specific part of the body where the microorganisms remain.

SYSTEMIC INFECTION
If the microorganisms spread and damage different parts of the body, the infection is a
systemic infection. When a culture of the person’s blood reveals microorganisms, the condition
is called bacteremia. When bacteremia results in systemic infection, it is referred to as
septicemia. Unfortunately, septicemia has become more common over time.

There are also acute and chronic infections

ACUTE INFECTION - generally appear suddenly or last a short time.

CHRONIC INFECTION - may occur slowly, over a very long period, and may last months or
years.

NOSOCOMIAL INFECTION are classified as infections that originate in the hospital. Nosocomial
infections can either develop during a client’s stay in a facility or manifest after discharge.
Nosocomial microorganisms may also be acquired by personnel working in the facility and can
cause significant illness and time lost from work.

Lesson 2: Chain of Infection

Transmission occurs when the agent leaves it reservoir or host through a portal of exit, is
conveyed by some mode of transmission, and enters through an appropriate portal of entry to
infect a susceptible host. This sequence is called the chain of infection.

6 links make up the chain of infection - the infectious agent, or microorganism; the place
where the organism naturally resides (reservoir); a portal of exit from the reservoir; a method
(mode) of transmission; a portal of entry into a host; and the susceptibility of the host.
1. Infectious Agent. The extent to which any microorganism is capable of producing an
infectious process depends on the number of microorganisms present, the virulence and
potency of the microorganisms (pathogenicity), the ability of the microorganisms to
enter the body, the susceptibility of the host, and the ability of the microorganisms to
live in the host’s body.
2. Reservoir. There are many reservoirs, or sources of microorganisms. Common sources
are other humans, the client’s own microorganisms, plants, animals, or the general
environment. People are the most common source of infection for others and for
themselves. For example, the person with an influenza virus frequently spreads it to
others. A carrier is a person or animal reservoir of a specific infectious agent that usually
does not manifest any clinical signs of disease.
3. Portal of Exit from Reservoir. Before an infection can establish itself in a host, the
microorganisms must leave the reservoir.
4. Method of Transmission. After a microorganism leaves its source or reservoir, it
requires a means of transmission to reach another person or host through a receptive
portal of entry.
Mechanisms of transmission:

1. Direct transmission. Direct transmission involves immediate and direct transfer of

microorganisms from person to person through touching, biting, kissing, or sexual intercourse.
Droplet spread is also a form of direct transmission but can occur only if the source and the
host are within 1 m (3 ft) of each other. Sneezing, coughing, spitting, singing, or talking can
project droplet spray into the conjunctiva or onto the mucous membranes of the eye, nose, or
mouth of another person.

2. Indirect transmission. Indirect transmission may be either vehicle borne or vector borne:
a. Vehicle-borne transmission is any substance that serves as an intermediate means to
transport and introduce an infectious agent into a susceptible host through a suitable
portal of entry. Fomites (inanimate materials or objects), such as handkerchiefs, toys,
soiled clothes, cooking or eating utensils, and surgical instruments or dressings, can act
as vehicles. Water, food, blood, serum, and plasma are other vehicles. For example,
food or water may become contaminated by a food handler who carries the hepatitis A
virus. The food is then ingested by a susceptible host.
b. Vector-borne transmission. A vector is an animal or flying or crawling insect that serves
as an intermediate means of transporting the infectious agent. Transmission may occur
by injecting salivary fluid during biting or by depositing feces or other materials on the
skin through the bite wound or a traumatized skin area.
c. Airborne transmission. Airborne transmission may involve droplets or dust. Droplet
nuclei, the residue of evaporated droplets emitted by an infected host such as someone
with tuberculosis, can remain in the air for long periods. Dust particles containing the
infectious agent (e.g., C. difficile, spores from the soil) can also become airborne. The
material is transmitted by air currents to a suitable portal of entry, usually the
respiratory tract, of another person.
 5. Portal of Entry to the Susceptible Host. Before a person can become infected,
microorganisms must enter the body. The skin is a barrier to infectious agents; however,
any break in the skin can readily serve as a portal of entry. Often, microorganisms enter
the body of the host by the same route they used to leave the source.
6. Susceptible Host. A susceptible host is any person who is at risk for infection. A
compromised host is a person at increased risk, an individual who for one or more
reasons is more likely than others to acquire an infection. Impairment of the body’s
natural defenses and a number of other factors can affect susceptibility to infection.
Examples include age (the very young or the very old); clients receiving immune
suppression treatment for cancer, for chronic illness, or following a successful organ
transplant; and those with immune deficiency conditions.

Lesson 3: Personal Protective Equipment

• PPE is a precautionary steps to protect yourself and the people around you.
• PPE is specialized clothing or equipment worn for protection against dangerous or
infectious materials.

Personal Protective Equipment (PPE) use in Standard Infection Control Precautions

 Gloves, aprons, long sleeved gowns, surgical masks, eye goggles, face visors and respirator
masks are all examples of PPE that may be worn in the provision of healthcare.
 PPE is used in healthcare settings to create a barrier between healthcare workers and an
infectious agent from the patient and to reduce the risk of transmitting micro-organisms from
healthcare workers to patient(s). In addition PPE may sometimes be used by the patient’s
family / visitors, particularly if they are providing direct patient care e.g. assisting patient with
toileting. In these circumstances carers must be fully inducted in the use of PPE and Hand
Hygiene.
 The choice of PPE should be based on a risk assessment of potential exposure to blood / body
fluids / infectious agents.
 PPE should be available at the point of use in both community and acute healthcare settings
and staff should receive training on the correct use and disposal of PPE.
 If used inappropriately PPE can increase the risk of transmitting infections and put people at risk
of acquiring an infection

1. Gloves
Gloves should be worn when there may be exposure to blood, bodily fluids, secretions
or excretions and when handling contaminated equipment. Gloves should also be worn when
patients require transmission based precautions. Increased awareness among healthcare
workers of the potential for gloves to provide protection against various pathogenic
microorganisms, has led to the increased use of gloves in health care. However, gloves cans
sometimes be used inappropriately and failure to remove them at the correct time and
complete hand hygiene effectively can increase the risk of transmitting infections to vulnerable
patients.

Things to remember about gloves:

• Gloves should be put on immediately before the commencement of a task and removed
as soon as it has been completed.
• Hands should be decontaminated and dried before applying gloves; cuts and broken
skin should be covered with a waterproof dressing.
• Gloves must never be decontaminated and reused. They are a single use item and
should only be worn once and then discarded.
• After gloves have been removed, hands should be washed and dried or decontaminated
with alcohol handrub.
• Gloves should be disposed of into the appropriate waste receptacle immediately after
use.
• If gloves cause irritation, healthcare workers should consult the Occupational Health
service or seek medical advice.
Aprons/Gowns
Disposable Plastic Aprons / Gowns are designed to protect uniforms / clothing from
moisture / soiling during direct patient care. In the majority of cases, plastic aprons will be
appropriate for standard precautions. In some cases, where extensive contamination of blood /
body fluids is anticipated e.g. maternity units, ED units or when the patient requires a
significant amount of direct care with close skin-to-skin contact, a long sleeved fluid repellent
gowns may be more appropriate. Gowns do not need to be sterile unless used for an aseptic
procedure such as central line insertion or in an operating theatre.

• Aprons/Gowns should be stored in a clean area. Wall-mounted storage units are

available for storing PPE and the storage unit should be cleaned regularly.
• Aprons/Gowns should not be worn routinely during shifts and must be changed
between patients. They may also need to be changed between different procedures on
the same patient.
• Care should be taken to remove aprons / gowns carefully using ties and taking care not
to touch the outer surface. The apron/ gown should be folded / rolled into a ball before
disposal into a waste receptacle.
• Used aprons / gowns should be discarded immediately after use.
• Hands should always be decontaminated after removal of apron/gown and gloves.
• When colour coded aprons are worn the colour must be appropriate to the task e.g.
green aprons for serving food.
 Eye protection, visors or full face protection
Eye and face protection must be worn when there is risk of splashing body fluids onto
mucous membranes e.g. eyes/nose. Eyes can be protected by wearing either goggles or a visor.
Personal glasses are not a suitable substitute. If reusable eye/face protection is used, it should
be decontaminated in accordance with the manufacturer’s guidelines. Hands should always be
decontaminated after removing the equipment.

Suitable protective eye/face equipment should:

• cover the entire face area (e.g. face shield) if protection of the mouth and nose area is
also required
• be changed if visibly soiled
• be removed using the ear-pieces / head-band to avoid touching potentially
contaminated surfaces
• be disposed of after use if single-use or placed into a receptacle for reprocessing
• fit over personal glasses and anti-fog properties should be consider.

Mask

Surgical masks (Fluid Repellent)

• Provide barrier protection to the wearer from splashes and droplets to the area of the
wearer’s nose, mouth and respiratory tract. They do not provide protection against
aerosolised particles and are not classified as Respiratory Protective Equipment.
• Should be worn appropriately (covering nose and mouth) by all members of the theatre
surgical team. If splashes of blood / body fluids are anticipated they can be replaced with a
full face visor.
• Should be worn when performing procedures such as lumbar puncture / spinal anaesthesia.
• Must be compliant with the Medical Devices Directive (MDD 93/42/EEC) and be “CE”
marked.
• Should be single-use and discarded immediately when soiled / following use. They should
not be left attached around the wearer’s neck following use and be reused.
• Should be stored in their original packaging prior to use and care should be taken to avoid
contamination.
• Should be removed using the ties/strings and disposed of in the appropriate waste stream
(e.g. clinical waste).

Respirator masks
 The purpose of respiratory protection is to protect the wearer from pathogens spread by the
airborne route e.g. measles, chickenpox, tuberculosis, and when performing aerosol generating
procedures on patients with suspected or known influenza or other respiratory tract infections.
Advice on their use is available from the IPC Team and may be required by healthcare workers
and visitors in certain circumstances.
 All healthcare workers that may require protection using a FFP3 respirator mask should be fit-
tested prior to use and should also receive training on the use of the mask; this will be
facilitated by the Occupational Health Department.
 Individuals are responsible for checking the seal on their own mask before each use.
 FFP3 respirator masks should be changed after every use or when visibly soiled. They should
also be changed if breathing becomes difficult

Lesson 4: Hand Hygiene

Is important in every setting, including hospitals. It is considered one of the most
effective infection prevention measures. Any client may harbor microorganisms that are
currently harmless to the client yet potentially harmful to another person or to the same client
if they find a portal of entry. It is important for both the health workers’ and the clients’ hands
to be cleansed at the following times to prevent the spread of microorganisms: before eating,
after using the bedpan or toilet, and after the hands have come in contact with and body
substances, such as sputum or drainage from a wound. In addition, health care workers should
cleanse their hands before and after giving
care of any kind.
Is performed so frequently, it provides a good opportunity for the health practitioner to
take a moment to breathe and prepare for the next client encounter. By allowing a full, quiet
breath in and a slow, complete exhalation, the health practitioner can focus his or her attention
and intention to remain mindful. This mindful attitude enhances the therapeutic presence and
increases the effectiveness and safety of care. Family members or other support persons, other
health professionals, records and reports, laboratory and diagnostic analyses, and relevant
literature are secondary or indirect sources. For routine client care vigorous hand washing
under a stream of water for 15 to 20 seconds using granular soap, soap-filled sheets, or liquid
soap at the beginning of the nurse’s shift, when hands are visibly soiled, and after using the
toilet is recommended (WHO, 2009).

The following measures can reduce a person’s susceptibility to infection

• Hygiene. Intact skin and mucous membranes are one barrier against microorganisms
entering the body. In addition, good oral care, including flossing the teeth, reduces the
 likelihood of an oral infection. Regular and thorough bathing and shampooing remove
microorganisms and dirt that can result in an infection.
• Nutrition. A balanced diet enhances the health of all body tissues, helps keep the skin
intact, and promotes the skin’s ability to repel microorganisms. Adequate nutrition enables
tissues to maintain and rebuild themselves and helps keep the immune system functioning
well.
• Fluid. Fluid intake permits fluid output that flushes out the bladder and urethra, removing
microorganisms that could cause an infection.
• Sleep. Adequate sleep is essential to health and to renewing energy.
• Stress. Excessive stress predisposes people to infections.
• Immunizations. The use of immunizations has dramatically decreased the incidence of
infectious diseases. It is recommended that immunizations begin shortly after birth and be
completed in early childhood

When disinfecting articles, health workers need to follow agency protocol and consider the
following:
1) The type and number of infectious organisms. Some microorganisms are
readily destroyed, whereas others require longer contact with the
disinfectant.
2) The recommended concentration of the disinfectant and the duration of
contact.
3) The presence of soap. Some disinfectants are ineffective in the presence of
soap or detergent.
4) The presence of organic materials. The presence of saliva, blood, pus, or
excretions can readily inactivate many disinfectants.
5) The surface areas to be treated. The disinfecting agent must come into
contact with all surfaces and areas.

Sterilizing
Sterilization is a process that destroys all microorganisms, including spores and viruses.
Four commonly used methods of sterilization are moist heat, gas, boiling water, and radiation.

Moist Heat
To sterilize with moist heat (such as with an autoclave), steam under pressure is used
because it attains temperatures higher than the boiling point.

Gas
Ethylene oxide gas destroys microorganisms by interfering with their metabolic
processes. It is also effective against spores. Its advantages are good penetration and
effectiveness for heat-sensitive items.
Its major disadvantage is its toxicity to humans.
Standard Precautions
Standard precautions are used in the care of all hospitalized individuals regardless of
their diagnosis or possible infection status. They are used in any situations involving blood, all
body fluids, excretions, and secretions except sweat (whether or not blood is present
or visible), non-intact skin, and mucous membranes.

Standard Precautions include

(a) hand hygiene;
(b) use of personal protective equipment (PPE), which includes gloves, gowns,
eyewear, and masks;
(c) safe injection practices;
(d) safe handling of potentially contaminated equipment or surfaces in the client
environment; and (e) respiratory hygiene/cough etiquette.

Lesson 5: Gloving
Gloves may be applied by the open method or the closed method. The open method is
most frequently used outside the operating room because the closed method requires that the
nurse wear a sterile gown. Gloves are worn during many procedures to enable the health
worker to handle sterile items freely and to prevent clients at risk (e.g., those with open
wounds) from becoming infected by microorganisms on unsterile gloves or the health worker’s
hands.

PURPOSES
• To enable the health worker to handle or touch sterile objects freely without
contaminating them
• To prevent transmission of potentially infective organisms from the health worker’s
hands to clients at high risk for infection

Gloves are worn for three reasons:

1. They protect the hands when the nurse is likely to handle any body substances, for
example, blood, urine, feces, sputum, and none intact skin.
2. Gloves reduce the likelihood of nurses transmitting their own endogenous
microorganisms to individuals receiving care. Health worker who have open sores or
cuts on the hands must wear gloves for protection.
3. Gloves reduce the chance that the health worker’s hands will transmit microorganisms
from one client or an object to another client. In all situations, gloves are changed
between client contacts.