Pathogenicity and laboratory diagnosis of Nosocomial infections

In addition to the clinical manifestations and physical examination, laboratory and other
diagnostic testing are used to confirm diagnoses of healthcare-associated infection (HAI).
Routine blood tests, which include complete blood counts, metabolic panels, inflammatory
markers, and blood gases will be useful to evaluate for HAI. Each type of HAI will require
different workup, as indicated below.
Central Line-Associated Blood Stream Infection (CLABSI)
With the clinical suspicion of CLABSI, in the absence of other localized infection(s), blood
cultures should be drawn. Ideally, samples for blood cultures should be drawn from two
different sites, for example, one from CVC and the other from a peripheral vein before
starting antibiotic therapy. Any purulent material at the exit site should be cultured.
Catheter-Associated Urinary Tract Infection (CAUTI)
Urine samples should be collected from a midstream sample after removal of the urinary
catheter, if possible. This prevents the chances of obtaining bacteria present in the biofilms
present on the walls of the catheter. Urinalysis and urine cultures should be obtained. Pyuria
is commonly seen in catheterized patients with bacteriuria. Bacteriuria, with culture growth
of 100,000 colony forming units (CFU)/mL of uropathogenic bacteria without UTI
symptoms, is referred to as asymptomatic bacteriuria and is typically not treated. In patients
with clinical manifestations of CAUTI not explained by another source of infection, and urine
culture growth greater than 1,000 CFU/mL of one or more pathogens are diagnosed with
CAUTI.
Skin and Soft Tissue Infection (SSI)
The clinical presentation should guide the evaluation of SSI. When an SSI is suspected, a
sample of the infected tissue, drainage, or purulent material should be cultured with an
antibiogram. Swabs may be done on deep wounds. However, superficial swabs may be
contaminated with polymicrobial colonization. Different modalities of imaging may be used
to identify organ or space-occupying SSI, especially to guide drainage of infected fluid or
abscess.
Hospital-Acquired Pneumonia (HAP)/Ventilator Associated Pneumonia (VAP)
A clinical diagnosis of pneumonia should be further evaluated with radiography and
microbiologic findings. A chest x-ray is most commonly used and may reveal new infiltrates.
Sputum samples should be obtained by non-invasive sampling from endotracheal aspiration
or expectoration or via bronchoscopy with bronchoalveolar lavage or specimen brushing.
Samples should be stained and cultured with antibiotic susceptibility testing. Depending on
the clinical scenario, a specialized culture medium may be necessary to grow fastidious
organisms, such as Mycobacterium tuberculosis or fungal pathogens.
C. difficile Infection (CDI)
Suspected CDI should be evaluated with stool tests for C. difficile toxin(s) or C. difficile
toxin gene. Liquid stool from only clinically significant diarrhea should be sampled to limit
false positives by highly sensitive diagnostic tests. A rectal swab may be done in patients
with ileus and suspected CDI. Nucleic acid amplification testing (NAAT) is highly sensitive
and may lead to overdiagnosis and overtreatment.[38]
An algorithmic approach with initial enzyme immunoassay for toxins A and B and glutamate
dehydrogenase antigen is recommended. Indeterminate toxin or antigen tests should be
confirmed with the use of NAAT. Colonoscopy is not typically done for the sole purpose of
diagnosing CDI. However, findings of pseudomembranous colitis are highly suggestive of
CDI. Radiographic imaging may be warranted for patients with severe illness and suspected
toxic megacolon or perforation.

Standard precautions
Standard precautions are the minimum infection prevention practices that apply to all patient
care, regardless of suspected or confirmed infection status of the patient, in any setting where
healthcare is deliver. They include: hand hygiene, use of personal protective equipment, safe
injection practices, safe handling of potentially contaminated equipment or surfaces in the
patient environment, and respiratory hygiene/cough etiquette.
l. Hand hygiene: good hand hygiene, including the use of alcohol-based hand rubs and
handwashing with soap and water, is critical to reduce the risk of spreading infections in
ambulatory care settings.
Key situations where hand hygiene should be performed include the following:
• Before touching a patient, even if gloves are to be worn
• Before coming out of the patient's care area after touching the patient or the patient's
immediate environment
• After contact with blood, body fluids or excretions, or wound dressings
• Prior to performing any aseptic task (for example, placing an intravenous line or preparing
an injection)
• If hands are likely to move from a contaminated body site to a clean-body site during
patient care;
and after removal of gloves.
2. Personal protective equipment (PPE): This refers to wearable equipment intended to
protect healthcare workers (HCWs) from exposure to or contact with infectious agents;
examples include gloves, gowns, face masks, respirators, goggles and face shields. With
reference to gloves, it is recommended that:
• Gloves should be worn when there is a possibility of contact with blood, body fluids,
mucous membranes, non-intact skin or contaminated equipment.
• The same pair of gloves should not be worn for the care of more than one patient.
• Gloves should not be washed for the purpose of reuse.
• Hand hygiene should be performed immediately after removing the gloves.
Other key recommendations are as follows:
• A gown should be worn to protect skin and clothing during procedures or activities where
contact with blood or body fluids is anticipated.
• The same gown should not be worn for the care of more than one patient.
• Mouth, nose and eye protection should be in place during procedures likely to generate
splashes or
sprays of blood or other body fluids. • A surgical mask should be worn when placing a
catheter or injecting material into the spinal canal or subdural space.
3. Injection safety (safe injection practices):
This refers to practices intended to prevent transmission of infectious diseases between
patients or between a patient and a healthcare worker (HCW) during preparation and
administration of parenteral medications.
The following are recommended:
• Aseptic techniques should be used when preparing and administering medications .
• Access diaphragms of medication vials should be cleaned with 70 % alcohol before
inserting a device into the vial.
•Medications should never be administered from the same syringe to multiple patients, even
if the needle
is changed or the injection is administered through an intervening length of intravenous
tubing.
• A syringe should not be reused to enter a medication vial or solution .
• Medications should not be administered from singledose or single-use vials , ampoules or
bags or bottles
of intravenous solution to more than one patient.
• Fluid infusion or administration sets (for example, intravenous tubing) should not be used
for more
than one patient.
• Multi-dose vials should be dedicated to a single patient whenever possible.
• Used needles should not be capped on any account.
4. Environmental cleaning: Cleaning refers to the removal of visible soil and organic
contamination from
a device or environmental surface using the physical action of scrubbing with a surfactant or
detergent and water, or an energy-based process (for example, ultrasonic cleaners) with
appropriate chemical agents. This process removes large numbers of microorganisms from
surfaces and must always be performed before disinfection.
Disinfection is generally a less lethal process of microbial inactivation (compared to
sterilisation) which eliminates virtually all recognised pathogenic microorganisms but not
necessarily all microbial forms
(for example, bacterial spores).
5. Medical equipment: Medical equipment may be reusable or for single-use. Reusable
medical equipment (for example, endoscopes) should be accompanied by instructions for
cleaning and disinfection or sterilisation as appropriate. Single-use devices are labelled by the
manufacturer for only a one- time use and do not have reprocessing instructions. Healthcare
facilities should ensure that reusable medical equipment (for example, blood glucose meters
and other point-of-care devices, surgical instruments,
endoscopes) is cleaned and reprocessed appropriately before being used on another patient.
6. Respiratory hygiene / cough etiquette: This represents an element of standard
precautions that highlights the need for prompt implementation of infection prevention
measures at the first point of encounter with the facility / ambulatory settings. Any individual
with signs of illness including cough, congestion, rhinorrhea or increased production of
respiratory secretions needs to be promptly identified when entering the facility and should
be monitored throughout the duration of the visit.
To prevent transmission of respiratory secretions in individuals (patients, accompanying
individuals) who
have signs and symptoms of a respiratory infection, notices should be posted at entrances
with instructions to all individuals to cover their mouths / noses when coughing or sneezing;
use and dispose of tissue; and perform hand hygiene after hands have been in contact with
respiratory secretions.
7. Isolation: All patients admitted with contagious infections must be isolated. Patients with
MRSA and pandrug-resistant organisms need to be isolated and treated by barrier nursing.

Precaution in the operating theatre

Operation theatre technologists, also known as surgical technologists or operating room (OR) technicians,
play a crucial role in reducing hospital-acquired infections (HAIs) through various detailed
responsibilities:

Sterile Field Maintenance: Technologists are responsible for creating and maintaining a sterile field within
the operating room. They ensure that all surfaces, equipment, and supplies are properly sterilized and free
from contaminants.

Instrument Sterilization: They oversee the proper sterilization of surgical instruments, ensuring that all
instruments are cleaned, disinfected, and sterilized according to established protocols. This is critical to
prevent surgical site infections (SSIs).

Hand Hygiene: Technologists adhere to strict hand hygiene protocols. They wash their hands thoroughly
and use appropriate hand sanitizers to minimize the risk of introducing pathogens into the surgical area.

Surgical Attire: They assist the surgical team in donning sterile gowns, gloves, masks, and caps. Proper
attire helps prevent shedding of skin cells and contaminants into the surgical field.

Environmental Control: Maintaining a controlled environment in the operating room is essential.

Technologists help ensure that the temperature, humidity, and airflow are controlled to reduce the risk of
infection. They also monitor and control traffic within the OR.

Equipment Sterilization: Technologists are responsible for sterilizing and maintaining surgical equipment,
including endoscopes and robotic surgical systems. Proper equipment sterilization is essential to prevent
device-related infections.

Infection Control Protocols: They are knowledgeable about infection control guidelines and ensure that the
surgical team follows them meticulously. This includes proper pre-operative skin preparation and the use
of antimicrobial agents.

Communication: Effective communication is vital in preventing HAIs. Technologists communicate with

the surgical team about any potential breaches in sterile technique or any issues related to infection control.

Waste Disposal: They manage the proper disposal of biohazardous waste and contaminated materials,
ensuring that waste is handled and disposed of according to regulations.

Patient Advocacy: Technologists may advocate for patients by ensuring that proper infection prevention
measures are in place, and they may voice concerns if they observe lapses in protocol.

Continuing Education: Staying up to date with the latest infection control and sterilization techniques is
crucial. Technologists often participate in ongoing education and training to maintain their knowledge and
skills.

Quality Assurance: They participate in quality assurance and quality improvement programs to identify
and address issues related to infection control and safety.

By diligently carrying out these responsibilities, operation theatre technologists help create a safe and
sterile environment for surgical procedures, significantly reducing the risk of hospital-acquired infections
and improving patient outcomes.