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CHAPTER 1. INTRODUCTION………………………………………… 2
CHAPTER 1
INTRODUCTION
develop infections every year .In developing countries, this may go up to 25%. One-third of
these are preventable. Diagnosing and treating these infections puts intense pressure on the
health services and health budget.
A Hospital Infection Control Manual is an essential part of any infection control
programme. It should establish standards in all aspects of infection control. In a large referral
hospital, doctors and nursing staff work in different specialties and super specialties. Each
specialty has evolved its own style of working and they have varied procedures which can be
performed only by skilled personnel. The procedures of infection control should thus be
adapted to suit the needs of all specialties and still maintain the basic principles needed for
effective control of infection. Over time all precautions tend to get diluted and recruitment of
new staff members without knowledge of infection control procedures followed will lead to
an increase in the hazard of spread of infection within the hospital. This can be overcome by
a standard manual which is updated yearly and is available to all staff for easy reference over
the hospital computer network system or in the wards/reading rooms.
The manual should include policy and procedures on:
1. Standard Precautions for HCWs
2. Isolation policies
3. Cleaning and decontamination of surfaces and equipment and management of spills
4. Antibiotic policy
5. Outbreak management.
6. Waste management and disposal of sharps. (Damani)
The Health Act 2006 Code of Practice for the Prevention and Control of Health Care
Associated Infections, Dept. of Health, UK
“The term “Health Care Associated Infections” (HCAI) encompasses any infection by
any infectious agent acquired as a consequence of a person’s treatment by the hospital or
which is acquired by health care workers in the course of their duties. Effective prevention
and control of HCAI has to be embedded into everyday practice and applied consistently by
everyone. It is particularly important to have a high awareness of the possibility of HCAI in
both patient and health care workers to ensure early and rapid diagnosis. This should result in
effective treatment and containment of the infection. Effective action relies on an
accumulating body of evidence that takes account of current clinical practices. This evidence
base should be used to review and inform practice. All staff should demonstrate good
infection control and hygiene practice. However, it is not possible to prevent all infections.”
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CHAPTER 2
3. Formulate an antibiotic policy based on the needs of the different specialties and
prevalent susceptibility patterns.
4. Implement policies for the safety of health care workers.
5. Regulate and give recommendations on purchase of equipment needed for infection
control e.g. autoclaves in CSSD, steam sterilizers etc.
6. Regulate and give recommendations on any construction or renovation work in the
hospital. The plan should be approved by the committee.
7. Discuss and find solutions to problems related to infection control encountered by
different doctors in their specialties.(Damani)
INFECTION CONTROL TEAM (ICT)
Infection Control Team (ICT) – Consists of: -
a) Infection Control Doctor (ICD).
b) Infection Control Nurse (ICN)
a) ICD – Microbiologist / Infectious Disease Specialist / Epidemiologist
Should be a Registered Medical Practitioner. One for every 1000 beds
Experience in: -
1. Sterilization / Disinfection
2. Microbiology
3. Hospital Infection Epidemiology
4. Surveillance
Functions:
1. Draws up annual plans for prevention of hospital infection.
2. Implementation of agreed policies
3. Sets quality standards and coordinates surveillance activities.
4. Coordinates with administrator, PWD, PHED and BM engineer for proper
maintenance, or upgradation of existing facilities. Should be involved in the
design ,construction and commissioning of any new building.
5. Help the ICN to conduct continuing education programmes in infection
control practices for the staff members.
b) ICN – Senior Registered Nurse(BSc or MSc)
Training in Infection Control is preferred.
Full-time job. One for 250 beds.
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This includes: -
1. Assists ICD and ICC in drawing up annual plans for prevention of hospital infection
2. Monitor all infection control procedures, e.g. sterilization procedures in the CSSD,
use of disinfectants and adherence to universal precautions by all members of staff.
3. Surveillance of infection to prevent outbreaks. She will identify, investigate and
follow-up on infections acquired from the hospital which will help in prevention of
outbreaks.
4. Conduct continuing education programmes on infection control practices to all grades
of staff.
In a large hospital there will be a team of ICDs and ICNs, who make up the ICT. The
ICT is responsible for the day-to-day activities of the infection control programme. The ICT
conducts monthly meetings presided over by the seniormost ICD.(Damani)
Infection Control Lab
It is recommended that for surveillance and outbreak investigation activities, an
infection control lab may be set up under the Microbiology Department. This may be
supervised by the senior most ICD who is also a Microbiologist. The processing of
specimens in the lab is done by:
1. Senior lab technician/Scientist - Preferably BSc MLT /MSc. Microbiology and
preference given to person with PhD in any subject related to infection control.
Experience in typing of organisms will be an added advantage.
2. Junior Lab technician – BSc MLT or DMLT
3. Junior Lab assistant(JLA) – Passed Higher secondary with experience in lab work
4. Cleaner/Attender .
Functions of the Lab:
1. Participate in Surveillance activities and outbreak investigation as instructed by the
ICD.
2. Maintain in stock all the pathogens identified in outbreaks.
3. Typing of nosocomial pathogens – phage typing, biocin typing, molecular methods.
All the other bacteriology labs should send the multi-drug resistant nosocomial strains
identified in pus, blood samples etc. to this lab for full identification and typing.
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CHAPTER 3
HOSPITAL HYGIENE
In the chain of infection, the mode of transmission is the easiest link to break and is the
key to control of cross-infection in hospitals.
· Feet should be well covered on all sides, especially while working in areas where
spillage of infectious material is common, like operation theatres, labour room,
laboratories. Soft shoes are preferred to sandals.
2. HAND WASHING: Protects both HCW and patients .The single measure that is
universally acknowledged and proved to reduce HCAI.
The main forms are:
a) Social handwashing – Done for simple cleaning of hands with soap and water. Reduces
the transient flora. A modification is careful handwashing which is done immediately
after touching a patient or after contamination. All areas of the hand upto the wrist are
cleaned by rubbing for at least 2 minutes. Fig 1 below shows the areas commonly missed
while washing, in red.
b) Hygienic hand disinfection – After social hand washing, to get a more sustained effect,
especially while caring for infected patients in special care units like ICUs and neonatal
units. 70% ethyl alcohol hand disinfectants may be rubbed thoroughly over the hands.
This effectively kills all transient flora, the action is fast and short-lived, hence has to be
repeated after touching each patient.
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6. USE OF DISPOSABLES
It is impossible to avoid all contact with infected tissue or potentially contaminated body
fluids. Even when they are not touched with the bare hands, they come into contact with
instruments, containers, linen etc. All objects that come into contact with patients should
be considered as potentially contaminated. If an object that comes into such contact is
disposable it should be discarded as waste. If it is reusable transmission of infectious agents
should be prevented by cleaning, disinfection or sterilization.
A. SURFACES: These are meant to be clean and not sterile. Cleanliness can be
ensured only if cleaning is repeated as often as contamination occurs.
The physical action of scrubbing with detergents and rinsing with water during
environmental cleaning effectively removes 90% of micro-organisms. Non-sporulating
bacteria are unlikely to survive on clean surfaces. It is essential that methods of cleaning do
not produce aerosols or dispersion of dust in patient care areas. Brooms should not be used in
intensive care facilities. Fresh cleaning solution should be made before each cleaning
procedure and discarded after use. There should be an area for cleaning and drying of used
mops.
1. Floors: Vacuum clean or dry mop twice daily.
Wet mop with detergent and phenol (1%) solution. Use 2% if there is obvious
contamination.
2. Furniture and ledges: Wet mopping daily with warm water and detergent.
3. Washbasin and sink: Clean with detergent. If contaminated use 0.5%Hypochlorite.
4. Mattresses and pillows: These should be enclosed in a waterproof cover. This should be
cleaned with a detergent after a patient is discharged and disinfected with 0.5%
hypochlorite, if contaminated.
5. Medicine trays: Keep all trays, with medicines and dressings inside a drawer or closed
cupboard. If kept exposed in a tray, keep covered and away from open windows.
6. Toilet seats: Wash daily with detergent and dry. Use 0.5% hypochlorite if soiling with
blood is likely as in Urology and Gynaecology units.
7. Beds, bed-frames: For normal cleaning use detergent and hot water. Perform cleaning
after discharge of patient and weekly in case of long stay patients. Use 0.5% hypochlorite
to disinfect if there is any contamination with blood or body fluids.
8. Cleaning of a room after source isolation of an infected patient: Fumigation of the
room or swabbing to monitor effectiveness of the cleaning procedure is NOT
needed.
a. Cleaner should wear apron and thick household gloves
b. Dust the high ledges window frames etc.
c. Wet mop all ledges, fixtures and fittings including taps and door handles
d. Vacuum clean the floor.
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Taken from the Guidelines for prevention of Nosocomial Pneumonia, CDC, Atlanta
C. INSTRUMENTS :
1. Speculums and rigid endoscopes: Clean and wash thoroughly. Rinse and dry. Send to
CSSD for autoclaving. An alternative is immersion in 2%Gluteraldehyde for 10 minutes after
disassembling any accessories. Rinse with sterile distilled water after disinfection.
2. Thermometers: Individual thermometers are recommended for each patient (at least in
ICUs). For multi-use, after each use wipe with 70%alcohol and store dry. Wash with
detergent at least twice daily. Alternatively, for individual thermometers, wash with detergent
and immerse in 70% alcohol for 10 minutes after the patient is discharged. Store dry.
3. Scissors: Surface disinfect with a 70% alcohol wipe.
4. Urinals and bedpans: Wash with detergent between each use. Store dry. Heat disinfect at
80oC between patients, clean and reuse.
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5. Cheatle forceps: Do not use. If necessary to use, autoclave daily and store dry in a closed
container.
6. Oxygen face mask: Wash with detergent and dry if contaminated. Before each use, wipe
with 70% ethyl or isopropyl alcohol.
SPECIFIC POLICIES
I. WARDS
1. Beds (centre) should be at least 3.6m away from each other.
2. There should be good ventilation.
3. Toilets and baths should be easy to clean and conveniently located.
4. Wash basins to be located within easy walking distance. One wash basin per 6 beds is
recommended.
5. Walls and ceilings should be kept in good repair, because micro organisms tend to
colonise only walls that are moist or sticky.
6. Pipe penetrations and plumbing fixtures should be smooth, and tightly sealed..
7. Overcrowding of wards should be avoided. Visiting hours should be fixed for 2 hours
daily and only one bystander allowed per patient.
8. It is recommended that food for the patient is provided by the hospital dietary
department based on recommendations by the attending doctor /dietician. This will
reduce the traffic in the wards during the day.
9. Cleaning schedule should be decided and followed. Brooms which raise dust are
NOT recommended. Instead, vacuum cleaning or dry mopping followed by wet
mopping may be done at least twice daily and after any contamination.
10. Detergent and 1% phenolic disinfectants may be used for floors. For non-metallic
surfaces 0.5% hypochlorite may also be used.
11. 70% ethyl or isopropyl alcohol may be used to wipe medicine trolleys and shelves
where instruments or medicines are kept, after thorough wet mopping.
Cleaning: Wet mopping with 1% phenol and detergent at least twice daily.
0.5% hypochlorite if there is visible contamination
1% hypochlorite for blood spills.
Clean ledges and window frames daily
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C. PATIENT
1. Pre-existing skin lesion diabetes and other immunosuppressive condition - to be
corrected.
2. Pre-operative stay in hospital – to be kept to a minimum.
3. Pre-operative shaving using razors & brushes – to be avoided. Clip the hair or use
depilatory creams.
4. Antibiotic prophylaxis – not to exceed 24 hrs.
5. Operative site - to be disinfected properly. Use 0.5% Chlorhexidine / 10% Povidone
Iodine followed by 70% Ethyl alcohol/Iso propanol. First incision to be put only after
the alcohol has dried.
IV. NEONATAL UNITS
A. ENVIRONMENT:
1. Floors: Cleaning should be performed in the following order – patient areas, accessory
areas and then adjacent halls. Brooms are NOT recommended inside the unit. In the cleaning
procedure, dust should not be dispersed into the air. Wet mopping with detergent and 1%
phenol/0.5% Hypochlorite should be performed twice daily and at the time of any
contamination. Mop heads should be machine laundered and thoroughly dried daily.
2. Surfaces: All ledges and fixtures should be cleaned by wet mopping with detergent once
daily. In addition, wipe surfaces where medicines and equipment are kept with 70% ethyl
alcohol. Cabinet counters, work surfaces, and similar horizontal areas should be cleaned
once a day and between patient use with a disinfectant/detergent and clean cloths, as they
may be subject to heavy contamination during routine use. Friction cleaning is important to
ensure physical removal of dirt and contaminating microorganisms.
3. Walls, windows, storage shelves and similar non-critical surfaces should be scrubbed
periodically with a disinfectant/detergent solution as part of the general housekeeping
program. Keep all medicines, vials and other minor equipment in closed shelves if not in use.
4. Sinks should be scrubbed clean at least daily with a detergent.
5. Always keep the doors closed with a self-closing device.
6. There should be a separate isolation room for babies with suspected sepsis, where source
isolation precautions are to be followed.
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B. EQUIPMENT:
1. Cradles / incubators/baby warmers: Surface clean once daily with detergent and 70% ethyl
alcohol. The mattresses may be cleaned between babies with detergent and wiped with
70%alcohol. Change sheets daily and use laundered linen from the hospital supply.
When the incubators / open care units are being cleaned and disinfected after the baby is
discharged, all detachable parts should be removed and scrubbed meticulously. If the
incubator has a fan, it should be cleaned and disinfected; the manufacturer’s instructions
should be followed to avoid equipment damage. The air filter should be maintained as
recommended by the manufacturer. Mattresses should be replaced when the surface covering
is broken, because such a break precludes effective disinfection or sterilization. Incubators
not in use should be thoroughly dried by running the incubator hot without water in the
reservoir for 24 hours after disinfection.
Infants who remain in the nursery for an extended period should be transferred
periodically to a different, disinfected unit so that the originally occupied unit can be
cleaned.
2. Suction catheters: Catheter tips should be sterile, disposable. Keep the bottles and rubber
tubes clean and dry when not in use. Wash the bottles with detergent and dry, daily and
between patients. Flush catheter with sterile distilled water after each use.
C. BABY CARE:
1. Hand washing: Medical and hospital personnel must follow careful hand-washing
techniques to minimize transmission of disease. The following steps are recommended by
the CDC, Atlanta:
I. Personnel should remove rings, watches, and bracelets before washing their hands and
entering the neonatal nursery. Fingernails should be trimmed short and no nail polish should
be permitted.
II. Before handling neonates for the first time, personnel should scrub their hands and arms to
a point above the elbow thoroughly with an antiseptic soap. After vigorous washing, the
hands should be rinsed thoroughly and dried. Antiseptic preparations (e.g. Chlorhexidine 4 %
or 70% alcohol ) should be used for scrubbing before entering the nursery, before providing
care for neonates, before performing invasive procedures, and after providing care for
neonates.
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III. A 10-second wash without a brush, but with soap and vigorous rubbing followed by
thorough rinsing under a stream of water, is required before and after handling each neonate
and after touching objects or surfaces likely to be contaminated with virulent microorganisms
or hospital pathogens.
Hand washing is necessary even when gloves have been worn in direct contact with
the infant. Hand washing should immediately follow removal of gloves, before touching
another infant. Alcohol-containing foams kill bacteria satisfactorily when applied to clean
hands and with sufficient contact. They can be used in areas where no sinks are available or
during emergency. But they are not sufficient in cleaning physically soiled hands, because
transient organisms are not removed.
2. Feeding of babies
Mother'
s milk is the best food for both normal and low birth weight babies. The
borderline term and growth retarded low birth weight babies can suckle fairly well at the
breast and should be given expressed breast milk in preference to formula feeds by
appropriate techniques such as clean cup and spoon or cleaned and sterilized ‘gokarnam’.
Milk should not be kept for long periods in open containers. The child should be put directly
to the breast as soon as possible. (IAP recommendation). The mother may be given
appropriate instructions regarding personal hygiene, which should include hand washing
techniques: a) Always wash your hands before expressing or handling your milk.
b) Be sure to use only clean containers to store expressed milk. Try to use screw-
cap bottles or hard plastic cups with tight caps. Do not use ordinary plastic bags or formula-
bottle bags. Do not store milk for more than 1 hr at room temperature. Use chilled milk (kept
at 0-4oC) within 24 hours.
3. Invasive procedures: For all invasive procedures, including lumbar puncture, introducing
a cannula or withdrawing blood for any investigation, ALL aseptic precautions have to be
taken. This includes STERILE gloves and wipe with povidone iodine and 70% alcohol, over
the area.
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CHAPTER 4
MANAGEMENT
1.ISOLATION STRATEGIES
In order to prevent the spread of infectious diseases the patients with communicable
diseases were often segregated. However as the knowledge about the different modes of
transmission increased the strategies involved have become more evidence based and
targeted. Though the Centres for Disease Control (CDC), Atlanta, USA, has published
guidelines regarding isolation practices in hospitals, each health care facility should devise its
own strategies based on the local needs. Though appropriate door signs may be necessary,
care must be taken to ensure no breach of confidentiality and not to stigmatise the patient.
Isolation procedures can be divided into two main categories:
Source isolation – A two- tier approach is recommended by the CDC. The Standard
precautions are for all patients admitted in the health care facility regardless of their disease
status. It reduces the risk of transmission of microbes from both known and unknown sources
of infection. These include: hand washing, gloves for body substances, gown if soiling is
likely, and mask if splash is likely. The additional precautions are dependent on the different
modes of transmission. Under this there are six categories of isolation or precaution:
1. Strict isolation - Spread is by contact or airborne. Single room with door shut.
Gloves, mask and gown for all those who enter. Diseases for which this is needed
are – Viral haemorrhagic fevers, pneumonic plague, pharyngeal diphtheria, primary
Varicella and disseminated zoster.
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2. Contact isolation – Spread is by contact. Single room. May cohort with patients with
same infection. Gloves and gown if there is likelihood of contact. Diseases include:
Scabies, infection of wounds or burns with multiply resistant organisms(e.g.
MRSA), rabies and rubella.
3. Droplet precautions – Spread is by large droplets. Requires close contact with the
person and occurs when the particles come into contact with eyes or mucous
membranes of a susceptible person. Single room. May cohort with similar patients,
but at least 1 m separation between patients. Gloves and gown if soiling is likely.
Masks only for those in close contact. Diseases are: Meningococcal meningitis,
measles, mumps, pertussis, H.influenzae epiglottitis.
4. Airborne precautions – Spread is by small droplets, e.g. pulmonary tuberculosis,
where patient is sputum positive. Small droplets remain suspended for longer
periods and travel farther. Single room with a negative pressure .At least six changes
of air / hour .The air has to be exhausted well away from any air intakes. Masks used
should be particulate respirator type with filter. The patient is kept here till at least
three consecutive sputum samples become negative for AFB. One month for
severely ill patients and those with multi-drug resistant tuberculosis. This is also
recommended for HIV infected patients with undiagnosed respiratory infection. Not
needed for atypical mycobacterial infection.
5. Enteric precautions – Diseases spread by faeco oral route. No need of separate room.
Toilet facilities may be shared if patient is hygienic.
2. SURVEILLANCE & OUTBREAK MANAGEMENT
Collection: Methods
1. Continuing Surveillance (CS) of all patients: All records, i.e. clinical, laboratory, nursing
etc. are continuously surveyed. This is time-consuming and some specialties may not have
any infection. This requires staff, IT resources, and a well organized reporting system.
2. Ward liaison (WL): Twice weekly visits to wards and review records.
3. Laboratory based: Laboratory records only. Depends wholly on the kind of investigation
done
4. Laboratory based Ward Surveillance (LBWS): Follow up lab records in the ward. This is
more accurate.
5. LBWS + WL: Time consuming but more accurate.
6. Targeted surveillance: Only high risk areas, e.g. ICUs, newborn units etc.
A minimum data set for surveillance includes:
Date of birth
Antibiotic sensitivity
Sex
Treatment given
Ward/Unit
Other risk factors
Name of consultant
Outcome
Date of admission
Date of discharge/death
Date of onset of infection
Site of infection
Analysis:
A simple comparison of actual number of cases with the expected number is routinely
carried out Validity of data - Incidence increases when there is awareness of a problem,
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4. Identifying outbreaks
An outbreak situation is detected and can be immediately brought under control if their
activities are well coordinated by the ICD. In the absence of an outbreak, the data may be
used by the administrators to convince the media and general public about the effective
infection control precautions taken by the administration. The ICD and ICN use the data to
monitor infection rates in wards and ICUs and post-operative infection rates. This helps in
targeting continuing education programmes and evaluating any gaps in implementation of the
hygiene policies of the hospital.
Outbreaks within hospitals can involve the whole hospital, one theatre, one ward ,one
unit or one wing of the hospital The exact measures taken depends on the kind of infection
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and its mode of spread. The ICT with the help of the hospital management has to plan the
steps to be taken and implement it on a day-day basis. The basic steps of outbreak control
alone are discussed here:
3. Create a case definition, i.e. the cases that come under the label ‘outbreak
case’, should be similar clinically / laboratory wise or both.
4. Identify the index case and construct an epidemic curve in time. This will help
in narrowing down the source and mode of transmission.
6. Take immediate control measures e.g. close down the ICU or source
ward/theatre, any major defects like a break in the chain of waste disposal or
sudden shortage of cleaning staff in that ward will have to be addressed on an
urgent basis.
7. Summarise the investigation and report on steps taken and disseminate the
information to the appropriate authorities. Communicate this information to
the personnel involved, in the hospital.
8. Implement long-term measures so that such an outbreak does not occur in the
future.
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CHAPER 5
ANTIBIOTIC POLICY
An antibiotic policy is not a restriction on the independence to prescribe antibiotics,
but a sensible guide to the practicing doctor on how to manage infections in the most
effective manner. The policy will help the doctor solve the most important problems of
rapidity of action, cost and availability, best route of administration, the most effective dose
and duration of therapy. Generally the microbiologist insists that the antibiotic should be
given according to the pattern of sensitivity obtained after the organism is grown and
identified. This takes a minimum of 24- 48 hrs. Many of the infections can be diagnosed
clinically, e.g. meningitis, lobar pneumonia, infective endocarditis, enteric fever etc. and
need early treatment. The antibiotic policy will help in the following ways:
1. Giving the correct advice to the clinician regarding the antibiotic to be started, after
appropriate cultures have been taken. The sensitivity report will then confirm
whether the same antibiotics may be continued. If the policy is good, there will be
almost no change in the antibiotics started.
2. Another important bonus to the administration is that the number of multi drug
resistant strains that typically cause nosocomial outbreaks will also dramatically
decrease.
3. The pharmacy can order the needed antibiotics in greater quantities rather than
spreading out the resources over drugs that are rarely needed.
The ICT cannot make this policy on its own. The HICC has a big role here. Since all
the specialists are members, the policy may be made by the Microbiologist or Infectious
disease specialist, after receiving suggestions from all of them. The policy can be
reviewed by the committee every year and updated. It should be available for easy
reference in tabular form in all the wards, ICUs and casualty services. If the hospital has
a computer networking system, this will help in easy dissemination to all the medical
officers.
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The following policy is based on one followed by the National Health Services
(NHS), UK. These guidelines were developed by a multi-disciplinary working group to
ensure balanced input. It has considered the antimicrobial choice for specific conditions, and
the existing policies for specific agents. By following the guidelines it will be possible to
maintain a high standard of patient care, delivered in a consistent way, by all the doctors in
the hospital. It may be modified appropriately based on cost and availability.
The use of antimicrobials has adverse consequences which compromise the efficacy of
therapy for individual patients and the hospital as a whole. These include:
CHOICE OF ANTIMICROBIAL
The sections in this policy indicate the suggested approach to treating the most
common forms of infection encountered in a hospital setting. The use of a restricted range of
antimicrobial agents provides greater familiarity with their efficacy and potential side effects.
It also allows the Microbiology services to provide appropriate sensitivity data to guide
therapy.
However this general guidance is not applicable to all patients. The choice of antimicrobial
may need to be modified in the following situations:
MONITORING TREATMENT
The continued need for antimicrobial therapy should be reviewed at least daily. For
most types of infection treatment should continue until the clinical signs and symptoms of
infection have resolved – exceptions to this are indicated in the relevant sections. Parenteral
therapy is normally used in seriously ill patients and those with gastrointestinal upset. Oral
therapy can often be substituted as the patient improves. Where treatment is apparently
failing, advice from a clinical microbiologist should normally be sought rather than
blindly changing to an alternative choice of antimicrobial agent.
ANTIBIOTIC POLICY
If meningitis is suspected, take blood samples and then give antibiotics before LP or CT
scan. LP may be done within one hour of starting antibiotics.
If confident that patient has typical meningococcal rash and no allergy - Benzyl penicillin
2.4g IV every 4 hours. If adult without a typical meningococcal rash - Cefotaxime IV 2g
QDS. If patient > 50 years, or immuno-compromised, or pregnant, and no typical
meningococcal rash - consider adding Amoxicillin 2g IV every 4 hours (to cover listeriosis)
5. PYELONEPHRITIS
Clinical signs:
Pyrexia, rigors, loin pain +/- urinary tract symptoms and renal colic
Initial antimicrobial therapy is almost always given intravenously.
Culture negative MSU with pyuria and/or persistent symptoms - consider urethritis including
Chlamydia or TB. Refer to Urologist after first time in males and second UTI in females.
Delay in diagnosis and effective treatment for PID can increase the risk of tubal damage.
Therefore, treatment should start immediately, without waiting for the results of the swabs.
The patient'
s sexual partner must have antibiotic therapy to prevent possible re-
infection. She should be advised to abstain from sexual intercourse until both she and her
partner have completed the antibiotics.
Outpatient
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
Or Ceftriaxone 250mg IM stat
Inpatient
Cefuroxime 750mg IV TDS and Metronidazole 500mg IV TDS
Or Metronidazole 1g PR TDS and Doxycycline 100mg PO BD
IV therapy should continue for a minimum of 24 - 48 hours, then:
Doxycycline 100mg PO BD for 14 days and Metronidazole 400mg BD for 14 days
6. OTITIS MEDIA
Inflammation of the middle ear which may be followed by profuse purulent discharge as the
ear-drum perforates. Discharge usually settles after a few days. Continuing discharge may
indicate mastoiditis. It may be associated with an obstruction of the eustachian tube.
Non antibiotic treatment:
Drain pus through acute perforation, clean debris
Analgesics such as paracetamol, NSAIDS and dihydrocodeine
Decongestants may be of some benefit.