19/05/2014

INFECTION

Titis Kurniawan, MNS

Objectives

Students able to:

Explain the definition of infection

Explain the infection chain

Explain the infection related factors

Explain the universal precaution

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……..Definition

An invasion of pathogens or
microorganisms into the body
that are capable of producing
disease.

The invasion and

reproduction of
microorganisms in a body
tissue that can result in a
local or systemic clinical
response such as cellulitis,
fever etc.

…………Infection Chain

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......Infection chain
CAUSATIVE AGENTS:

A biologic agent/s capable of
causing infectious diseases.

E.g; Bacteria, Parasites, amoeba,
Fungi & Viruses

Number & Pathogenity

Characteristic;

Need adequate environement;
oxygen, pH, nutrition

Able to be Resistance

Able to mutated

......Infection chain
Reservoir

Place in which an infectious
agent can survive but may or
may not multiply
– Salmonella in milk: survives
and multiplies
– Hepatitis B virus on surface of
hemodialysis machine:
survives but does not multiply.

Two Major Types of Human
Reservoir;
– Cases (patient); acute &
subclinical
– Carier; HBV, HIV

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......Infection chain

Portal of Exit (Human Reservoirs)

Respiratory Tract

Genitourinary Tract

Gastrointestinal Tract

Skin/Mucous Membrane

Transplacental (mother to fetus)

Blood

......Infection chain
Modes of Transmission

The mechanism for transfer of an
infectious agent from a reservoir to a
susceptible host.

Five main routes; Droplet, Airborne,
Common Vehicle (Food, blood), Vector-
borne, Contact (direct/indirect)

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......Infection chain
Portal of Entry
• The path by which an
infectious agent enters the
susceptible host
– Respiratory tract
– Genitourinary tract
– Gastrointestinal tract
– Skin/mucous membrane
– Transplacental (fetus from
mother)
– Parenteral (percutaneous, via
blood)

......Infection chain
Susceptible Host

A person usually lacking effective
resistance to a particular pathogenic
agent.

To reduce susceptibility – provide
adequate nutrition & rest, promote body
defenses against infection & provide
immunization.

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Sources & Modes of Transmission

1. Person-to-Person Transmision

Skin-to-skin contact, clothes, (folliculitis with Staphylococci or
MRSA ,viral as HSV1)

Droplets  coughing, sneezing (common cold, flu, swine flu,
pneumonia, bacterial meningitis), or kissing (infectious
mononucleosis, cold sores)

Stool-to-mouth (fecal-oral) spread  dirty hands or utensils
(hepatitis A, Giardia, pinworms(oxyuris), cholera, poliomyelitis)

Sexually transmitted (gonorrhea, Chlamydia, genital HSV2, genital
warts (human papillomavirus – HPV), AIDS & syphilis)

Contaminated blood;

Contaminated needles, usually by drug addicts or health workers
(hepatitis B, C, AIDS)

Blood transfusion (hepatitis B,C, AIDS, viral hemorrhagic fevers)

Vectors: mosquitoes (Malaria, Dengue fever)

.......Sources & Modes of Transmission

Spread from mother to

fetus/Transplacenta  during pregnancy
(hepatitis B, C, HIV, HSV-1, HSV-2, rubella,
toxoplasma, varicella, syphilis, bird flu), or
delivery (Chlamydia trachomatis, Neisseria
gonorrheae, group B
Streptococci=S.agalactiae)

An autoinfection – the spread of an infection
from one body part to another, usually by
hands or clothes (folliculitis, impetigo).

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.......Sources & Modes of Transmission

2. Waterborne Infections

By drinking contaminated water, one can contract,
cholera, dysentery, typhoid fever, amebiasis &
cryptosporidium . Tap water in hospitals may contain
Legionella.

By swimming in contaminated swimming or spa pools,
or lakes, intestinal parasite Cryptosporidium, eye and
middle ear infections. Certain parasites may enter
through the skin(schistosoma).

Water in public showers may hold Legionella

Flood water may contain various pathogenic microbes

.......Sources & Modes of Transmission

3. Airborne Infections

Industrial cooling or hot water systems

Droplet nuclei; remain infectious when spread in the
air  TB, measles, varicella, and variola

4. Soil

Walking barefoot  Clostridium tetani, or intestinal
parasites, like Strongyloides stercoralis or
hookworms(Ancylostoma) can be contacted.

Eating with soil-contaminated hands  result in
infection by parasites.

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.......Sources & Modes of Transmission

5. Food-Borne Infections

Food poisoning is an infection of the gastrointestinal
tract caused by microbes from contaminated food:
bacteria like Salmonella or E.coli, toxins from
Staphylococcus aureus or Clostridium botulinum or
viruses like Enterovirus

6. Nosocomial Infection

Health-care acquired infections(HAI)

Caused by bacteria that are resistant to antibiotics (multi-
drug resistant strains)

The most;

Urinary tract infections from urinary catheters (CA-UTI) .

Surgical-site infections (SSI).

Catheter related Blood stream infections(CR-BSI).

Ventilator associated pneumonia(VAP)

Fungal infections, in patients with low immunity.

Infection Related Factors

Internal factors
External factors

Age
Pathogenity

Immunity status
Environment

Psychological status (equipments)

Skin integrity
Policy

Mobility

Personal hygiene

Behaviors

Underlying disease

Inserted medical devices

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Kewaspadaan Universal

Setiap tindakan/upaya dalam mencegah infeksi untuk
mengurangi risiko transmisi patogen melalui paparan
darah tanpa memandang status infeksi penderita

Body substance issolation; infection prevention that
protect patients and healthcare staffs from all body
substances; body fluid, secretion, that potentially
infected

Darah dan semua jenis cairan tubuh, sekret, ekskreta
(kecuali keringat), kulit yang tidak utuh dan selaput
lendir penderita dianggap sebagai sumber potensial
untuk penularan infeksi

Breaking the Chain of Infection

Source control measures

Cough etiquette, cleaning, disinfection

Modes of transmission

Contact: hand hygiene

Droplet: distance from source >1 m

Airborne: ventilation

Vector: bednets

Portal of entry into the host

Adding barriers, e.g., PPE

Host

Strengthen host defences, e.g., vaccination

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Universal Precaution

Hand hygiene

Personal protection equipment

Contaminated Equipment management

Waste product management

Patients issolation

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...........Universal Precaution
Hand Hygiene

Is Cleaning Hand

Why;

Colony of bacteria; 1 x 106 colony forming units
(CFUs)/cm2 on the scalp, 5 x 105 CFUs/cm2 in the
axilla, 4 x 104 CFUs/cm2 on the abdomen, and 1 x
104 CFUs/cm2 on the forearm, 3.9 x 104 to 4.6 x 106
hands of medical personnel (Selwyn, 1980; Price
1938; Maki, 1987; Larson, 1998)

Most common transmission; Hand

Type;

Routine/social

Aseptic

Surgical

...........Universal Precaution
Routine Hand Hygiene

To render the hands physically clean and to
remove transient micro-organisms.

When; 5 moments hand hygiene

Material used; Liquid soap (plain or
antimicrobial) & alcohol hand rub

Alcohol based Vs. Liquid soap

Alcohol (70% isoprolol) >> effective than
antimicrobial (4% chlorhexidine/ plain soap

Alcohol less damaging skin effects

Alcohol >> shorter time for applied

Alcohol storage >> efficient

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5 Moments Hand Wash

Routine Hand Wash

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Alcohol Hand Rub

...........Universal Precaution
Aseptic Hand Hygiene

To remove transient micro-organisms & inhibit the growth
of resident micro-organisms prior to any care activity that
implies a direct/indirect contact with a mucous membrane,
non-intact skin or an invasive medial device.

When; all aseptic procedures on the ward

Material used; antiseptic detergent/ antimicrobial soap
(eg 2 - 4% Chlorhexidine gluconate or 7.5% Povidone
iodine).

Procedures:

Remove jewellery

Wash hands thoroughly using an antimicrobial soap for
one minute using the technique outlined in
Routine/Social Hand Hygiene

Rinse carefully

Do not touch taps with clean hands – if elbow or foot
controls are not available, use paper towel to turn off
taps

Pat dry hands using clean paper towels

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...........Universal Precaution
Surgical Hand Hygiene
Procedure: first scrub of the day five minutes:
Step 1: Duration 1 minute
1. Open & prepare a nail cleaner and scrub brush for later use (single
use disposable brush/sponges impregnated with antimicrobial
soap).
2. Rinse and wash hands & arms with sufficient antimicrobial soap
until 2.5 cm above the elbow and contact time with the antimicrobial
soap
3. With the hands under gently running water, use the nail cleaner to
remove debris from underneath the fingernails. The antimicrobial
soap is left in contact with the forearms while the fingernails are
cleaned
4. When finished with the nail cleaner discard in a safe manner and
rinse the hands and forearms

Step 2: Duration 2 minutes

5. Apply antimicrobial soap to the bristles of the scrub brush and
continue cleaning the fingernails.
6. Apply antimicrobial soap to the sponge side of the brush and wash
all surfaces of hands and forearms working from the nail beds and
between fingers before proceeding to wash the forearms (to the
level of the elbow) using circular hand motions. Apply more
antimicrobial soap if necessary. On completion, dispose of the scrub
brush in a safe manner and rinse the hands and forearms.

...........Universal Precaution
Surgical Hand Hygiene
Step 3: Duration 2 minutes
7. Hands and forearms are washed again using the same principles and
procedures above, but stopping at mid forearm. On completion, rinse
the hands and forearms.
8. Hands are washed again using the same principles and procedures.
9. Finally, the hands and forearms are rinsed thoroughly.
10. Remain at the scrub sink until the hands and arms are free of excess
water, being careful to avoid splash, contamination or injury on wet
surfaces.
11. Approach the gown trolley and grasp the sterile towel by one corner,
being careful to avoid contamination of the sterile field with drips from
hands (which are clean, not sterile)
12. Step back from the sterile field and with hands outstretched, allow the
towel to unfold, being careful to avoid contamination by contact with
unsterile scrub attire.
13. Using one half of the unfolded towel as a barrier between hands, pat
dry or wipe the opposite fingers and hand, moving down the forearm to
the elbow in a circular motion, without returning to the hand. This half of
the towel comes in contact with skin above the elbow and is not used
again.
14. Grasp the opposite half of the towel and release the contaminated half.
Pat dry or wipe the opposite fingers and hand, moving down the
forearm to the elbow in a circular motion, without returning to the hand.
15. Drop the used towel into an appropriate container being careful to
avoid contamination from further handling of the towel. Hands are to
remain above the waste level and away form the unsterile scrub suit at
all times.

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...........Universal Precaution

Principle in Donning & Removing PPE

Donning squence;

Gown, mask, google, face shield, gloves

Contaminated & Clean Area of PPE

Contaminated; PPE area that likely contact
with patients body site, equipment,
contamonated enviroment (outside front)

Clean; PPE area that not likely contact with
contaminated area (outside back, inside, tieson
head & back)

Removing squence;

Gloves, face shield, google, gown, mask  HH

Where ; doorway, before leave the patients’ room
(anteroom) where the HH facilities available

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...........Universal Precaution

Gown

To; protect arms and exposed body areas and
prevent contamination of clothing with blood,
body fluids, and other potentially infectious
material

1st personal protection equipment (PPE)
must be donned when indicated

Protected area; body front, from neck to the
mid-thigh or below

Removed;

should be removed in a manner that prevents
contamination of clothing or skin. The outer,
“contaminated”, side is turned inward and rolled
into a bundle, and then discarded into a
designated container for waste or linen to
contain contamination

Should be removed before leaving the patient
care area to prevent possible contamination of
the environment outside the patient’s room

Donning & Removing Gown

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...........Universal Precaution

Gloves

Type of medical gloves

Examination gloves

Surgical gloves

Chemotherapy gloves

To; reduce risk for contamination (patients – staffs
vice-versa & patients – to patients)

When;

during all patient-care activities that may involve
exposure to blood and all other body fluid (including
contact with mucous membrane and non-intact skin)

Contact with potentially contaminated patients’
equipment/environment

Change between procedure

Change between patients

Disposible  always performed HH after gloves

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Removing Gloves

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...........Universal Precaution

Mask

For;

Droplet or airborne precaution 
cough/sneeze, suspect or confirmed TB

Steril technique (staff potent to spread disease)

Procedure produce splashes or sprays of blood,
body fluids, secretions, or excretions (suction,
broncoscopy, etc)

Must cover mouth & nose

Type;

Surgical

Procedure/isolation mask

Respirator  higher protection (common
used N95, N99, N100, or Powered air-
purifying respirator (PAPR)

...........Universal Precaution

Google/Face Shield

For;

Droplet or airborne precaution  cough/sneeze,
suspect or confirmed TB

Minimize  droplet – eye contact

Procedure produce splashes or sprays of blood,
body fluids, secretions, or excretions (suction,
broncoscopy, etc)

Should be considered

Size

Comfortable

Vision

Face shield; Should cover forehead, extend
below chin and wrap around side of face

Removing (Mask, google, face shield)

after gloves removed & HH performed

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...........Universal Precaution
Needle & sharp-related injury

Recap The needle;

Never two hands recap needle
X

One hand recap

Needles and other sharps must be
discarded in rigid, leak-proof, puncture
resistance containers X

√ √
X

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...........Universal Precaution
When Exposed/injured Occured
1. Wash the exposed part;

Body surface; rinse using clean water/NaCl 0,9% & soap/antiseptic  Betadine
(povidone iodine 2.5%) selama 5 mnt/Alcohol 70% selama 3 mnt

Mouth ; spoiled & gargling

Eye; irigated

NEVER sucking
2. Report  warning system
3. Identify the risk of infection (HIV, Hepatitis B, other infected
diseases)
4. Profilaxis medication if indicated

Anti retroviral prophylaxis, if necessary should started within 2 hours, (if injury is
from HIV positive or high risk group).

Vactination Hepatitis B
5. Conselling

Preparing psychological consequences

Minimizing further infection spread (no sex intercouse untill 3 months
negative infection is confirmed)
6. Documented Lesson learned

Management Medical Equipmens (Reused)

Dekontaminasi
Rendam dalam larutan klorin 0.5% selama 10 menit

Cuci bersih dan tiriskan

Pakai sarung tangan dan pelindung terhadap objek tajam

Sterilisasi Disinfeksi Tingkat Tinggi

Uap Bertekanan Pemanasan Kimiawi Kimiawi Uap Rebus
Tinggi–Autoclaf Kering Rendam dalam
121oC larutan disinfektan rendam dalam Tutup dalam uap diamkan
106 kPa (1 atm) 170o C 10 - 24 jam larutan disinfektan air mendidih mendidih selama
20 – 30 menit selama 60 menit 20 menit selama 20 menit 20 menit

Pendinginan & Penyimpanan

Siap pakai

Catatan:
1 Alat yang terbungkus dalam bungkusan steril dapat disimpan sampai satu minggu bila tetap kering
2 Alat yang tidak terbungkus harus disimpan dalam tempat (tromol) steril
3 Alat yang diolah dengan disinfeksi tingkat tinggi disimpan dalam wadah terutup yang tidak mudah terbuka
atau segera dipakai

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Disinfektan
Disinfektan Pemakaian Keunggulan Kekurangan
DTM, Antiseptik kulit Konsentrasi , inaktif oleh
Kerja cepat, tanpa
Alkohol Termometer, residu, tidak berbekas
bahan organik, karet
stetoskop, mengeras

DTM, Alat dialisis,

tanki, CPR, Korosif, inaktif oleh bahan
Murah, kerja cepat,
Klorin dekontaminasi alat dan
tersedia di pasar
organik, iritasi, tidak stabil
permukaan, percikan pada pengenceran 1:9 (>)
darah
Kerja lambat dan butuh
Untuk alat yang tidak
Etilin waktu lama untuk
Sterilisasi gas tahan panas dan
Oksida menghilangkan residu yang
tekanan
toksis
Terbatas,
Formalde- Tahan terhdp bahan Karsinogeni, toksik, iritan,
dekontaminasi
hid organik bau menyengat
biosafety lab, fumigasi
Nonkorosif, tahan Iritasi, cepat inaktif bila
DTT (2%), endoskopi,
Glutaralde- bahan organik, cocok diencerkan, mahal, sulit
alat terapi pernafasan,
hid untuk alat optik, dipantau konsentrasinya,
alat anestesi
sterilisasi dlm 6-10jam residu

Disinfektan
Disinfektan Pemakaian Keunggulan Kekurangan
3% - DTR, lantai,
dinding, perabot RT Oksidan kuat, kerja Korosif bagi aluminium,
H2O2 cepat, terurai – O2 tembaga, kuningan dan
6%- DTT, endoskop, dan air seng
lensa kontak

DTM- termometer, Tdk cocok utk permukaan

tanki keras, korosif u/ metal,
Kerja cepat, tidak
Yodofor kulit terbakar, tdk tahan
DTR- permukaan keras toksik & tdk iritatif
bhn organik meninggalkan
kursi roda, TT, bel bercak
Aman u/ lingkungan
DTT ut alat tdk tahan
Asam (air, O2, H2O2, asam Korosif, tidak stabil bila
panas, untuk mesin
Parasetat asetat), kerja cepat, diencerkan
sterilisasi
aktif thd organik
Tidak u/ kamar bayi
DTM/ DTR, lantai, Residu dipermukaan, (hiperbilirubinemia), tidak
Fenol
dinding, perabot RT. banyak di pasar utk kontak dg makanan,
diserap kulit, lengket
DTR, Lantai, dinding,
Amonium Tdk untuk alkes, terbatas
perabot, percikan Non-iritatif, detergent
Kuarterner spektrum sempit
darah

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Linen Management

Clean Linen

Definition: Linen,which is not from a patient in source isolation
and is not visibly soiled with blood or body fluids.

Plastic disposable apron must be worn to handle the linen.

The linen should be placed directly into nylon/polyester/plastic

laundry bags.

Bags should be coloured white/off white and must be securely

fastened by knotting the bag to prevent spillage before leaving
the ward.

Ensure the bag is only ¾ full.

Take the bag directly to the appropriate holding area

........Linen Management

Soiled Linen

Definition: Linen soiled with blood and/or body fluids.

Disposable gloves and a plastic disposable apron
must be worn to handle the linen.

The linen should be placed directly into white
polythene laundry bags and must be securely
fastened by knotting the bag to prevent spillage
before leaving the ward.

Ensure the bag is only ¾ full.

Take the bag directly to the appropriate holding area

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........Linen Management
Infected Linen/Heavily Soiled Linen

Definition: Linen from a patient in source isolation or which is heavily
soiled with blood or body fluids.

Disposable gloves and a plastic disposable apron must be worn when
handling infected linen/heavily soiled linen.

Linen in this category must be placed into a red water-soluble bag
which is securely tied using the tear off tie strip (attached to the bag).
Under no circumstances should linen be disposed of as clinical
waste unless authorised by Infection Prevention (Out of hours
contact the Duty Manager)

This must then be placed into a red plastic bag avoiding contamination
to the red outer bag, and securely fastened by knotting the bag to
prevent spillage before leaving the ward. If removing from source
isolation then the outer bag should be held open by another staff
member (wearing gloves and apron) outside the room or isolation area.

Take the bag directly to the appropriate holding area; do not leave bags
in side rooms with soiled linen in them.

Waste Product Management

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