Infection Control

Indications

The primary goal of an infection control program is to prevent and halt the transmission of infections. Specific precautions are necessary to prevent the transmission of infection, depending on the microorganism. The following are examples of indications for transmission-based precautions:

• Standard precautions: These precautions are used for all patient care. Standard precautions include hand hygiene, use of personal protective equipment, appropriate patient placement, cleaning and disinfection of patient care equipment, management of textiles and laundry, safe injection practices, and proper disposal of needles and other sharp objects.

• Contact precautions: These precautions are used for patients with known or suspected infections that can be transmitted through contact. For these patients, standard precautions, including the use of nonsterile gloves and gowns, are necessary. Additionally, the transport and movement of patients should be limited, disposable patient care equipment should be used, and thorough cleaning and disinfection strategies should be implemented. Contact precautions are indicated for patients with conditions such as acute infectious diarrhea caused by Clostridium difficile, vesicular rashes, respiratory tract infections caused by multidrug-resistant organisms, abscesses, or a draining wound that cannot be covered.

• Droplet precautions: These precautions are used for patients with known or suspected infections that are transmitted by air droplets through coughing, sneezing, or talking. In such cases, patients should wear a mask to control the spread of the source. In addition to standard precautions, it is essential to limit the patient's transport and movement. Droplet precautions are indicated for patients with respiratory tract infections, especially in infants and young children; those with petechial or ecchymotic rash accompanied by fever; and those with meningitis.

• Airborne precautions: These precautions are used for patients with known or suspected infections that can be transmitted by the airborne route. These patients should be placed in an airborne infection isolation room with all the previously mentioned protections, along with respirators, sterile gowns, and gloves for examination. Airborne precautions are essential for infections such as tuberculosis, measles, chickenpox, and disseminated herpes zoster. Airborne precautions are also indicated for patients with a suspected vesicular rash, those with a cough and fever accompanied by pulmonary infiltrates, and those with a maculopapular rash who also have cough, coryza, and fever.

Multiple clinical scenarios may require more than one type of precaution to ensure appropriate implementation of standard and transmission-based infection control measures. For example, patients with suspected C difficile infection require both contact and standard precautions, whereas those with suspected or confirmed tuberculosis require airborne, contact, and standard precautions.

Table 1. Summary of Transmission-Based Precautions in Healthcare Settings

Equipment

Healthcare facilities must have the necessary equipment to implement standard precautions for all patients. Among these, hand hygiene is the most effective measure for preventing the transmission of infections, which is achieved by washing hands with soap and warm water or by rubbing hands with alcohol- or non-alcohol-based hand sanitizers. Gloves can also be used as a standard precaution; new gloves must be used for each patient and disposed of after each patient interaction. Other personal protective equipment includes facial protection—such as procedure masks, surgical masks, goggles, and face shields—and gowns before entering the patient's room. Infection control equipment also includes the housekeeping tools, where adequate and routine disinfection of surfaces and floors is implemented. Additionally, linens must be handled and transported in a manner that prevents exposure to skin and mucous membranes using the appropriate personal protective equipment.

Personnel

Hospitals must recruit hospital epidemiologists and infection preventionists and establish an infection control committee to organize and implement a well-structured infection control program. The hospital epidemiologist is required to interface with various hospital departments and administrators to discuss their responsibilities, expectations, and available resources. Infection preventionists are trained healthcare experts responsible for creating and enforcing infection control policies, educating both staff and patients on preventive measures, and investigating outbreaks. The role of infection preventionists in formulating effective infection prevention strategies and safeguarding public health became increasingly crucial with the onset of the COVID-19 pandemic.[4][4] The epidemiologist generally oversees the infection prevention program and, in some cases, the quality improvement program. A clinician with a subspecialty in infectious disease typically holds the position.[5][6] A registered nurse with a background in clinical practice, epidemiology, and basic microbiology typically holds the title of infection preventionist. Hospitals can have multiple infection preventionists depending on the number of beds available, mix of patients, and the Centers for Disease Control and Prevention (CDC) recommendations.[7][8] The final aspect of a functioning infection control program is the infection control committee, which comprises an interprofessional group of clinicians, nurses, administrators, epidemiologists, infection preventionists, and other representatives from the laboratory, pharmacy, operating rooms, and central services. The responsibilities of this committee include generating, implementing, and maintaining policies related to infection control.[7]

Technique or Treatment

To achieve a successful and functioning infection control program, hospitals can implement several key measures.

Surveillance

The primary aim of surveillance programs is to assess the rate of infections and endemic likelihood. Generally, hospitals target surveillance for health care–associated infections in areas where the highest rates of infection are found, including intensive care units, hematology or oncology units, and surgery units. However, in recent years, surveillance has expanded to include hospital-wide surveillance, as it has become a mandatory requirement by public health authorities in multiple states.[9] This change has also been further supported by the widespread implementation of electronic health records in most hospitals in the United States, enabling medical providers to access electronic records at patients' bedside and assess risks and surveillance data for each patient. Most hospitals have developed sophisticated algorithms in their electronic health systems that can streamline surveillance and identify patients at highest risk for health care–associated infections. Hence, a hospital-wide surveillance targeting a specific infection can be implemented relatively easily. Public health agencies require hospitals to report specific infections to strengthen the public health surveillance system.[9]

Isolation

The main purpose of isolation is to prevent the transmission of microorganisms from infected patients to others. Isolation is an expensive and time-consuming process; therefore, it should only be utilized if necessary. Conversely, failure to implement isolation when necessary can lead to increased morbidity and mortality, thereby increasing overall healthcare costs. Hospitals that operate with a single patient per room can implement isolation efficiently; however, many facilities still have a substantial number of double-patient rooms, which pose a challenge for isolation.[10] The CDC and the Healthcare Infection Control Practice Advisory Committee have issued a guideline to outline approaches for enhancing isolation. These guidelines are based on standard and transmission-based precautions. Standard precautions refer to the assumption that all patients are possibly colonized or infected with microorganisms; therefore, precautions are applied to all patients at all times and in all departments. The main elements for standard precautions include:

• Hand hygiene before and after patient contact
• Personal protective equipment for contact with any body fluid, mucous membrane, or nonintact skin
• Safe needle practices, including the use of a new needle and syringe for each dose and the proper disposal of the syringe in a safe container [11]

Other countries, such as the United Kingdom, have also adopted the bare below the elbows initiative, which requires all healthcare providers to wear short-sleeved garments with no accessories, including rings, bracelets, and wristwatches. For transmission-based precautions, a cohort of patients is selected based on their clinical presentations, diagnostic criteria, or confirmatory tests with a specific indication of infection or colonization of microorganisms to be isolated. In these cases, airborne, droplet, and contact precautions are necessary. These precautions are designed to prevent the transmission of disease based on the type of microorganism.[12]

Outbreak Investigation and Management

Microbial outbreaks can be identified through the surveillance system. Once a particular infection's monthly rate crosses the 95% confidence interval threshold, an investigation is warranted for a possible outbreak. Additionally, clusters of infections can be reported by the healthcare providers or laboratory staff, which should be followed by an initial investigation to assess if this cluster is indeed an outbreak. Typically, clusters of infections involve a common microorganism, which can be identified using molecular techniques such as pulsed-field gel electrophoresis or whole-genome sequencing, allowing for more precise tracking and characterization of the pathogen. Most outbreaks result from direct or indirect contact involving a multidrug-resistant organism. Infected patients must be separated and isolated if necessary, and the implementation of the necessary contact precautions, depending on the suspected cause of infection, must be enforced to control such outbreaks.[13]

Education

Healthcare professionals require ongoing education and periodic reinforcement of their knowledge through seminars and workshops to ensure a thorough understanding of how to prevent the transmission of communicable diseases. Hospitals may develop an infection prevention liaison program by appointing a healthcare professional who can reach out and disseminate infection prevention information to all hospital members.

Employee Health

The infection control program must collaborate closely with the employee health service. Both teams need to address important topics related to employee well-being and infection prevention, including the management of exposure to bloodborne communicable diseases and other communicable infections. Generally, all new employees undergo a screening by the employee health service to ensure they are up-to-date with their vaccinations and have adequate immunity against common communicable infections, such as hepatitis B, rubella, mumps, measles, tetanus, pertussis, and varicella. Moreover, healthcare employees should always be encouraged to receive the annual influenza vaccination. Additionally, periodic tests for latent tuberculosis should be conducted to assess for any new exposure. The employee health service should develop proactive campaigns and policies to promote employee well-being and prevent the spread of infections.[8]

Antimicrobial Stewardship

Effective antimicrobial stewardship is essential in both hospital and outpatient settings to ensure the appropriate use of antibiotics. Given the widespread prescription of antibiotics, there is significant variation in how often and under what circumstances they are administered to patients [Centers for Disease Control and Prevention. (2021, December). About Antibiotic Resistance. U.S. Department of Health and Human Services]. To address the growing problem of antimicrobial resistance, improve patient outcomes, and reduce healthcare costs, many hospitals have established antimicrobial stewardship programs [CDC. Core Elements of Hospital Antibiotic Stewardship Programs]. These programs focus on tracking patterns of antimicrobial resistance and linking these trends to the specific antibiotics prescribed. By monitoring resistance profiles, hospitals can adapt treatment plans accordingly. Antimicrobial stewardship programs are generally classified as either active or passive, targeting different phases of the prescription process.

In the pre-prescription phase, active antimicrobial stewardship strategies include setting restrictions on certain antibiotics or requiring preauthorization before they are prescribed. These measures help ensure antibiotics are used only when necessary and are prescribed in accordance with the latest evidence-based guidelines. On the other hand, passive strategies involve educating healthcare providers, sharing clear guidelines, and distributing reports on antimicrobial susceptibility. These initiatives are designed to keep prescribers informed and guide them in making well-informed decisions. During the post-prescription phase, active measures involve providing clinicians with real-time feedback on antibiotic use, dosage, bioavailability, and susceptibility patterns. Additionally, active stewardship may include switching from intravenous to oral antibiotics when appropriate. In contrast, passive measures rely on electronic medical records to flag issues such as unnecessarily prolonged prescriptions or mismatches between antibiotics and the pathogens they are intended to treat [Code of Federal Regulations. 482.42 Condition of participation: Infection prevention and control and antibiotic stewardship programs.]

Policy and Interventions

The main purpose of the infection control program is to develop, implement, and evaluate policies and interventions to minimize the risk of health care–associated infections. Policies are typically developed by the hospital's infection control committee to enforce procedures that are generalizable to the hospital or certain departments. These policies are developed in accordance with the hospital's needs and evidence-based practices. Interventions that impact infection control can be categorized into 2 types—vertical and horizontal interventions. Vertical interventions aim at reducing the risk associated with a single pathogen. For example, surveillance cultures and subsequent isolation of patients infected with methicillin-resistant Staphylococcus aureus. In contrast, horizontal intervention targets multiple pathogens that are transmitted through the same mechanism. An example is hand hygiene protocols, which require clinicians to wash their hands before and after patient contact to prevent the transmission of multiple pathogens. Vertical and horizontal interventions can be implemented simultaneously and are not mutually exclusive. However, vertical interventions may be more expensive and do not impact the other drug-resistant pathogens. In contrast, horizontal interventions may be a more affordable option with more impactful results if implemented appropriately.[14]

Environmental Hygiene

As the inpatient population becomes more susceptible to infections, the emphasis on environmental hygiene has increased. Hospital decontamination through traditional cleaning methods is notoriously inefficient. Newer methods, including steam, antimicrobial surfaces, automated dispersal systems, sterilization techniques, and disinfectants, have demonstrated greater effectiveness in reducing pathogen transmission through the surrounding environment.[15] The CDC has published guidelines that emphasize collaboration among federal agencies, hospital engineers, architects, public health experts, and medical professionals to manage a safe and clean environment within hospitals, encompassing air handling, water supply, and construction.[16]

Clinical Significance

Infection control in clinical practice involves the timely identification and containment of infections to prevent their spread. Clinicians play a significant role in infection control by identifying signs and symptoms suspicious of a transmissible infection, such as tuberculosis. Precaution orders must be placed and implemented even before a confirmatory diagnosis is reached to prevent the possible transmission of the infectious pathogen. Clinically, an efficient infection control program results in fewer infection rates and a lower risk for the development of multidrug-resistant pathogens. Hospital-acquired infections are one of the most common healthcare complications. Therefore, simple standard precautions such as hand hygiene can prove to be highly effective. Handwashing before and after every patient interaction is one of the most effective and least expensive ways clinicians can uphold infection control principles.[17] Hence, hospitals should actively promote hand hygiene by providing reminders at each bedside and ensuring the availability of sinks or hand sanitizer stations at the entrance of every patient room.

Another simple measure is to educate patients always to use their forearms to block their coughs or sneezes. This practice prevents the transmission of droplets and the direct contamination of hands, which can transfer pathogens to other surfaces. The clinical significance of infection control was especially highlighted during the COVID-19 pandemic.[18] The experience of managing a highly contagious respiratory virus underscored the critical importance of infection control measures, including early identification, isolation protocols, and rigorous hygiene practices. With COVID-19, the transmission dynamics required healthcare systems to rapidly adapt, with an increased emphasis on personal protective equipment, patient screening, and contact tracing. During this time, the implementation of additional precautions, such as airborne precautions for patients suspected of having COVID-19, became commonplace. Hospitals witnessed firsthand how effective these practices can be in reducing transmission rates, but also how quickly infections can spread if precautions are not consistently followed. The pandemic further highlighted the need for constant vigilance, clear communication of guidelines, and a collaborative approach to infection prevention. The pandemic led to advancements in infection control technologies and systems, such as the use of advanced ventilation systems in healthcare settings, telemedicine, and contactless monitoring tools.

Enhancing Healthcare Team Outcomes

Infection control has many challenges, especially with the increasing number of hospitalized patients, a greater prevalence of invasive technologies, and a higher prevalence of immunocompromised patients.[19] Poor infection control programs contribute to higher infection rates, increased likelihood of multidrug-resistant bacteria, and a greater risk of outbreaks in specific departments that may spread to the entire hospital and community. Limited resources represent a significant barrier to implementing optimal infection control programs. Hospital epidemiologists should carefully balance cost, clinical outcomes, patient satisfaction, and economic impact when considering new interventions. They also need to assess the latest evidence-based literature to ensure that all infection control policies are up-to-date and monitor the emergence of newly resistant pathogens. 

The primary direct complication of a poorly managed infection control program is the increased risk of infection for patients. Patients may be at risk for bacterial, viral, fungal, or parasitic infection. If the infection is severe, it can spread to the bloodstream, leading to sepsis and possible septic shock, which are life-threatening. All healthcare workers share the responsibility of preventing infections and maintaining an aseptic environment when possible. Nurses are on the front lines of this issue, as they routinely have the highest level of contact with the patient and have access to all aspects of the facility. Their observations and recommendations should be taken seriously by all members of the interprofessional healthcare team. Among all preventive strategies, hand hygiene remains the most fundamental and effective method for reducing the risk of infection.