1. Nosocomial Infection ----Prevention and control Wang kefang （王克芳） kefangwang@126.com

2. Questions: 1. What kind of signs and symptoms indicated that there’re something wrong with Helen? 2. How do you explain Mrs. Helen’s pain in her hip and fever? Scenario Ⅰ Mrs. Helen is a 63-year-old woman with diabetes who underwent a total hip replacement. She did well after surgery, and her blood glucose levels are well controlled with medication and diet. On the afternoon of her seventh postoperative day, she complains to her nurse Kathy that she is having increased pain in her hip. Mrs. Helen also has a low-grade fever with a temperature of 37.7 ℃. Kathy observes the incision and notes that it is red, swollen, and warm. Kathy and a registered dietitian do a nutritional assessment on Mrs. Helen and find that she had a poor nutritional intake 1 month before her surgery because of hip pain and an inability to stand to prepare meals.

4. Nosocomial Infection ---- Hospital Acquired Infection Broad concept  Any infection or disease that any individual suffers from the invasion of pathogens in hospital. Narrow concept  Any infection that patient suffers during their hospital care which was not present or incubating at the time of admission.  This includes infections acquired in hospital but appearing after discharge, and also occupational infections among heath-care workers. Concepts

5. Classification Endogenous infection (autogenous infection)  can occur when part of the client’s flora becomes altered and an overgrowth results. Exogenous infection (cross infection)  The causative microorganisms from the source other than the clients’ themselves, such as ： hospital personnel, other clients, and hospital environment.

6. 宿州眼球事件 宿州眼球事件 2005 年 12 月 11 日，宿州市立医院眼科为 10 名患者做白内 障手术，至 17 日 9 名患者因感染实施单眼眼球摘除手术。 西安交大医院 8 名新生儿死亡 西安交大医院 8 名新生儿死亡 自 2008 年９月３日起新生儿科９名新生儿相继出现发热 、心率加快、肝脾肿大等临床症状，至 9 月 15 日 8 名新生 儿发生弥漫性血管内凝血相继死亡。 肌注部位分支杆菌感染暴发 肌注部位分支杆菌感染暴发 1998 年 8 月～ 11 月某诊所 59 例病人发生肌注部位感染 山西煤炭中心医院血液透析感染事件 山西煤炭中心医院血液透析感染事件 2008 年 12 月至 2009 年１月， 47 名患者在太原公交公司职 工医院进行血液透析， 20 名患者丙肝抗体阳性。

7. 宿州眼球事件  医院手术室布局、流程、环境、设施等不 符合开展无菌手术的基本要求  手术器械的消毒和灭菌工作没有达到基本 标准  术中微创手术器械不能做到一人一用一灭 菌

8. 西安交大医院 8 名新生儿死亡  新生儿科建筑布局和工作流程不合理，人流 与物流相互交叉  对部分新生儿使用的物品和器具采用了错误 的消毒方法  医务人员没有规范地进行手卫生  用于新生儿的肝素封管液无使用时间标识 。。。。。。

9. 肌注部位分支杆菌感染暴发 玻璃注射器 15 支 煮沸消毒，时间凭经验 病人多时使用同种药物者换针头不换注射 器

10. 山西煤炭中心医院血液透析感染事件  重复使用一次性血液透析  对丙肝抗体阳性患者不能实施专机血液 透析和专区处理血液透析器  使用工业用过氧乙酸对血液透析器进行 消毒。

11. SARS During the SARS pandemic, the proportion of infected health-care workers ranged from approximately 20% to 60% of cases worldwide.

12. Impact of nosocomial infection  more serious illness  prolong of stay in a health-care facility  long-term disability  excess deaths  high personal costs on patients and their families  high additional financial burden

13. Scenario Ⅱ Mrs. Helen was diagnosed as surgical site infection. It is hospital acquired infection (HAI). Her doctor orders a wound culture for Etiological diagnosis and treatment. In addition, Mrs. Helen is receiving wound care, antibiotic therapy, and supportive care, including nutrition and progressive exercise.

14. Questions: The presence of a pathogen does not mean that an infection will begin. The process resulting in an infection is referred to as the chain of infection. Please list the components of the chain, and explain in detail. The number of microorganisms needed to cause an HAI depends on the virulence of the organism, the host’s susceptibility, and the body site affected. Please list the common factors affect host’s susceptibility to infection. What are the possible risk factors for Mrs. Helen’s fever? Do you have any suggestion for the hospital to prevent patient like Mrs. Helen from infection? Please describe in details.

15. Chain of Infection Source of Infection Mode of Transmission Susceptible Host Chain of Infection

16. Sources of Infection Human  may have active infections  Carrier may be in the asymptomatic and/or incubation period of an infectious disease,  Endogenous patients’ normal flora Animal and Insect Health care setting  Environment, equipment and apparatus patients, healthcare personnel, family members and other visitors Chain of Infection

17. Modes of Transmission Contact: the most common  Direct contact  Indirect contact Airborne  Droplet ??  Droplet nuclei  Dust Other Chain of infection

18. Contact Direct contact  transferred from one infected person to another person directly. Indirect contact  the transfer of an infectious agent through a contaminated intermediate object or person.  Extensive evidence suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission Chain of Infection

19. Droplet A form of contact transmission Respiratory droplets:  an infected person coughs, sneezes, or talks  during procedures such as suctioning, endotracheal intubation, and cardiopulmonary resuscitation Short distance  a distance of <3 feet （ 1feet=30.48cm ） around the patient Chain of Infection

20. Airborne occurs by dissemination of airborne droplet nuclei containing infectious agents that remain infective over time and distance  Mycobacterium tuberculosis over long distance  not had face-to-face contact with (or been in the same room with) the infectious individual. Chain of Infection

21. Other  Common environmental sources contaminated food, water, blood medications (e.g. intravenous fluids)  Vectorborne transmission of infectious agents mosquitoes, flies, rats, and others Chain of Infection

22. Susceptible hosts Factors affecting susceptibility include  age, gender, race and heredity  normal immune defenses  underlying disease and medical therapy  nutritional status  social life  mental health  stress Chain of Infection

23. Susceptible hosts younger children and older adults; severely impaired immune defenses; malnutrition; receiving various immune suppressed treatment; long-term use of antibiotics; receiving numerous invasive procedures; long operation time; extended length of hospitalization; not in good spirits, lack of active cooperation. Chain of Infection

24. Source of Infection Mode of Transmission Susceptible Host Chain of Infection

25. Risks for Nosocomial Infection Immune defense decline  Physiologic factors  Pathologic factors  Psychological factors Numerous invasive procedures  Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection Antibiotics abuse  can cause resistant microorganisms to colonize in clients Ineffective management  Health care workers who use poor aseptic or hand washing techniques

26. 隔离 消毒灭菌 增强抵 抗力 Chain of Infection

27. WHO: Measures Cleaning Disinfection Sterilization Aseptic technique Isolation Correct use of antibiotics Surveillance of disinfection and sterilization efficacy Infection control

28. Concepts Classification Risk factors Chain of infection Measures for infection control 1 Basic Knowledge

29. 下列物品或情形该怎样处理？ 体温计需要消毒吗？该怎样处理？ 你发现手上扎了一根小刺，同学找来缝衣针要给你 挑出来，这根缝衣针可以直接用吗？ 你从商店里买来一件 T 恤衫，你穿之前处理吗？ 有个亲戚在你家吃住 2 天，他走后你想消毒一下餐具 和被褥，如何做？ 2 Cleaning, Disinfection and Sterilization

30. Concepts Cleaning Cleaning is to remove the dirt from item surface by the use of water, detergents and mechanical actions. Will remove most organisms from a surface. Remove and reduce; not kill Hospital floors, walls, furniture and other items Should always precede disinfection and sterilization procedures.

31. Disinfection A process that eliminates almost all pathogens on objects, except of bacterial spores, to decrease the number of them to a harmless level. Used in: Items (such as thermometers), skin, and environmental disinfection Sterilization A process that destroys all forms of microorganisms, including bacterial spores For surgery and aseptic technique.

32. Decontamination Steps

33. Methods of Disinfection and Sterilization Physical Methods Chemical Methods: Heat Microwave Ionizing radiation Radiation Mechanical removing microorganisms Dry heat ： Moist heat: Boiling Steam Disinfection Low Temperature Steam Disinfection High-Pressure Steam Sterilization Sunshine Ultraviolet light ozone Immersion; Rubbing; Nebulization; Fumigation burning 、 toasting

34. Physical Methods High-Pressure Steam Sterilization Sterilization the most common and effective method Advantages:  Highly effective;  Rapid heating and rapid penetration of items;  Nontoxic;  Inexpensive; 用途 :  常用于 : 耐高温、耐高压、耐潮湿物品的灭菌 ---- 金属、玻璃、橡胶、搪瓷、敷料等  不能用于凡士林等油剂、滑石粉等粉剂的灭菌

35. Sterilization parameters Sterilization SterilizersPressureTemperatureTime 下排气式灭菌器 103kPa121ºC20-30 min 预真空灭菌器 205kPa132ºC5-10 min Physical Methods High-Pressure Steam Sterilization

36. Notes: Clean and dry items Package size ： 下排气式 30 ×30 × 25cm ；预真空式 30 ×30 × 50cm Arrange all packages in a way that allows the steam to circulate freely. Timing until the autoclave reaches the required temperature and pressure. Follow the instruction for operating the autoclave. Packs should NOT be pick out of the autoclave until dry. Label accurately with contents, date of processing and expiration and store in storage cabinet. Monitor the effectiveness of sterilization Sterilization

37. Monitoring the Effectiveness Indicatiors Mechanical indicators Chemical indicators Biological indicators

38. Mechanical Indicators These indicators, which are part of the autoclave or dry-heat oven itself, record and allow you to observe time, temperature, and/or pressure readings during the sterilization cycle. Indicators

39. Chemical Indicators Each pack must have external chemical indicators. Indicator strips will change color when temperature, time, and pressure has been achieved. Indicators

40. Biological Indicators 非致病性嗜热脂肪肝菌芽孢. If the bacterial spores have been killed after sterilization, you can assume that all microorganisms have been killed as well. Advantages:  It directly measures the effectiveness of sterilization. Disadvantages:  This indicator is not immediate. Bacterial culture results are needed before sterilization effectiveness can be determined. Indicators

41. Toasting Sterilization (Hot Air Oven) 用途 :  适用于在高温下不变形、不损坏、不蒸发的物品： glass, metal instruments, oil, ointments and powders  不适用于纤维织物、塑料制品等的灭菌。 灭菌参数：  160 ºC, 2 hours;  170 ºC, 1 hour;  180 ºC, 0.5 hour. Sterilization Physical Methods

42. Notes: Clean and dry all items to be sterilized. Package size ： 10cm×10cm×20cm. Organic items ： temperature no more than 170 ℃ Sterilization

43. Other Physical Methods  Disinfection by Boiling  Ultraviolet Light Radiation  Microwave Disinfection High Level Disinfection

44. Boiling For items which are resistant to moisture and high temperature, such as mental, glass, rubber. High Level Disinfection Notes: Clean Open all hinged instruments and other items. Catheter should be filled with water. Make sure that all items are completely submerged because water must touch all surfaces. Once the water is in a rolling boil, start timing for 5- 15 minute. From this point on do not add or remove any water or items.

45. Notes: A 1-2% solution of sodium bicarbonate( 碳酸氢钠 ) rises the boiled temperature to 105 ℃ and helps to prevent corrosion of the instruments. The boiling point of water is affected by air pressure. Generally, every 300 meters is added, disinfection time should be prolonged for 2 minutes. Never leave boiled items in water that has stopped boiling; they can become contaminated as the water cools. High Level Disinfection

46. Air disinfection  A 30W UV light for every 10 m 2  The effective distance ： ≤ 2 meters  The radiation time ： 30-60 min. Object surface disinfection  The effective distance: 25-60 cm  The radiation time ： 20-30min. Fluid disinfection  The fluid depth : ≤ 2 cm High Level Disinfection Ultraviolet (UV) Light Radiation The best anti-bacterial effect: 250-270nm.

47. Notes: Keep UV light clean: alcohol cotton twice a week. Effective condition:  Temperature: 20-40 ºC Humidity: 40-60% Record radiation time after the UV light has been on for 5-7 minutes. When turned off, the light should be cooled off for 3-4 minutes before being turned on again Regularly check the output of the UV light  Intensity≤ 70µW/cm 2, change the light.  Time ≥ 1000 hours, change the light. Keep people off the room; cover eyes and skin if people couldn’t leave. High Level Disinfection

48. Microwave disinfection Uses: food, tableware, medication and some heat- tolerant non-metal instruments. High Level Disinfection Notes: Microwave is harmful to health, so avoid long term contact in small dose or large dose. Microwave can not penetrate metal, do not put objects in metal container. Water is a strong microwave absorbing medium, so wet wrapped item or put a glass of water in the microwave oven can enhance disinfection efficacy.

49. Methods of Disinfection and Sterilization Physical Methods Chemical Methods: Immersion; Rubbing; Nebulization; Fumigation Heat Microwave Ionizing radiation Irradiation Mechanical removing microorganisms Dry heat ： burning 、 toasting Moist heat: Boiling Steam Disinfection Low Temperature Steam Disinfection High-Pressure Steam Sterilization Sunshine Ultraviolet light ozone

50. Chemical Methods Sterilant  A chemical agent that can destroys all forms of microorganisms to achieve sterilization. Disinfectant  A chemical agent that destroys most pathogens but may not kill bacterial spores. LevelBacteriaFungi ( 真菌 ) Viruses VegetativeTubercle bacilli SporesLipidNonlipid HLD ﹢﹢ ± ﹢﹢﹢ ILD ﹢﹢﹣﹢﹢ ± LLD ﹢﹣﹣ ± ﹢ ± Low-level disinfection (LLD),Intermediate-level disinfection (ILD),High-level disinfection (HLD)

51. Disinfectant/Sterilant 消毒灭菌水平、用法及浓度、注意事项 Glutaraldehyde （戊二醛） Chlorine disinfectant ( 含氯消毒剂 ) Alcohol （乙醇） Iodophor （碘伏） Iodine tincture ( 碘酊 ) Textbook p118 表 7-3

52. Principles for Chemical Sterilization/Disinfection Before deciding to use a chemical method, consider whether a more appropriate physical method is available. Select appropriate disinfectant and method according to the characteristics of items and microorganisms Pay attention to the effective concentration of disinfectant and contact time  Make sure the solution is still effective when you use a previously prepared solution or a new solution.  Put it in a sterile container with a lid and mark the container with the preparation date and expiration date.  Do not put gauze, cotton in disinfectant.

53. 妇儿医院手术切口分枝杆菌感染暴发 （广东深圳， 1998 ） 表现： 1998 年 4 月 1 日～ 5 月 31 日共手术 292 例， 4 月 22 日～ 7 月 14 日发生切口感染 166 例。 调查： 20 份切口分泌物标本培养出分支杆菌（脓肿亚 型）。使用中和未启用的戊二醛半小时不能杀灭金葡 菌、 1 小时不能杀灭分支杆菌，测浓度为 0.137% 。 结论：戊二醛浓度错配导致手术器械分支杆菌污染， 从而引起切口感染

54. Principles for Chemical Sterilization/Disinfection Before deciding to use a chemical method, consider whether a more appropriate physical method is available. Select appropriate disinfectant and method according to the characteristics of items and microorganisms Pay attention to the effective concentration of disinfectant and contact time Clean, and dry all items to be sterilized /disinfected. Maintain enough contact time for items with disinfectant solution Rinse thoroughly with sterile/clean saline to remove the residue that is left on items. This residue is toxic to skin and to tissues.

55. Common methods 浸泡法（ immersion ） 擦拭法 (rubbing) 喷雾法 (nebulization) 熏蒸法 (fumigation)

56. Immersion Open all hinged instruments and other items. Place all items in the solution so that they are completely submerged. 应用范围  耐湿不耐热的器械物品  如锐利器械（刀剪）、贵重仪器（导管、胃镜等）、 塑料尼龙制品等

57. Rubbing 应用范围  擦拭被污染物体的表面或皮肤、黏膜 选用：  易溶于水、穿透力强、无显著刺激的消毒剂  如用含氯消毒剂擦拭墙壁、地面

58. Nebulization 用喷雾器将消毒剂均匀地喷洒于空气或物品表 面进行消毒的方法。 常用于地面、墙壁、空气等的消毒。

59. Fumigation 将消毒剂加热或加入氧化剂，使其产生气体进行消 毒的方法。如手术室、换药室、病房的空气消毒。 在消毒间或密闭的容器内，也可用熏蒸法对被污染 的物品进行消毒灭菌。 常用的有甲醛气体和环氧乙烷气体。

60. Daily Cleaning, Disinfection and Sterilization in Hospital Levels of disinfection and sterilization Principles for selecting disinfection and sterilization Daily Cleaning, Disinfection and Sterilization Surveillance of the effectiveness

61. Levels of disinfection and sterilization LevelsMethods Sterilization Heat/Microwave/Ionizing radiation Glutaraldehyde ( 戊二醛 )/formalin （福尔马林） /ethylene oxide （环氧乙烷） /peracetic acid （过氧乙 酸） High-level disinfection Ultraviolet light/ozone Chlorine disinfectant （含氯消毒剂） Intermediate-level disinfection Alcohol （乙醇） /Iodophor （碘伏） /Iodine tincture( 碘酊 ) Low-level disinfection Mechanical removing microorganisms 季铵盐类 / 双胍类消毒剂

62. Think about items’ risk  High risk(critical) items  Intermediate risk (semi-critical) items  Low risk (noncritical) items Principles for selecting disinfection and sterilization

63. Think about items’ risk  High risk(critical) items Items that reach the sterile tissues or organs( such as body cavities and the vascular system). Items: Surgical instruments, syringes Items should be sterilized before using Principles for selecting disinfection and sterilization

64. Think about items’ risk  High risk(critical) items  Intermediate risk (semi-critical) items Items that do not enter sterile areas of the body but contact with mucous membranes or skin closely. Items: thermometer, gastrointestinal endoscopy, ventilator tube High or Intermediate Level Disinfection. Sterilization is preferred. Principles for selecting disinfection and sterilization

65. Think about items’ risk  High risk(critical) items  Intermediate risk (semi-critical) items  Low risk (noncritical) items Items that contact with intact skin, not mucous membranes Items: gown, sheet, blood pressure cuff Low Level Disinfection (in some cases, cleaning is acceptable) Principles for selecting disinfection and sterilization

66. Think about items’ risk Consider the type and risk of contaminated microorganisms 致病性芽胞、真菌孢子 — 灭菌、高水平消毒 致病性细菌、真菌、亲水病毒、支原体、衣原体 — 中水 平以上消毒 一般细菌和亲脂病毒 — 中水平和低水平消毒 Principles for selecting disinfection and sterilization

67. Think about items’ risk Consider the type and risk of contaminated microorganisms By the Characteristics of items 耐热、耐湿物品和器材，应首选压力蒸汽灭菌法 耐高温的玻璃器材、油剂类和干粉类可选用干热灭菌 怕热、忌湿和贵重物品，可选择甲醛或环氧乙烷气体 金属器械的浸泡灭菌，应选择腐蚀性小的灭菌剂 在进行物品表面消毒时，应考虑到表面性质 Principles for selecting disinfection and sterilization

68. Daily Cleaning, Disinfection and Sterilization Hospital environment Preventive disinfection and disinfection of epidemic focus Textiles and laundry Skin and mucous membrane Equipment, instruments/devices Waste and sewage

69. Environmental ： Air Disinfection CategoryIncludingMethods Ilaminar flow operation room, laminar flow ward and sterile pharmaceutical preparation room, et al. laminar flow II operation room, obstetrical ward ， infant room, premature infant room, protective isolation room, burn ward, ICU, et al. air disinfector IIIcommon ward, examination room, injection room, emergency room, et al. II methods ozone, ultraviolet light, and chemical solution IVcontagious wardII and III methods

70. Environmental ： Surface Disinfection Floor:  If no obvious contamination, Wet cleaning.  If contaminated by pathogenic microorganisms, use chemical disinfectants to mop or spay the floor. Wall:  Do not need regular disinfection;  if contaminated, use chemical disinfectants to spay or rub the wall. Object surfaces:  Use clean cloth or cloth with disinfection solution to rub the surfaces bed, bedside tables, chair, doorknob, windows, door and urinal.  If contaminated, use chemical disinfectant to spay or rub them, or use ultraviolet light.

71. Preventive Disinfection and Disinfection of Epidemic Focus Preventive disinfection Disinfection of epidemic focus  Concurrent disinfection  Terminal disinfection

72. Textiles and Laundry The textiles and laundry used by patients are sterilized by ethylene oxide, then washed and prepared for use. If there is no ethylene oxide sterilization room, use the following methods:  wash and then disinfect patients’ cloth and sheet by high temperature;  use ultraviolet light to disinfect blankets, pillows, bed mattress;  wash and disinfect contagious patients’ and other patients’ textiles and laundry separately;  wash and disinfect health care workers’ and patients’ textiles and laundry separately.

73. Skin and Mucous Membrane Skin and mucous membrane provide protective barrier to microorganisms. choose appropriate antiseptics according to patients’ skin and mucous membrane site, pathogenic microorganisms.  Use 2% iodine tincture to disinfect skin, after dry deiodinize it with 75% alcohol.  Use 0.5%-2% iodophor.

74. Surveillance Environmental air, object surfaces and HCW’s hands Equipment, instruments/devices Disinfection solution High pressure sterilization and ultraviolet light Dishware and eating utensils Sanitary utensils Drink water Textiles and laundry, medical waste Waste

75. 教学内容 清洁消毒灭菌概念 消毒灭菌的方法 医院清洁、消毒、 灭菌工作 教学目标 解释术语：清洁、消毒、灭菌 掌握常用物理消毒灭菌法的方 法和注意事项 掌握常用化学消毒剂的名称、 浓度、使用注意事项 2 清洁、消毒、灭菌

76. Words: Nosocomial Infection Chain of Infection Source of Infection Mode of Transmission Susceptible Host Cleaning Disinfection Disinfectant Sterilization Sterilant

77. 下列物品或情形该怎样处理？ 体温计需要消毒吗？该怎样处理？ 你发现手上扎了一根小刺，同学找来缝衣 针要给你挑出来，这根缝衣针可以直接用 吗？ 你从商店里买来一件 T 恤衫，你穿之前处 理吗？ 有个亲戚在你家吃住 2 天，他走后你想消 毒一下餐具和被褥，如何做？