Hospital Acquired Infections Nursing CE Course

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This learning activity aims to increase nurses' knowledge of hospital-acquired infections (HAIs), such as Clostridium difficile, central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, and antibiotic-resistant organisms such as methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci. This includes understanding HAIs' epidemiology and pathophysiology, risk and protective factors, signs and symptoms, diagnosis, treatment and management, and nursing implications. 

By completing this educational module, learners should be able to:  

• define important terminology in infection control, discuss the elements of the chain of infection, and identify the modes and mechanisms of pathogen transmission in the healthcare environment  

• describe the pathophysiology of HAIs  

• outline the causes, prevention, treatment, and nursing care of patients with HAIs 

• explain factors that influence the transmission of HAIs, identify strategies for infection prevention and control to reduce patient and HCP exposure, and minimize the opportunity for the transmission of pathogens 

• distinguish multidrug-resistant organisms (MDROs) from other infections 

• identify practices to reduce the opportunity for patient exposure to potentially infectious materials in hospital settings 

Terminology  

Many terms are associated with HAIs, the organisms that cause them, and treatment and prevention techniques. A summary of those terms is listed as follows: 

• antibody: a protein the immune system produces to neutralize a threat of some kind, such as an infecting organism, a chemical, or some other foreign body 

• antimicrobial: able to destroy or suppress the growth of pathogens and other microorganisms 

• antiseptic: a substance that reduces the number of pathogens on a surface 

• asepsis: method(s) used to ensure an environment is as pathogen-free as possible 

• aseptic: as pathogen-free as possible 

• bacteriostasis: the inhibition of further bacterial growth 

• chlorhexidine: an antibacterial compound with a substantial residual activity that is used as a liquid antiseptic and disinfectant 

• cleaning: the process of removing all foreign material (e.g., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object 

• common vehicle: contaminated material, product, or substance that serves as an intermediate means by which an infectious agent is introduced into a susceptible host through a suitable portal of entry 

• contact precautions: measures taken to prevent the spread of diseases transmitted by the physical transfer of pathogens to a susceptible host's body surface 

• contamination: the process of becoming unsterile or unclean 

• disinfectant: any chemical agent used to destroy or inhibit the growth of harmful organisms 

• empiric antibiotic therapy: antibiotics administered before receiving a culture and sensitivity test result 

• endemic: prevalent in or characteristic of a particular environment 

• endogenous: produced within an organism or a system rather than externally caused 

• exogenous: externally caused rather than produced within an organism or a system 

• flora: the aggregate of bacteria, fungi, and other microorganisms typically found in a specific environment, such as the gastrointestinal tract or the skin 

• immunosuppression: the inhibition of the body's protective response to a pathogenic invasion, usually due to disease, drug therapy, or surgery 

• infection: invasion and proliferation of pathogens in body tissues 

• isolation: the separation of an infected person from others for the period of communicability of a particular disease 

• latex: a milky fluid produced by rubber trees that is processed into a variety of products, including gloves used for patient care 

• medical asepsis: infection-control practices common in health care, such as hand hygiene 

• pathogen: a biological, physical, or chemical entity capable of causing disease, such as bacteria, viruses, fungi, protozoa, helminths, or prions 

• personal protective equipment (PPE): devices used to protect employees from workplace injuries or illnesses resulting from biological, chemical, radiological, physical, electric, mechanical, or other workplace hazards 

• pneumococcal: pertaining to or caused by pneumococci, organisms of the species Streptococcus pneumoniae (S. pneumoniae), a common cause of pneumonia and other infectious diseases 

• portal of exit: the route by which microorganisms exit the reservoir on their way to a susceptible host 

• portal of entry: the route by which microorganisms enter a host 

• reservoir: a place in which an infectious agent can survive but may or may not multiply (HCPs may be reservoirs for nosocomial organisms) 

• sepsis: the presence of pathogens or their toxins in blood or tissues 

• standard precautions: a group of infection prevention and control strategies that combine the significant features of universal precautions and body substance isolation, based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents 

• staphylococcus: a genus of gram-positive bacteria that are potential pathogens, causing local lesions and severe opportunistic infections 

• surgical asepsis: techniques used to destroy all pathogenic organisms, also called sterile technique 

• susceptible host: a person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting an infection or a disease when exposed to the agent 

• transmission: any mechanism by which a source or reservoir spreads a pathogen to a person 

• transmission-based precautions: measures taken to prevent the spread of diseases from people suspected to be infected or colonized with highly transmissible pathogens that require protections beyond standard precautions to interrupt transmission—specifically, airborne, droplet, and contact precautions 

• virulence: the ability of a microorganism to cause disease (McCance & Heuther, 2019; New York State Department of Health and State Education Department, 2018; Potter et al., 2021) 

The Infectious Process 

Transmission of infection in health care consists of six major elements that occur in order, as displayed in Figure 1. If all these elements are not present or do not happen in sequence, an infection will not develop. Understanding the chain of infection allows HCPs to disrupt the cycle and prevent infection (Ignatavicius et al., 2021). 

Current Context 

Hospital-acquired infections, also referred to as healthcare-associated infections (HCAIs), are nosocomial infections that manifest in a healthcare setting while the patient is receiving care for another condition. This terminology does not imply that an infection was solely caused by the healthcare services rendered, only that it manifested following admission to the healthcare facility. HCAIs can develop in any healthcare facility, including hospitals, ambulatory clinics, surgical centers, inpatient rehabilitation facilities, and long-term care settings. Since some references have stated that HCAI is a retired term and other sources refer to both categories of infection as hospital-acquired with the designated acronym "HAI," this terminology is used throughout this learning module (Centers for Disease Control and Prevention [CDC], 2021d; Monegro et al., 2022; CDC's National Healthcare Safety Network [NHSN], 2022; Stiller et al., 2017).  

HAIs can be endogenous (developing from the patient's flora) or exogenous (originating outside the patient's body). Reservoirs known for causing exogenous HAIs include the hands of HCPs, other patients, equipment (e.g., blood pressure cuffs, urine collection devices), and the environment (e.g., contaminated surfaces, toilets, sinks, doorknobs). In the US, HAIs affect about 2 million inpatients annually, leading to more than 75,000 deaths yearly. According to the CDC (2022), approximately 1 in 31 hospitalized patients and 1 in 43 residents of skilled nursing facilities (SNFs) report at least one HAI daily. HAIs are associated with high morbidity and mortality with devastating impacts, including prolonged hospitalization, increased suffering, lost productivity, and substantial costs to the healthcare system and society. HAIs are monitored closely by agencies such as the NHSN, the most widely used HAI-tracking system. The NHSN collects data to identify problematic areas and standardize infection rates to measure, track, and evaluate HAI prevention modalities. This monitoring allows for a more accurate and direct comparison of infection rates between healthcare facilities and trends over time. Common HAIs include central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), Clostridium difficile (C. diff) infection, methicillin-resistant Staphylococcus aureus (MRSA) infection, and vancomycin-resistant enterococci (VRE) infection (CDC, 2021d; Monegro et al., 2022; NHSN, 2022; Stiller et al., 2017).  

The risk for HAIs depends on multiple influences, such as the infection control practices of the healthcare facility, the prevalence of pathogens within the community or healthcare setting, and individual patient factors (e.g., compromised immune system, increased length of stay, and comorbidities such as heart disease, chronic obstructive pulmonary disease [COPD], and diabetes mellitus [DM]). Across healthcare settings, the risk for HAIs is highest among patients admitted to intensive care units (ICUs). In a study involving 231,459 patients across 947 hospitals, 19.5% of patients admitted to the ICU had at least one HAI. The most common HAIs are described below; while not representative of all HAIs, they are among the most common and are associated with severe complications. Most are preventable with appropriate infection prevention strategies (CDC, 2021d; NHSN, 2022; Stiller et al., 2017). 

Types of Hospital-Acquired Infections 

Clostridium Difficile  

Epidemiology and Pathophysiology 

C. difficile (C. diff) is responsible for a spectrum of C. diff infections (CDIs), including uncomplicated diarrhea, pseudomembranous colitis, and toxic megacolon (life-threatening inflammation of the colon that can lead to sepsis and death). CDI is bacterial diarrhea that affects patients who have recently taken antibiotics (usually within two months). Pseudomembranous colitis is a more severe form of CDI in which pseudomembranous plaques are visualized by colonoscopy on the surface of the colon. C. diff is the most well-known cause of infectious diarrhea in healthcare settings. C. diff is a Gram-positive, spore-forming anaerobic bacterium that produces toxins A and B. A third toxin—binary toxin—has been identified in about 5% of C. diff isolates. The ability of the organism to form spores allows C. diff to survive for months in the hospital environment (Bowling, 2018; McDonald et al., 2018). 

The prevalence of CDIs in the United States has tripled since 2000. CDC (2021a) data indicate that C. diff infections cause almost 500,000 illnesses and 14,000 deaths in the US each year, and 1 in 5 patients diagnosed with a C. diff infection will have a recurrence. According to the Infectious Disease Society of America (IDSA), surveillance for hospital-acquired C. diff infections should be conducted in all inpatient facilities to screen for elevated rates or outbreaks (Bowling, 2018; McDonald et al., 2018). 

Risk Factors and Protective Factors  

Acute care facilities are considered a high-risk environment for C. diff infection due to high antimicrobial use and significant contamination with C. diff spores. Poor antibiotic prescribing practices, such as prescribing an unnecessary or inappropriate antibiotic, put patients at increased risk for C. diff infections. Risk factors include the recent use of antibiotics, gastric acid suppressants, and non-steroidal anti-inflammatory (NSAID) medications (Monegro et al., 2022). 

Signs and Symptoms  

C. diff most commonly occurs following antibiotic use; clinical manifestations typically develop within 10 days after starting antibiotics but may appear as early as the first day or as late as 2 months later. CDI is characterized by at least 3 to more than 20 watery or unformed stools per day. The stools may exhibit a characteristic odor. Patients with C. diff infection may also have abdominal cramping, anorexia, nausea, fever, and leukocytosis. In addition, 28% of patients with CDI have occult fecal blood (Bowling, 2018; CDC, 2021a). 

Diagnosis  

According to the IDSA guidelines, laboratory testing for C. diff should not be performed on patients who have received a laxative within the previous 48 hours. Diagnostic testing should be done for symptomatic patients (Johnson et al., 2021; McDonald et al., 2018). Diagnostic tests for C. diff infection include: 

• a stool culture that has high specificity and low sensitivity for C. diff; this test has a 7-day turnaround time 

• enzyme immunoassays for toxins A and B, which use monoclonal antibodies to detect toxin A and polyclonal antibodies to detect toxin B; these are rapid tests with high specificity and low sensitivity 

• latex test or immunoassay for C. diff antigen, which detects glutamine dehydrogenase (GDH); this test uses a two-step algorithm to identify C. diff infection 

• colon endoscopy to detect pseudomembranous colitis 

• nucleic acid amplification tests (NAATs) that use two different methods: a polymerase chain reaction and loop-mediated amplification of DNA to detect toxic genes for C. diff in stool samples; NAATs have a high sensitivity and specificity with a turnaround time of only a few hours; for these reasons, they are the principal diagnostic tests used for C. diff infection in the US (Bowling, 2018; CDC, 2021a) 

According to the IDSA, repeat testing should be done when there is a recurrence of symptoms of CDI infection following a successful course of treatment; however, there is no clinical value in repeat testing if the patient remains asymptomatic after treatment (McDonald et al., 2018). 

Treatment and Management  

The first step in treating and managing CDI is the discontinuation of the provoking antibiotic therapy. Symptoms will resolve in 20% to 25% of patients by stopping the prescribed antibiotic. A 10-day course of fidaxomicin (Dificid) or oral vancomycin (Vancocin) is recommended for an initial episode of CDI. Fidaxomicin (Dificid) is more expensive than vancomycin (Vancocin); however, the IDSA recommends fidaxomicin (Dificid) rather than vancomycin (Vancocin) due to its beneficial effects and safety profile. In situations with limited availability of vancomycin (Vancocin) or fidaxomicin (Dificid), a 10-day course of metronidazole (Flagyl) may be prescribed. For a repeat episode of CDI, another course of oral vancomycin (Vancocin) or fidaxomicin (Dificid) is indicated (Johnson et al., 2021; McDonald et al., 2018).  

Fecal microbiota transplantation (FMT) is recommended for patients with multiple recurrences of CDI who have not responded to antibiotics. FMT is based on the concept that recurrent CDI persists because of the altered colonic microbiota in the bowel due to prior antibiotic therapy. FMT reestablishes the normal fecal microbiota by administering healthy donor feces through a nasogastric (NG) tube, a nasojejunal tube, esophagogastroduodenoscopy (EGD), colonoscopy, or a retention enema (MedlinePlus, 2020).  

Prevention 

Healthcare professionals (HCPs) must prevent transmission when caring for patients with a suspected or confirmed CDI. Hospitalized patients who have three or more watery or unformed stools in 24 hours, in the absence of another cause, should be placed in contact isolation and tested for CDI. Because patients with CDI continue to shed the organism, contact precautions should be maintained for several days after frequent, watery, or unformed stools have resolved. When a patient with a CDI transfers to a new facility, the nurse must notify the receiving facility that the patient has a CDI. Hand hygiene is another critical prevention strategy. In routine situations, HCPs should perform hand hygiene before and after removing gloves after entering a patient's room with a suspected or confirmed CDI. Handwashing with soap and water is necessary as alcohol-based products do not kill C. diff. For this reason, handwashing with soap and water is the preferred method of hand hygiene during CDI outbreaks. Disposable patient care equipment should be used whenever possible. Reusable equipment requires thorough cleaning with a sporicidal disinfectant (CDC, 2021a; McDonald et al., 2018).  

Nursing Implications  

Nursing care for patients with suspected or confirmed CDI begins with scrupulous hand hygiene, along with prompt initiation of contact precautions. An important consideration when placing patients with a CDI in isolation is the requirement for a private room with a dedicated toilet. In situations where a private room is unavailable, patients may be placed in a semi-private room with another patient with a confirmed or suspected CDI (McDonald et al., 2018; Bowling, 2018). 

In addition to initiating and maintaining appropriate isolation precautions for the duration of the CDI, nurses are responsible for monitoring for and reporting the occurrence of three or more watery, unformed stools in 24 hours, monitoring the patient's lab work for C. diff test results, and administering prescribed antibiotic therapy. Nurses must also ensure appropriate cleaning and disinfection of affected patients' rooms, including daily use of a sporicidal agent or a 1:10 bleach solution in areas with high CDI rates. In addition, some hospitals have added terminal disinfection with UV radiation or hydrogen peroxide vapor to their cleaning regimen. New data released in March 2022 suggest that utilizing aerosolized hydrogen peroxide can effectively reduce C. diff spores and prevent infection. One study of a large acute care facility that implemented aerosolized hydrogen peroxide into their disinfection protocol showed a reduced rate of hospital-acquired CDIs by 41%, from 4.6 per 10,000 patient days to 2.7 per 10,000 patient days (Association for Professionals in Infection Control and Epidemiology [APIC], 2022; CDC, 2021a; McDonald et al., 2018). 

Central Line-Associated Bloodstream Infection  

Epidemiology and Pathophysiology 

Central line-associated bloodstream infections (CLABIs) are severe and potentially fatal bloodstream infections that can occur from a breach in sterile technique during the insertion procedure, improper or inadequate care or management of the line, and medication administration. Central lines provide direct access to the major vessels in the venous circulatory system and remain in situ for long periods. Since the catheter provides a portal of entry and a direct pathway to the venous system, an infectious agent can quickly spread throughout the bloodstream, generating critical and systemic illness. Bloodstream infections can induce hemodynamic changes, leading to organ dysfunction, sepsis, shock, and death. According to the NHSN (2022), there has been a 46% decrease in CLABSIs across US hospitals between 2008 and 2013; however, more than 30,000 CLABSIs still occur in acute care facilities (including ICUs) each year. The estimated cost of each CLABSI is around $46,000 and carries a mortality rate of up to 25% (CDC, 2017; Haddadin et al., 2022; Young & Yuo, 2020). 

Risk Factors and Protective Factors  

Risk factors for CLABSI include prolonged hospitalization, central line duration, heavy microbial colonization at the insertion site or catheter hub, femoral catheter placement in adults, prematurity in infants, excessive catheter manipulation, high nurse-to-patient ratios in the ICU, and patients receiving total parenteral nutrition. Protective factors against CLABSI include female sex and antibiotic administration (Avalos, 2019). 

Signs and Symptoms  

Signs and symptoms of CLABSI depend on the severity of the illness. The most common symptoms include fever and chills. Patients at the extreme ends of the age spectrum (i.e., very old or young) may have atypical symptoms, including altered mental status, hypotension, and lethargy. Assessment of the exit site may show inflammation, redness, or swelling, and the patient may report tenderness with palpation of the area (Haddadin et al., 2022).  

Diagnosis  

Blood cultures must be obtained to identify the causative organism and treat the CLABSI successfully. This should be done before initiating empiric antibiotics. Proper technique must be used, and the patient's skin must be thoroughly disinfected to prevent contamination when obtaining the blood cultures. Blood cultures are obtained from two sites when a CLABSI is suspected: one directly from the central line and the second from a peripheral vein. An adequate amount of blood (at least 20 to 30 mL per patient or 10 to 15 mL per site) must be obtained. A diagnosis of CLABSI requires the same pathogen to be found in both blood cultures, with the bacterial count at least three times higher in the culture taken directly from the central line (Avalos, 2019; Haddadin et al., 2022). 

Treatment and Management  

Once blood cultures are obtained, all non-tunneled catheters should be removed. Tunneled catheters should be removed if the patient has persistent symptoms lasting over 36 hours, severe sepsis, shock, blood cultures that remain positive 72 hours after the initiation of appropriate treatment, infection with a difficult-to-treat organism (e.g., S. aureus, Pseudomonas, or fungi), the recurrence of a CLABSI. Treatment of a CLABSI targets the causative organism based upon blood culture results, antimicrobial susceptibility results, host factors, and the overall clinical picture. Empiric antibiotic therapy should be initiated promptly while awaiting culture and sensitivity results. Once antimicrobial susceptibility is determined, treatment should be adjusted to a more specific and appropriate medication to target the organism (Haddadin et al., 2022; Miller et al., 2016). In patients with an uncomplicated CLABSI (e.g., without endocarditis, hardware, or immunocompromise), the following intravenous (IV) antimicrobial therapy and duration are recommended:  

• S. aureus: 14 days with penicillins or cephalosporins such as nafcillin (Unipen) or cefazolin (Ancef)  

• Coagulase-negative staphylococci: 7 days with vancomycin (Vancocin)  

• Enterococci and gram-negative bacilli: 10 to 14 days with third-generation cephalosporins such as ceftriaxone (Rocephin) 

• Candida: 14 days with fluconazole (Diflucan; Haddadin et al., 2022)  

Prevention  

Since October 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburse for HAIs, including CLABSI. In addition, the CDC published revisions to their 2011 Intravascular Catheter-Related Infections Guidelines in 2017. In partnership with several other accredited organizations, these guidelines determined the evidence-based practice (EBP) standards for preventing CLABSI and other HAIs. The CDC, Institute for Healthcare Improvement (IHI), and the Infusion Nurses Society (INS) guidelines present consistent recommendations. Table 1 offers an overview of these critical aspects of vascular access device (VAD) care to prevent a CLABSI (CDC, 2017; Gorski et al., 2021; IHI, 2012). 

Nursing Implications 

Nursing care for patients at risk for CLABSIs includes hand hygiene and appropriate infection control precautions, such as disinfecting the catheter hub or injection port before accessing the line. To prevent CLABSIs and increase compliance, The Joint Commission (TJC) implemented "Scrub the Hub!" to remind HCPs to disinfect the catheter hub before accessing the line. Antiseptic barrier caps have also been shown to decrease the risk of CLABSIs. These devices are in constant contact with the catheter hub and optimize disinfection without active scrubbing of the hub. All IV tubing should be changed per policy, usually within 24 hours for intermittent infusions and 96 hours for continuous infusions (excluding lines used for lipids or blood products). All ordered antibiotics should be administered as prescribed to ensure the patient receives the proper treatment. Nurses also need to continue to monitor for signs that the CLABSI is resolving or worsening (Haddadin et al., 2022; TJC, 2013; Voor in't holt et al., 2017). For more information on central lines, see the Vascular Access Devices Part 1 and Part 2 NursingCE courses.

Catheter-Associated Urinary Tract Infection  

Epidemiology and Pathophysiology 

A urinary tract infection (UTI) involves any part of the urinary system, including the urethra, bladder, ureters, and kidneys. UTIs account for over 9.5% of all infections reported by acute care hospitals. According to the NHSN (2022), 12% to 16% of hospitalized adults will have an indwelling urinary catheter at some point during their hospitalization. Indwelling urinary catheters contribute to 75% of healthcare-acquired UTIs. A catheter-associated UTI (CAUTI) is diagnosed based on a positive urine culture when an indwelling urinary catheter has been in place for more than 48 hours. CAUTIs can occur from unsterile catheterizations, repeated catheterizations, and improper drainage system management. Gram-negative bacilli are the primary bacteria that cause UTIs (American Nurses Association [ANA], n.d.; Imam, 2021; NHSN, 2022).  

Risk Factors and Protective Factors  

Risk factors for developing a CAUTI include extended catheter use, female sex, having DM, being immunocompromised, having a spinal cord injury, and opening a closed urinary drainage system. Another factor predisposing a patient to develop a CAUTI is a suboptimal aseptic technique when the indwelling catheter is inserted. The protective factor is using the proper sterile techniques when inserting and managing indwelling urinary catheters (Iman, 2021).   

Signs and Symptoms  

Signs of a CAUTI may resemble those of a UTI; however, dysuria and frequency are not typical symptoms of a CAUTI but may be present following catheter removal if an infection is already present. Common symptoms include a fever greater than 38.0°C (100.4°F), suprapubic tenderness, and costovertebral angle pain or tenderness without another cause. Patients may also have nonspecific symptoms such as malaise, flank pain, and altered mental status (Iman, 2021; NHSN, 2022).  

Diagnosis  

The initial diagnostic test for CAUTI is a urinalysis, followed by urine culture and sensitivity testing. If a CAUTI is suspected, the indwelling urinary catheter must be removed. A urine sample can be obtained from a newly inserted indwelling urinary catheter to avoid culture results containing colonized bacteria. Nurses should always use aseptic technique and sterile supplies to obtain a urine specimen for culture and sensitivity testing. The urine sample should be obtained before initiating treatment with broad-spectrum antibiotics. Once available, targeted antibiotic treatment is based on the urine culture and sensitivity results (Imam, 2021). 

For a patient to be diagnosed with a CAUTI at any age, all the following criteria must be met: 

• presence of an indwelling urinary catheter for at least two consecutive days while at the healthcare facility and on or right before the day symptoms appeared or was removed the day before the appearance of symptoms  

• the presence of at least one of the symptoms listed above  

• the presence of no more than two different organisms in the urine culture (NHSN, 2022) 

Treatment and Management  

The most common causes of CAUTIs include E. coli (23.9%), Candida (17.8%), and Enterococcus (13.8%). Empiric broad-spectrum antibiotic therapy can be initiated while waiting for culture and sensitivity results. Initial broad-spectrum antibiotic choices include penicillins, beta-lactams, cephalosporins, fluoroquinolones, or carbapenems. Patients should be treated with antibiotics for seven days; if bacteremia is present, the course of treatment should be extended to 10-14 days (Flores-Mireles et al., 2019; Iman, 2021; Monegro et al., 2022; Sabih & Leslie, 2022).  

Prevention 

The most effective strategies to prevent CAUTIs are to avoid using an indwelling urinary catheter and to remove an existing catheter as soon as possible. For patients with an indwelling catheter inserted before surgery, removing the catheter within 24 hours postoperatively is critical for prevention. Intermittent catheterization is preferable to an indwelling catheter whenever possible. Nurses must also utilize appropriate aseptic technique and sterile equipment for catheter insertion in the hospital environment. If breaks in aseptic technique, disconnection of the closed system, or leaks occur, the catheter and drainage bag should be replaced using aseptic technique and sterile supplies. A nurse-driven CAUTI prevention tool from the ANA features a decision-making tree based on the 2009 CDC criteria for inserting an indwelling urinary catheter to determine whether insertion is indicated (ANA, n.d.; Imam, 2021).   

Nursing Implications 

According to evidence-based guidelines, the vital elements of nursing care to prevent infection center on the appropriate management of urinary catheters: 

• only insert an indwelling urinary catheter when indicated 

• remove the urinary catheter as soon as it is no longer indicated  

• properly secure indwelling catheters after insertion 

• maintain a sterile closed drainage system 

• replace the catheter and drainage bag using aseptic technique 

• obtain urine samples by aspirating urine from the sampling port using a sterile syringe 

• maintain unobstructed urine flow 

• always keep the urinary drainage bag below the level of the bladder; do not place the bag on the floor 

• perform routine hygiene and do not use antiseptics to clean the periurethral area (ANA, n.d.; Iowa Department of Public Health [IDPH], 2022) 

Hospital-Acquired Pneumonia 

Epidemiology and Pathophysiology 

Pneumonia is defined as an excess of fluid in the lungs resulting from an inflammatory process. The inflammation can be triggered by an invasion of an infectious organism or inspiration of an irritating agent, and it occurs in the alveoli, interstitial spaces, and bronchioles. Hospital-acquired pneumonia (HAP), or a non-ventilator-associated pneumonia event (PNEU), refers to pneumonia that first occurs 48 hours or more after admission to the hospital. The most common bacterial causes of HAP include MRSA and P. aeruginosa (Ignatavicius et al., 2021; NHSH; 2022).  

Risk Factors and Protective Factors  

Risk factors for HAP include increased age, chronic lung disease, gram-negative colonization of the upper gastrointestinal tract, an altered level of consciousness, recent aspiration, the presence of a tracheostomy or nasogastric (NG) tube, poor nutritional status, immunocompromise, the use of medications that increase gastric pH (e.g., histamine-2 antagonists [H2 blockers]), or alkaline tube feedings. Risk factors for developing HAP following surgery include being older than 70 and having abdominal or thoracic surgery (Ignatavicius et al., 2021; Sethi, 2020a).  

Signs and Symptoms  

Signs and symptoms of HAP mimic those of community-acquired pneumonia: malaise, fever, chills, cough, dyspnea, hypoxia, and chest pain (Sethi, 2020a).  

Diagnosis  

Sputum is often obtained for Gram stain, culture, and sensitivity testing in an inpatient setting. The offending organism is not identified in many cases. A sputum sample can be obtained easily from patients who can cough into specimen containers, but these specimens are contaminated with upper airway organisms. Patients who are extremely ill or unable to cough for collection may need suctioning to obtain a specimen using a sputum trap. There are several steps that the medical team can take to optimize the quality of a sputum sample. The specimen should be obtained before antibiotic administration. The mouth should be rinsed before expectoration. The patient should avoid eating or drinking for 1-2 hours before expectoration, and the specimen should be inoculated onto the culture media immediately after collection. Diagnosis can also be made based on chest x-ray results or chest computed tomography (CT) combined with clinical data. Based on patient presentation, a bronchoscopy is sometimes performed, and blood cultures may be obtained (Boruchoff & Weinstein, 2021; Ignatavicius et al., 2021). 

Treatment and Management  

Patients with suspected HAP should be treated with antibiotics based on the results of noninvasive respiratory cultures (i.e., spontaneous expectoration, sputum, and nasotracheal suctioning). The current guidelines recommend using narrow-spectrum empiric antibiotics whenever possible to prevent resistance. Despite the risk for resistance, the adequacy of the initial antibiotic used plays a significant role in overall patient outcomes (Sethi, 2020a).   

Prevention and Nursing Implications 

To prevent the development of HAP, nurses must encourage pulmonary hygiene and ambulation. Patients should consume adequate fluids to maintain hydration. Nurses should assess each patient for signs of aspiration using an evidence-based tool such as the Toronto Bedside Swallowing Screening Test (TOR-BSST) or the Simple Standardized Bedside Swallowing Assessment (SSA). Nurses should also provide or promote thorough and frequent oral care. Performing proper hand hygiene and implementing standard precautions can also prevent the development of HAP (American Speech-Language-Hearing Association [ASHA], n.d.; Ignatavicius et al., 2021).  

Ventilator-Associated Pneumonia  

Epidemiology and Pathophysiology 

A specific type of HAP is ventilator-associated pneumonia (VAP), which develops 48-72 hours after endotracheal intubation. Ventilators directly connect the environment and the patient's lower respiratory passageways. Infectious organisms enter through the tube, invade the ordinarily sterile lower respiratory tract, colonize the lungs, and overwhelm the host's defense system. VAP can develop from poor technique while suctioning the airway, using contaminated respiratory equipment, or ineffective hand hygiene. According to Papazian and colleagues (2020), the primary route of bacterial invasion occurs from the aspiration of oropharyngeal secretions contaminated by endogenous flora around the endotracheal tube cuff. VAP is one of the most frequent ICU-acquired infections. Although incidence rates vary from 5% to 40% depending on the setting and diagnostic criteria, in a 2015 survey of 427 HAIs identified in US acute care hospitals, pneumonia was the most common, with VAP accounting for 32% of these infections. VAP carries an estimated mortality rate of approximately 10%, extends the length of stay by 7 days, and increases healthcare costs by about $40,000. Reducing the exposure to risk factors for VAP is the most efficient way to prevent VAP, including avoiding intubation and using noninvasive ventilation whenever possible, minimizing sedation, and maintaining and improving physical conditioning (e.g., through early exercise and mobilization; Magill et al., 2018; Monegro et al., 2022; Papazian et al., 2020; Timsit et al., 2017).  

Risk Factors and Protective Factors  

Endotracheal (ET) intubation is the most significant risk factor for developing VAP. Insertion of an ET tube bypasses the body's natural airway defenses, impairs the cough reflex and mucociliary clearance of irritants and pathogens, and facilitates the microaspiration of secretions containing bacteria. Bacteria may also form a biofilm within the ET tube that antibiotics or the body's defenses cannot reach. Additional risk factors for VAP include emergent intubation, nasotracheal intubation, etomidate (Amidate, which has an immunosuppressive action) use during intubation, not having the head of the bed elevated, and suboptimal oral care. Protective factors involve strategies to prevent VAP (Sethi, 2020b).  

Signs and Symptoms  

Symptoms of VAP include fever, tachypnea, tachycardia, and increased respiratory or post-oral secretions. The patient may also have leukocytosis, purulent secretions, or worsening hypoxemia (Sethi, 2020b).  

Diagnosis and Treatment 

VAP is diagnosed based on patient symptoms such as fever, increased secretions, hypoxemia, or the presence of leukocytosis and a chest x-ray with evidence of a new infiltrate; however, no symptom, sign, or x-ray finding is specific to VAP due to similarities to atelectasis, pulmonary embolism, and pulmonary edema. The 2016 IDSA Guidelines for Management of Adults with Hospital-Acquired VAP recommend that sputum specimens be obtained using noninvasive sampling such as endotracheal aspiration. The IDSA guidelines endorse using an antibiogram, which specifies local antibiotic resistance data, to guide empiric treatment decisions. Empiric antibiotic therapy is started as the initial treatment for VAP due to these patients being critically ill (Kalil et al., 2016). According to Sethi (2020b), "the mortality associated with hospital-acquired VAP is high, despite the availability of effective antibiotics" (para. 12). Once sputum culture results become available, they should guide the most effective pathogen-specific therapy. A 7-day course of antimicrobial therapy is recommended (Kalil et al., 2016; Sethi, 2020b). 

Prevention  

Measures to prevent VAP include keeping the patient in an upright or semi-upright position at 30-45 degrees. This reduces the risk of aspiration and is the simplest and most effective method of preventing VAPs. Other verified prevention practices include utilizing noninvasive ventilation options, including continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) and high-flow oxygen instead of intubation. Using noninvasive oxygenation avoids bypassing innate protective factors that occur with ET intubation. Although this is not possible for all patients, in some cases, using a CPAP, BiPAP, or high-flow oxygen eliminates the need for intubation. Interrupting sedation daily, assessing readiness to extubate daily, performing spontaneous breathing trials with sedatives turned off, implementing early mobilization, and changing ventilator circuits only when they are visibly soiled or malfunctioning can also decrease a patient's risk of developing VAP (NHSN, 2022; Papazian et al., 2020; Sethi, 2020; Taito et al., 2016).   
Nursing Implications 

Nursing care for patients with VAP includes administering antibiotics as prescribed, monitoring lab work, assessing the patient's response to treatment, and consistently implementing infection prevention and control strategies. A patient diagnosed with VAP requires consistent hand hygiene and standard precautions (CDC; 2021c; Seigel et al., 2022b). For more information on ventilator-associated pneumonia, see the Pneumonia NursingCE course. 

Surgical Site Infection  

Epidemiology and Pathophysiology 

The CDC defines a surgical site infection (SSI) as an infection that occurs because of a surgical procedure, often near the incision or entry point, within 30 days of the procedure (90 days if an implant is used). SSIs occur when bacteria enter the body through a surgical incision. SSIs can develop from a breach in sterile technique, improper skin preparation, contamination during dressing changes, or using a contaminated antiseptic solution (Evans & Hedrick, 2022). According to the NHSN (2022), SSIs carry a 3% mortality rate and are the most expensive HAI, with an estimated annual cost of $3.3 billion US dollars and 1 million additional inpatient days per year. 

Risk Factors and Protective Factors  

Risk factors for developing an SSI include older age, medical comorbidities (e.g., DM, co-existing infections), obesity, malnutrition, and surgical factors (e.g., length of the procedure, surgical technique, skin asepsis, and antimicrobial prophylaxis). SSIs are most common following colon surgery, coronary artery bypass graft (CABG), hip replacement, and hysterectomy procedures (Monegro et al., 2022).  

Signs and Symptoms  

The scoring system ASEPSIS has been used to describe the signs and symptoms of an SSI using objective data. ASEPSIS stands for:  

• Additional treatment 

• Serous discharge 

• Erythema 

• Purulent exudate 

• Separation of the deep tissues 

• Isolation of bacteria 

• length of inpatient Stay (Evans & Hedrick, 2022) 

Other symptoms include fever, pain or tenderness at the incision site, and localized edema (Kim et al., 2021).  

Diagnosis  

Laboratory tests such as leukocyte count, neutrophils, erythrocyte sedimentation rate (ESR), and c-reactive protein (CRP) are used, along with assessment data, to determine whether an SSI may be present. In the presence of an infection, these laboratory values increase compared to the patient's baseline. Magnetic resonance imaging (MRI) with contrast must be used for some SSI sites to determine whether an infection is present (Kim et al., 2021).   

Treatment and Management  

A diagnosis of SSI requires treatment with empirical antibiotics. Once the organism is identified, antibiotic therapy can be changed to align with the organism's sensitivity. In cases of infected implants, a repeat operation may be required to remove the device (Kim et al., 2021).  

Prevention  

SSI prevention has gained more attention as the number of surgical cases and treatment costs continue to rise each year. Preoperative antibiotic prophylaxis and skin decontamination before the patient arrives at the surgical area (i.e., showering with an antiseptic agent the night before surgery) and before any incision can prevent common pathogens attributed to SSIs. Pre-existing infections should be treated before the patient undergoes a non-emergent or elective surgery. To prevent an SSI postoperatively, proper hand hygiene and infection prevention strategies must be utilized when caring for the surgical site (Berrios-Torres et al., 2017; IDPH, 2022). 

Nursing Implications 

Nurses need to implement interventions to prevent SSIs from developing and monitor patients for signs of an SSI. Proper hand hygiene should be performed, and standard precautions must be maintained. It is essential to perform wound care and dressing changes as ordered and when they become soiled. Any drains present postoperatively should also be emptied regularly. Monitor each patient and surgical site for signs of infection, including erythema, heat, pain, edema, vital sign changes, and worsening laboratory results (Ignatavicius et al., 2021).  

Multidrug-Resistant Organisms  

MDROs are defined as microorganisms (primarily bacteria) that are resistant to one or more classes of antimicrobial agents; common types include MRSA and VRE. MDROs have increased in prevalence over the last few decades. Although transmission most frequently occurs in acute care facilities, all healthcare settings are affected by the emergence and transmission of antibiotic-resistant bacteria. Therefore, MDROs have important implications for patient safety, infection control, and the proper selection of antibiotics. Options for managing MDRO infections are limited; these infections are harder to eradicate and are associated with increased length of stay, higher costs, and greater mortality rates. The severity and extent of illness caused by MDROs vary by the population and setting; therefore, prevention and control strategies must be tailored to the specific needs of each population and facility. In response, the Healthcare Infection Control Practices Advisory Committee (HICPAC) developed guidelines for the control and management of MDROs in 2006. Last updated in 2017, the guidelines outline the epidemiology of emerging MDROs, focusing on evidence-based prevention and treatment strategies. The prevention of antibiotic-resistant bacteria depends on appropriate clinical practices that should be incorporated into routine patient care. The core HICPAC prevention categories are listed in Table 2 (CDC, 2021b; HICPAC, 2017). 

Methicillin-Resistant Staphylococcus aureus  

Epidemiology and Pathophysiology 

Staphylococci are gram-positive aerobic organisms that are a part of the human bacterial flora or microbiota. Staphylococcus aureus is the most pathogenic of these staphylococci and can commonly cause skin infections, pneumonia, endocarditis, and osteomyelitis. Methicillin was the treatment of choice for infections caused by beta-lactamase-producing penicillin-resistant S. aureus beginning in October 1960. However, within six months, strains resistant to methicillin emerged. MRSA is the term used to describe S. aureus strains resistant to beta-lactam antibiotics: penicillins, cephalosporins, and carbapenems. MRSA is a frequent pathogen in HAIs and has been associated with significant morbidity, mortality, and increased hospital length of stay. The higher morbidity and mortality rates related to MRSA are due primarily to other factors such as the delayed initiation of appropriate antibiotic therapy, less effective antibiotic therapy, or the increased severity of underlying illness for hospitalized patients with infections caused by MRSA (Bush & Vazquez-Pertejo, 2021b).  

Risk Factors and Protective Factors  

Risk factors for hospital-acquired MRSA infections include prolonged hospitalization, compromised immune system, invasive devices such as CVCs, antibiotic treatment, or proximity to individuals infected or colonized with MRSA (Harris 2020; Siddiqui & Koirala, 2022).  

Protective factors for hospital-acquired MRSA infection include hand hygiene for patients and HCPs, meticulous environmental cleaning, and following contact precautions when caring for patients colonized with MRSA and those diagnosed with an active MRSA infection. The minimum required PPE includes a gown and gloves. If the patient has a respiratory infection or pneumonia caused by MRSA, nurses must wear goggles and a face mask due to potential contact with respiratory secretions. HCPs hands can become a vehicle for MRSA transmission from contact with skin, wounds, dressings, secretions, equipment, or environmental surfaces contaminated with MRSA. Thorough hand hygiene and equipment cleaning (i.e., stethoscope) between patients is essential to decrease transmission (CDC, 2020b; Harris, 2020; Siegel et al., 2022). 

Signs and Symptoms  

MRSA is the leading cause of both HAP and VAP and can also cause endocarditis, CAUTIs, bloodstream infections (including CLABSIs), soft tissue infection, and wound infection (including SSIs). MRSA symptoms vary depending on the site of the infection. Patients with soft tissue, wound, or SSIs may have erythema, tenderness, edema, and drainage from the site. Patients with a bloodstream infection, CLABSI, pneumonia, VAP, or CAUTI often have fatigue, fever, pain, or swelling at the site of the infection (Harris, 2020; Siddiqui & Koirala, 2022). 

Diagnosis and Treatment  

MRSA is diagnosed based on culture results; however, treatment should not be delayed while awaiting confirmation of infection. The selection of an appropriate empiric antibiotic is based on the location of the infection, potential risks, and clinical data. Culture and sensitivity results will guide the selection of the most appropriate antibiotic to treat the infection. Other diagnostic tests that may be ordered include a complete blood count and urinalysis with culture and sensitivity. For patients with an infection of the lung, bone, joint, or another internal structure, imaging studies are required (i.e., a chest x-ray, CT scan, or echocardiogram; Harris, 2020; Siddiqui & Koirala, 2022). 

Intravenous vancomycin (Vancocin) is the antibiotic of choice to treat most hospital-acquired MRSA infections. It can be used as both empiric and definitive therapy, as most MRSA are susceptible to vancomycin (Vancocin). Vancomycin (Vancocin) dosing is adjusted based on the patient's serum trough level and renal function. Trough levels are obtained just before the administration of the fourth dose. IV daptomycin (Cubicin) can be used when vancomycin (Vancocin) is unavailable or is not well-tolerated by the patient. The duration of therapy may last from 5 to 14 days (Siddiqui & Koirala, 2022).  

Prevention  

The reservoir for MRSA in hospitals includes colonized or infected patients or HCPs and contaminated objects or surfaces in the patient care environment. Thorough cleaning of the hospital environment and using reusable patient care equipment are critical to preventing MRSA transmission. Other infection control steps include strict adherence to hand hygiene practices and the use of contact precaution PPE. Another preventative measure includes surveillance screening for MRSA colonization in patients. This is completed using a PCR MRSA test or cultures of the nares, oropharynx, or perineum. If the patient is MRSA positive, proper contact precautions can be initiated (Siddiqui & Koirala, 2022).   

Nursing Implications 

Nursing care for patients with hospital-acquired MRSA infections includes performing hand hygiene, maintaining contact precautions, and administering antibiotics as prescribed. The administration of antibiotics on time is vital to attaining adequate serum levels of the medication to resolve the infection. Since vancomycin (Vancocin) dosing is based on the serum trough level, nurses must understand the appropriate timing of obtaining a blood sample. It is also important to monitor the patient's lab work, including antibiotic peak and trough levels and white blood cell count, to ensure values return to normal as the infection resolves (Siddiqui & Koirala, 2022).

Vancomycin-Resistant Enterococci

Epidemiology and Pathophysiology 

Enterococci are Gram-positive, non-spore-forming cocci that colonize the gastrointestinal and biliary tracts and the female genital tract. These bacteria are also found in the environment. Enterococci can cause various infections, including UTIs, intraabdominal infections, bacteremia, and endocarditis. Enterococci are less virulent than S. aureus and mainly infect individuals with an underlying condition, impairing their ability to fight off infection. Vancomycin (Vancocin) is an antibiotic commonly used to treat drug-resistant enterococci infections; however, certain strains of enterococci have become resistant to vancomycin (Vancocin). The incidence and prevalence of VRE have increased significantly in the past few decades, particularly in ICUs. VRE is shed through the stool, found on the skin, and spread when a person comes into contact with a contaminated object. Colonization with VRE precedes VRE infection, but not all patients colonized with VRE will become infected. Infection with VRE increases treatment costs and mortality rates compared to vancomycin (Vancocin) susceptible enterococci (Levitus et al., 2022; Vehreschild et al., 2019). 

Risk Factors and Protective Factors  

Risk factors for VRE colonization or infection include prolonged hospital or ICU stays, invasive procedures, immunocompromise, severe illness, abdominal surgery, enteral nutrition, and prior exposure to vancomycin (Vancocin) or third-generation cephalosporins. Since VRE can live on almost any surface for days or weeks and still be infectious, being in close contact with an infected individual is also a risk factor. Exposure to healthcare personnel assigned to care for another patient with VRE colonization or infection also increases risk. Prior exposure to antimicrobials is the most significant predictor of VRE colonization (Ignatavicius et al., 2021).  

Signs and Symptoms  

VRE can cause various symptoms based on the location and type of infection. Some common sites for VRE infections include the urinary tract, the bloodstream, and wounds associated with catheters or surgical procedures. Common symptoms of VRE consist of fever and pain at the site, as well as swelling, redness, and purulent drainage for wounds (Levitus et al., 2022).  

Diagnosis and Treatment  

To make a diagnosis, a specimen from the potential source of infection should be sent for culture and sensitivity. Culture results will guide the selection of the most appropriate antibiotic therapy. Antibiotic therapy may also change depending on the site of the infection. The provider may need to consult with an infectious disease specialist to determine a plan of care due to the antibiotic resistance of VRE and its various strains (Bush & Vazquez-Pertejo, 2021a; Levitus et al., 2022).  

Prevention 

Use of good infection prevention practices, such as contact precautions (i.e., wearing a gown and gloves when caring for patients with VRE) and frequent hand hygiene by HCPs, patients, and visitors can limit the spread of VRE in healthcare settings. Patients with VRE should follow all instructions the HCP gives and keep their hands clean, especially after touching the infected area or using the bathroom. Environmental factors, such as proper cleaning and disinfecting equipment and dedicated equipment to single-patient use when possible, can prevent the spread of infection (Siegel et al., 2022).  

Nursing Implications 

Nursing care for patients with hospital-acquired VRE infections follows the same guidelines as care for those with MRSA. This includes hand hygiene, contact precautions, and administering antibiotics as ordered. Nurses must administer antibiotics on time, which is critical for attaining therapeutic blood levels and resolving the infection. Nurses must also monitor the patient's lab work for signs that the infection is resolving, such as the white blood cell count returning to normal (Ignatavicius et al., 2021).  

Healthcare Professional Protection 

According to the CDC (2021e), protecting HCPs from infectious disease exposures in the workplace involves four primary components: 

• training and administrative controls (e.g., infection control policies and procedures) 

• engineering controls (e.g., negative pressure rooms for patients with airborne diseases such as TB) 

• workplace safety practice controls (e.g., work practice controls such as not recapping) 

• PPE, including HCP training on how to identify the proper PPE based on the clinical situation and how to correctly put on (don), wear, remove (doff), and dispose of PPE (CDC, 2021e) 

Prevention 

In 2000, the Institute of Medicine (IOM; now called the National Academy of Medicine [NAM]) released its landmark report, To Err Is Human. The report relayed the astronomical data surrounding medical errors in acute care hospitals, citing nearly 98,000 hospitalized patient deaths due to preventable medical errors annually. This momentous study ignited a focus on medical practices, spawning new policies and procedures and setting performance standards and expectations for patient safety and quality improvement. In addition, the report identified several factors that contributed to patient harm and drew attention from national agencies to examine strategies to deliver safe, effective, and high-quality healthcare. In response, TJC generated standards requiring healthcare organizations to create a culture of safety. In 2002, TJC published its first set of National Patient Safety Goals (NPSGs), requiring organizations to focus on priority safety practices pertaining to patient care. The NPSGs are updated annually, and the 2021 NPSG for infection control is outlined in Table 3. Infection control programs within healthcare organizations are coordinated and implemented by HCPs trained in infection control practices and are designed to reduce the risk of HAIs. Hospitals execute infection tracking and surveillance systems, alongside evidence-based infection control practices, to reduce the rates of HAIs, improve patient safety, and reduce morbidity and mortality (IOM et al., 2000; TJC, 2021). 

Hand Hygiene 

Proper hand hygiene is the most effective risk-reduction strategy to prevent HAIs. According to the CDC, HCPs wash their hands or perform hand hygiene less than 50% of the time that it is indicated. Performing hand hygiene in the presence of the patient and family promotes trust and models good behavior for others. Figure 2 illustrates the 5 moments for hand hygiene during patient care. The term "hand hygiene" refers to handwashing with an antimicrobial or plain soap and water and alcohol-based products such as gels, foams, and rinses. Alcohol-based products contain an emollient that does not require the use of water. According to the CDC, in the absence of visibly soiled hands or when contamination from spore-forming organisms (e.g., C. diff) is unlikely, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience in the absence of a sink (CDC, 2020a, 2021c).  

As outlined in the CDC hand hygiene guidelines, HCPs should use an alcohol-based hand rub in the following clinical situations: 

• immediately before direct contact with a patient (e.g., touching) 

• before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices (e.g., IV site, urinary catheter) 

• before transitioning care from a soiled body site to a clean body site on the same patient 

• after touching a patient or the patient's immediate environment (e.g., bed linens, surfaces, IV pole) 

• after contact with blood, body fluids, or contaminated surfaces 

• immediately after removing gloves (CDC, 2020a, 2021c)  

To use an alcohol-based hand sanitizer properly, the product should be applied to the hands, covering all surfaces, and rubbed together until the hands feel dry. This process should take approximately 20 seconds. HCPs should wash hands with soap and water instead of using an alcohol-based hand rub in the following clinical scenarios: 

• when hands are visibly soiled 

• after caring for a patient with known or suspected infectious diarrhea 

• after known or suspected exposure to spores (e.g., B. anthracis, C. diff; CDC, 2020a, 2021c)  

To clean the hands using soap and water, wet them with water, apply the amount of soap product recommended by the manufacturer, and rub the hands together vigorously for at least 15 to 20 seconds, covering all surfaces of the hands and fingers. Next, the hands should be rinsed with water and dried with a disposable towel. Finally, the CDC recommends using a disposable towel to turn off the faucet to prevent recontamination of the hands (CDC, 2020a). 

HCPs are advised to inspect their hands for breaks, cuts, or lacerations in the skin or cuticles before the start of each workday. These open areas provide a portal of entry for organisms. If any breaks in skin integrity are identified, a dressing should be applied before caring for patients. To prevent cross-contamination between different body sites, performing hand hygiene between tasks and procedures on the same patient may be necessary. Artificial nails are discouraged since they harbor microorganisms. Fingernails should be trimmed to one-quarter of an inch, and rings should be avoided if possible. If the areas beneath the fingernails are soiled, they should be cleaned with an orangewood stick, if available (CDC, 2020a, 2021c). 

Personal Protective Equipment 

The Occupational Safety and Health Administration (OSHA) defines PPE as specialized equipment worn by HCPs to protect against infectious materials and minimize exposure to hazards that can cause serious illness. In healthcare settings, PPE such as gloves, masks, eyewear, and gowns are necessary for specific clinical situations to prevent the transmission of infectious materials by contact with patients and their blood, body fluids, secretions, or excretions. Choosing which PPE items are appropriate for each infectious organism is based on how the organism is transmitted and facility policies and procedures (CDC, 2021e; OSHA, n.d.). 

Standard Precautions 

Standard precautions are the basis of infection control practices and are of utmost importance to prevent the transmission of infectious agents and communicable diseases in healthcare settings. Standard precautions apply to the care of all patients in healthcare settings (regardless of the suspected or confirmed presence of an infectious agent). They are the first line of defense to break the chain of infection and protect HCPs and patients. Standard precautions are premised on the concept that every patient's blood or body fluids are potentially contaminated with infectious agents. Standard precautions are employed with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. In addition to hand hygiene practices, standard precautions include selecting and using proper PPE based on the level of anticipated contact with a patient and the potential for exposure to infectious material, including blood, body fluid, or splash exposure. Providing care using standard precautions includes hand hygiene, gloves, a gown, a facemask, and a face shield; respiratory hygiene/cough etiquette; and safe injection practices. The use of facemasks during spinal/epidural access procedures falls within the definition of standard precautions. The efficacy of standard precautions is related directly to how well individuals and institutions adhere to the recommended guidelines (CDC, 2021e; Siegel et al., 2022).  

In 2013, the CDC recommended that respiratory hygiene/cough etiquette be incorporated into infection control as a component of standard precautions. These should be instituted in the healthcare setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a robust evidence base. Respiratory hygiene or cough etiquette applies to anyone entering a healthcare setting (patients, visitors, and staff) with signs or symptoms of illness (coughing, congestion, rhinorrhea, or increased respiratory secretions; Siegel et al., 2022). The components of respiratory hygiene/cough etiquette include the following: 

• covering the mouth and nose when coughing and sneezing 

• using disposable facial tissues to contain respiratory secretions, with prompt disposal into a hands-free receptacle 

• wearing a surgical mask when coughing to minimize contamination of the surrounding environment 

• turning the head when coughing and staying at least 3 feet away from others, especially in common waiting areas 

• washing hands with soap and water or alcohol-based hand rub after contact with respiratory secretions (CDC, 2021e; Siegel et al., 2022). 

Transmission-Based Precautions 

Transmission-based precautions are the second tier of infection control and are intended for use alongside standard precautions. Transmission-based precautions are reserved for patients suspected of being infected or colonized with specific infectious agents. Also referred to as isolation precautions, transmission-based precautions are based on the infectious organism's mode of transmission. The major categories of transmission-based protection include contact, droplet, and airborne precautions (Siegel et al., 2022). These are used for patients with highly transmissible pathogens when the route of transmission is not entirely interrupted by standard precautions. Regardless of the specific type of transmission-based precautions required, the following principles should be routinely adhered to: 

• thoroughly perform hand hygiene before entering and leaving the room of a patient in isolation 

• properly dispose of contaminated supplies and equipment according to agency policy 

• apply knowledge of the mode of infection transmission when using PPE 

• protect all persons from exposure during the transport of an infected patient outside of the isolation room 

• prioritize single private rooms when available, but cohort rooming may be implemented during outbreaks of infections (i.e., the placement of patients infected with the same organism in the same room, based on organizational needs; Siegel et al., 2022). For more information on PPE, see the Personal Protective Equipment NursingCE course.  

Antibiotic Stewardship  

According to the CDC, antibiotic stewardship in acute care facilities is crucial for reducing hospital-acquired infections. The Core Elements of Hospital Antibiotic Stewardship Programs consist of the following: 

• Leadership Commitment: dedicating necessary human, financial, and information technology resources 

• Accountability: appointing a single leader responsible for program outcomes; experience with successful programs shows that a physician leader is effective 

• Drug Expertise: appointing a single pharmacist leader responsible for working to improve antibiotic use 

• Action: implementing at least one recommended action, such as systemic evaluation of ongoing treatment needs after a period of initial treatment (i.e., "antibiotic time out" after 48 hours) 

• Tracking: monitoring antibiotic prescribing and resistance patterns 

• Reporting: regularly reporting information on antibiotic use and resistance to doctors, nurses, and relevant staff 

• Education: educating clinicians about resistance and optimal prescribing (Siegel et al., 2022) 

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