Table Of ContentControl of Hospital Infection
A PRACTICAL HANDBOOK
Control of Hospital
Infection
A PRACTICAL HANDBOOK
Edited by
E. J. L. LOWBURY, G. A. J. AYLIFFE,
A. M. GEDDES and J. D. WILLIAMS
SECOND EDITION
SPRINGER-SCIENCE+BUSINESS MEDIA, B.V.
Firstpublished 1975
Second edition 1981
© 1975, 1981 Springer Science+Business Media Dordrecht
Origina11y published by Chapman and Hall Ltd in 1981
Softcover reprint ofthe hardcovar JD.d editi.011 1981
Ali rights reserved. No part of this book
may be reprinted, or reproduced or utilized in
any {orm or by any electronic, mechanical or
other means, now known or herea{ter invented,
including photocopying and recording, or in
any in{ormation storage and retrieval system,
without permission in writing {rom the
Publisher
British Library Cataloguing in Publication Data
Working Party on Control of Hospital lnfection
Control of hospital infection. - 2nd ed.
1. Cross in{ection 2. Hospitals - Hygiene
I. Title II. Lowbury, Edward Joseph Lister
614.4'4 RA969
ISBN 978-0-412-16300-5 ISBN 978-1-4899-6884-5 (eBook)
DOI 10.1007/978-1-4899-6884-5
Contents
Preface to the First edition vii
Preface to the Second Edition ix
Acknowledgements xi
West Midlands Regional Health Authority: Working Party on xii
Control of Hospital lnfection
1 lntroduction 1
Section A: Administration, Surveillance and Responsibility
2 Administration and Responsibility 13
Appendix 2.1: Diseases notifiable to the Medical Officer for
Environmental Health in the United Kingdom 23
3 Surveillance, Records and Reports 26
Appendices 3.1, 3.2 and 3.3: Examples of infection record forms 34
Appendix 3.4: Example of Kardex record 37
Section B: Sterilization, Disinfection and Cleaning
4 Sterilization and Physical Disinfection 41
Appendix 4.1: Autoclave tests 46
Appendix 4.2: Methods of sterilization and disinfection of
equipment and supplies in hospitals 50
5 Central Sterile Supply 53
6 Disinfection (1) Types of Chemical Disinfectant and Formulation of
Policy for Disinfection 63
7 Disinfection (2) Cleaning and Disinfection Procedures 72
Appendix 7.1: Summary of methods for cleaning and decon-
tamination of equipment and of environment 93
Appendix 7.2: Disinfectants for environmental use 99
Appendix 7.3: Disinfectants ('antiseptics') for skin and mucous
membranes 100
Appendix 7.4: Disinfection of Cape Ventilator with hydrogen
peroxide 101
Appendix 7.5: Cleaning and Disinfection of ambulances after
transporting infected patients 102
V
Contents
Section C: Prevention of Spread of Infection
8 Prevention of Infection in Wards (1) Ward Procedures and
Dressing Techniques 107
Appendix 8.1: Use of packs in surgical procedures 120
9 Prevention of Infection in Wards (2) Isolation of Patients 123
10 Asepsis in Operating Theatres 159
11 Laundry, Kitchen Hygiene and Refuse Disposal 172
Appendix 11.1: Questionnaire for catering staff 181
Appendix 11.2: Catering staff agreement to report infection 183
Appendix 11.3: Kitchen and food-handling staff: rules for
personal hygiene 183
Section D: Chemotherapy, Chemoprophylaxis and Immunization
12 Use of Antibiotics and Chemotherapeutic Agents 187
Appendix 12.1: Antiobiotic names, prices and dosage
(February 1980) 207
13 Immunization and Specific Prophylaxis 212
Appendix 13.1: Prophylaxis against tetanus in patients with
open wounds 225
Section E: Care of Hospital Staff: Infection
14 Hospital Staff Health Services in the Control of Infection 229
Appendix 14.1: Hospital staff immunization record 232
Section F: Special Wa rds and Departments
15 Special Wards and Departments (1) Intensive care; paediatrics;
matemity; milk kitchens; bums and injuries; skin diseases;
ophthalmic departments; ear, nose and throat departments;
problems in the community 237
16 Special Wards and Departments (2) Neurosurgery; urology;
psychiatry and geriatrics; out-patients and casualty;
radiology and radiotherapy; physiotherapy; pharmacy;
pathology; mortuary and post-mortem room 266
Section G: Miscellaneous Problems
17 Diseases Caused by Dangerous Pathogens 289
18 Control of Hepatitis in Hospital 296
19 Dialysis and Renal Transplantation Units 304
Selected Bibliography 316
Index 317
vi
Preface to the First Edition
This Handbook has been prepared as a guide for use by the staffs of hospitals. It
is addressed to doctors, nurses, pbysiotherapists, radiographers and otbers wbo
are involved in the treatment and care of patients, and in part also to admini-
strators, architects, engineers, domestic superintendents and otbers whose work
may influence the cbances of infection among patients and staff.
Before tbe introduction of antiseptic and aseptic methods by Lister and
others in tbe last century, major surgical infection ('bospital gangrene') was an
overwbelming hazard and a common cause of deatb in bospitals. Altbougb ful-
minating infection of tbis type was eliminated by tbe new measures, a residue of
less dangerous infection persisted, and tbe development of new fields of surgery
and tberapy, including metbods whicb interfere with the patients' immunity,
has introduced new hazards of infection. Antibiotic treatment bas brougbt
relief against some of tbese infections, but it bas often been frustrated by the
emergence of antibiotic resistant bacteria. In addition to the bardsbip tbat it
causes to patients (and sometimes to members of staff), bospital infection bas, in
the words of Sir Wilson Jameson, been 'a steady drain on tbe bospital purse and
efficiency'. Abundant researcb in the past 25 years bas sbown tbat bospital
infection can be greatly reduced by tbe correct application of a number of im-
proved methods of asepsis and hygiene; but it is also a familiar experience that
hospital infection is still common and tbat recommendations are often unknown
or unobserved. Tbe purpose of this Handbook is to offer tbe guidance and infor-
mation needed for a more effective use of current knowledge on ways of con-
trolling infection.
To be effective such a handbook must be understood clearly by ali who wisb
to use it, and we have therefore tried to express, in as simple terms as we can,
tbe elaborate and ever-developing strategy and tactics used in the control of
hospital infection. Tbis bas involved calling many products by tbe proprietary
names which are commonly used rather tban (oras well as) by tbeir official or
chemical names; in many cases (e.g. tbe clear soluble pbenolic compounds) no
other names are available. Wben we refer to a disinfectant or antiseptic for a
particular purpose, it must be regarded as an example, and one wbich we have
examined; otber products of wbicb we bave no information or personal experi-
ence may well be as effective- perbaps even more effective. Wbere our studies
and tbose of otbers have sbown one product or group of products tobe more
effective than others, we have naturally cbosen tbat product or group of
products; and occasionally where a commonly used product bas been found, in
careful studies, to fali short of expectation or to be ineffective, it has been
vii
Preface to the First Edition
necessary to mention this fact so that hospitals should choose a more effective
product. The recommendations which we have made refer only to hospital
practice and it must not be inferred that methods judged unsuitable for hospital
use are not suitable for domestic and other purposes.
Cost as well as effectiveness must be considered, and we have therefore
appended some information about retail prices at the time this Handbook was
prepared, relating to a number of alternative products which we have found to
be effective. Of course, prices will change frequently. Furthermore, it has not
been possible to include the price structures which might apply to alternatives
that we did not ha ve the opportunity to assess, or to take account of special
terms which might be available through contracting or bulk purchasing. Because
such special terms may affect different materials to a different degree, we have
presented some examples of the relative costs to hospitals of different com-
pounds or mixtures which have been used for the same purpose. We feei that the
information we have provided will be of some value to Health Authorities.
Hospital hygiene and aseptic practices have changed repeatedly with the
arrival of new knowledge and the assessment of new materials. It is expected
that many of the recommendations presented here will, in the course of time, be
-- and some may already have been- superseded by new and improved methods,
which will caii for a revision of the Handbook. Many alternative procedures are
equally effective, and there should be no conflict in the choice between such
alternatives. Sometimes the most effective method cannot be applied (e.g. be-
cause the equipment required is not available); under these circumstances a less
desirable alternative must be recommended. It is important that the Bacteriolo-
gist, the Infection Control Officer and the lnfection Control Nurse should be
consulted on questions of uncertainty about procedures or principles; the Area
Supplies Officer and the Area Pharmaceutical Officer should be consulted, and
other officers as appropriate, in respect of costs. The handbook, supplemented
by more recent information, will be used by the Infection Control Team in its
handling of current infection problems.
viii
Preface to the Second Edition
This book, originally conceived as a code of practice for one Region of the
British National Health Service, bas answered a much wider need and been
found useful by hospital workers in many countries. In preparing a second edi-
tion the Editors have incorporated new knowledge, ideas and practices, and
taken note of useful advice and comments made by readers of the first edition,
to produce, we hope, an up-to-date and improved compilation. We have not
changed the basic design of the book, which aims to provide hospital workers
with practicat guidance supported by a limited selection of relevant references -
books, reviews and a few papers - for further reading; it is not, and does not
aim tobe, a fully documented textbook on hospital infection. As in the first
edition, the Editors have called upon the expertise of a Working Party for advice
and for some contributions to the text.
Since our first edition appeared there have been many improvements in pro-
cedure, and also some important changes in the pattern of infection; new (or
rather, newly recognized) infections, such as Legionnaire's disease and Campylo-
bacter enteritis, have been described, while others (notably smallpox) have
receded. There bas been, in many centres, a reduced incidence of cross-infection,
especially of staphylococcal sepsis, and a decline in the presence of multiresistant
'hospital' staphylococci. In abdominal surgery endogenous infection, particu-
larly with Bacteroides and other anaerobic bacteria normally present in human
faeces, bas been recognized as the major form of postoperative wound infection;
its prevention by short-term chemoprophylaxis bas been an important develop-
ment in the control of hospital infection. There have been changes in availability
and recommended choice of drugs and disinfectants, and considerable changes
in their cost. Since our first edition, too, the responsibility of hospitals for the
protection of staff against infective hazards bas been strongly reinforced in
Great Britain by the Health and Safety at Work Act of 1974 and the publication
of the Code of Practice for the Prevention of lnfection in Clinical Laboratories
and Postmortem Rooms (Howie ). There is still uncertainty about the application
of some of the far-sighted improvements put forward in these publications, and
it is important to recognize that a balance of hazard may exist - both for staff
and for patients - between infection that might occur if some recommended
procedures were not used and adverse effects (e.g. allergic or toxic reactions)
that might occur as the result of using them. In situations involving such uncer-
tainty, judgements based on clinical and microbiological expertise should be the
deciding factor in the choice of procedures for the control of infection rather
than adherence to rigid rules; the personal factor is of special importance in this
ix
Preface to the Second Edition
fleld, and cannot be replaeed by a code of practice. Nevertheless the Editors
hope that this book will prove useful as a guide and reference to those who are
called upon to make such decisions.
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