HES032 (Microbiology and Parasitology)
STUDENT ACTIVITY SHEET BS NURSING/ SECOND YEAR
Session # 8
LESSON TITLE: Healthcare Epidemiology Materials:
LEARNING OUTCOMES: Book, pen, notebook, and paper
At the end of the lesson, the nursing student can:
1. Differentiate among healthcare-associated, community Reference:
acquired, and iatrogenic infections;
2. State the four most common types of healthcare- Engelkirk, P., & Engelkirk, J. (2015). Burton's
th
associated infections; Microbiology for the Health and Sciences. 10 ed.,
3. List six types of patients who are especially vulnerable to Philadelphia: Lipincott Williams & Wilkins
healthcare-associated infections;
4. State the three major contributing factors in healthcare
associated infections;
5. Differentiate between medical and surgical asepsis;
6. State the most important and effective way to reduce the
number of healthcare-associated infections and;
7. Differentiate between Standard Precautions and
Transmission-Based Precautions and state the three types
of Transmission-Based Precautions.
Daily Productivity Tip:
Find a study partner. Discuss with your partner the discussions of today’s module.
LESSON PREVIEW/REVIEW (5 minutes)
Before we start this session, enumerate the most common ―superbugs‖ and give examples.
Carbapenem-Resistant Enterobacteriaceae ____________________________________
1. ____________________________________, - Escherichia coli (E. coli) and Klebsiella pneumoniae.
Vancomycin-resistant Enterococcus (VRE),____________________________________
2. ____________________________________, Enterococcus faecium
Multidrug-resistant Pseudomonas aeruginosa,
3. ____________________________________, Ciprofloxacin
____________________________________
Multidrug-resistant Acinetobacter, Fluroquinolones
4. ____________________________________, ____________________________________
Extended-spectrum -lactamase (ESBL)-producing
5. ____________________________________, Enterobacteriaceae, Klebsiella spp.
____________________________________
Good! Now, you are ready for today’s session.
MAIN LESSON (50 minutes)
Healthcare epidemiology can be defined as the study of the occurrence, determinants, and distribution of health and
disease within healthcare settings.
Healthcare-associated infections or HAI are infections that are acquired within hospitals or other healthcare facilities.
Community-acquired infections are those that are present or incubating at the time of hospital admission. All other
infections are considered HAIs, including those that erupt within 14 days of hospital discharge. An iatrogenic infection is
an infection that results from medical or surgical treatment—an infection that is caused by a surgeon, another physician, or
some other healthcare workers.
Approximately 70% of HAIs involve drug-resistant bacteria, which are common in hospitals, nursing homes, and other
healthcare settings as a result of the many antimicrobial agents in use there. The drugs place selective pressure on the
microbes, meaning that only those that are resistant to the drugs will survive.
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Modes of Transmission
The three principle routes by which pathogens involved in HAIs are transmitted are contact, droplet, and airborne.
1. Contact Transmission
There are two types of contact transmission:
In direct contact transmission, pathogens are transferred from one infected person to another person without a
contaminated intermediate object or person.
Indirect contact transmission happens when pathogens are transferred via a contaminated intermediate object or
person.
2. Droplet Transmission
In droplet transmission, respiratory droplets carrying pathogens transmit infection when they travel from the respiratory
tract of an infectious individual (e.g., by sneezing or coughing) to susceptible mucosal surfaces of a recipient. Droplets
traditionally have been defined as being larger than 5 m in size.
3. Airborne Transmission
Airborne transmission occurs with dissemination of either airborne droplet nuclei or small particles containing
pathogens. Traditionally, airborne droplets are defined as being less than or equal to 5 m in size.
Most Common Types of Healthcare-Associated Infections
1. UTIs, which represent about 32% of all HAIs and cause about 13% of the deaths associated with HAIs
2. Surgical site infections, which represent about 22% of all HAIs and cause about 8% of the deaths associated with
HAIs
3. Lower respiratory tract infections (primarily pneumonia), which represent about 15% of HAIs and cause about 36%
of the deaths associated with HAIs
4. Bloodstream infections (septicemia), which represent about 14% of HAIs and cause about 31% of the deaths
associated with HAIs
Gastrointestinal diseases caused by Clostridium difficile is a common cause of gastrointestinal
HAIs, which are referred to as C.difficile-associated diseases. C.difficile (often referred to as ―C.
diff‖) is an anaerobic, spore-forming, Gram-positive bacillus. It is a common member of the
indigenous microflora of the colon, where it exists in relatively small numbers. Although C. difficile
produces two types of toxins (an enterotoxin and a cytotoxin), the concentrations of these toxins are
too low to cause disease when only small numbers of C.difficile are present.
Twelve Steps to Prevent Antimicrobial Resistance among Hospitalized Adults
A. Prevent Infection Step
o Vaccinate - give influenza vaccine and Streptococcus pneumoniae vaccine to at-risk patients before discharge.
Healthcare workers should receive the influenza vaccine annually.
o Get the catheters out - use catheters only when essential. Use the correct catheter. Use proper insertion and catheter-
care protocols. remove catheters when they are no longer essential.
B. Diagnose and Treat Infection Effectively
o Target the pathogen. - target empiric therapy to likely pathogens and your facility’s antibiogram information. Target
definitive therapy to known pathogens and antimicrobial susceptibility test results.
o Access the experts - consult infectious disease experts for patients with serious infections.
C. Use Antimicrobials Wisely
o Practice antimicrobial control - engage in local antimicrobial control efforts.
o Use local data - Know your facility’s antibiogram. Know your patient population.
o Treat infection, not contamination - use proper antisepsis for blood and other cultures. Culture the blood, not the skin or
catheter hub. Use proper methods to obtain and process all cultures.
o Treat infection, not colonization - treat pneumonia, not the tracheal aspirate. Treat bacteremia, not the catheter tip or
hub. Treat urinary tract infection, not the indwelling catheter.
o Know when to say ―no‖ to Vancomycin - treat infection, not contaminants or colonization. Fever in a patient with a
vancomycin intravenous catheter is not a routine indication for vancomycin.
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o Stop antimicrobial treatment - When infection is cured. When cultures are negative and infection is unlikely. When
infection is not diagnosed.
D. Prevent Transmission
o Isolate the pathogen Use standard infection control precautions. - contain infectious body fluids. (Follow Airborne,
Droplet, and Contact Precautions.) When in doubt, consult infection control experts.
o Break the chain of contagion - stay home when you (the healthcare worker) are sick. Keep your hands clean. Set an
example.
Think and Learn: As a nursing student, how important is vaccination?
Major Factors Contributing to Healthcare-Associated Infections
The three major factors that combine to cause HAIs are:
1. An ever-increasing number of drug-resistant pathogens
2. The failure of healthcare personnel to follow infection control guidelines
3. An increased number of immunocompromised patients
Additional contributing factors are:
The indiscriminate use of antimicrobial agents, which has resulted in an increase in the number of drug resistant and
multidrug-resistant pathogens
A false sense of security about antimicrobial agents, leading to a neglect of aseptic techniques and other infection
control procedures
Lengthy, more complicated types of surgery
Overcrowding of hospitals and other healthcare facilities, as well as shortages of staff
Increased use of less-highly trained healthcare workers, who are often unaware of infection control procedures
Increased use of anti-inflammatory and immunosuppressant agents, such as radiation, steroids, anticancer
chemotherapy, and antilymphocyte serum
Overuse and improper use of indwelling medical devices
What can be done to reduce the number of Healthcare-Associated Infections?
The primary way to reduce the number of HAIs is strict compliance with infection control guidelines. Handwashing is the
single most important measure to reduce the risks of transmitting pathogens from one patient to another or from one
anatomic site to another on the same patient.
Patients Most Likely to Develop
Wash your hands before you: Healthcare-Associated Infections:
Prepare or eat food
Immunosuppressed patients are
Treat a cut or wound or tend to someone who is sick especially likely to develop HAIs. Listed
Insert or remove contact lenses here are the most vulnerable patients in
Wash your hands after you: a hospital setting:
Elderly patients
Use the restroom
Women in labor and delivery
Handle uncooked foods, particularly raw meat, poultry, or fish
Premature infants and newborns
Change a diaper
Surgical and burn patients
Cough, sneeze, or blow your nose
Patients with diabetes or cancer
Touch a pet, particularly reptiles and exotic animals
Patients with cystic fibrosis
Handle garbage
Patients having an organ transplant
Tend to someone who is sick or injured
Patients receiving treatment with
Wash your hands in the following manner: steroids, anticancer drugs,
Use warm or hot running water antilymphocyte serum, or radiation.
Use soap (preferably an antibacterial soap)
Wash all surfaces thoroughly, including wrists, palms, back of hands, fingers, and under fingernails (preferably with a
nail brush)
Rub hands together for at least 10 to 15 seconds
When drying, begin with your forearms and work toward your hands and fingertips, and pat your skin rather than
rubbing to avoid chapping and cracking.
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Infection Control
Infection control measures are designed to break various links in the chain of infection. Aseptic techniques are actions
taken to prevent infection or break the chain of infection.
Medical asepsis is a clean technique. Its goal is to exclude pathogens. Medical asepsis includes all the precautionary
measures necessary to prevent direct transfer of pathogens from person to person and indirect transfer of pathogens
through the air or on instruments, bedding, equipment, and other inanimate objects (fomites).
Disinfection
Categories of Disinfectants
1. Chemical sterilant kills bacterial spores with prolonged exposure times (3–12 hours).
2. High-level disinfectants kill all microbes (including viruses), except large numbers of bacterial spores.
3. Intermediate-level disinfectants might kill mycobacteria, vegetative bacteria, most viruses, and most fungi, but do not
necessarily kill bacterial spores.
4. Low-level disinfectants kill most vegetative bacteria, some fungi, and some viruses within 10 minutes of exposure.
Surgical Asepsis
Surgical asepsis, or sterile technique, includes practices used to render and keep objects and areas sterile (i.e., free of
microbes). Note the differences between medical and surgical asepsis:
1. Medical asepsis is a clean technique, whereas surgical asepsis is a sterile technique.
2. The goal of medical asepsis is to exclude pathogens, whereas the goal of surgical asepsis is to exclude all microbes.
Surgical aseptic techniques are practiced in operating rooms, in labor and delivery areas, and during invasive procedures.
Standard Precautions
In a healthcare setting, one is not always aware of which patients are infected with HIV, HBV, HCV, or other communicable
pathogens. Standard Precautions are to be applied to the care of ALL patients in ALL healthcare settings, regardless of the
suspected or confirmed presence of an infectious agent.
Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated
transmission of infectious agents among patients and healthcare personnel.
Vaccinations
Because healthcare personnel are at particular risk for several vaccine-preventable infectious diseases, the CDC
recommends that they receive the following vaccines:
Hepatitis B recombinant vaccine
Influenza vaccine
Measles live-virus vaccine
Mumps live-virus vaccine
Rubella live-virus vaccine
Varicella-zoster live-virus vaccine
Personal Protective Equipment
There are many components of personal protective equipment (PPE). The most common are listed here.
1. Gloves. Gloves can protect both patients and healthcare personnel from exposure to infectious materials that may be
carried on hands
2. Isolation Gowns. Isolation gowns are worn in conjunction with gloves and with other PPE when indicated. Gowns are
usually the first piece of PPE to be donned.
3. Masks. Masks are used for three primary purposes in healthcare settings:
They are worn by healthcare personnel to protect them from contact with infectious material from patients.
They are worn by healthcare personnel when engaged in procedures requiring sterile technique to protect
patients from exposure to pathogens that may be present in a healthcare worker’s mouth or nose.
They are placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the
patient to others.
4. Eye Protection. Types of eye protection include goggles and disposable or non-disposable face shields. Masks
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may be used in combination with goggles, or a face shield may be used instead of a mask and goggles.
5. Respiratory Protection. Respiratory protection requires the use of a respirator with N95 of higher filtration to prevent
inhalation of infectious particles.
Think and Learn: Why wearing PPE is important even though it is the lowest among the hierarchy of
control?
Transmission-Based Precautions
1. Contact Precautions. Contact transmission is the most important and frequent mode of transmission of HAIs.
Contact Precautions are used for patients known or suspected to be infected or colonized with epidemiologically
important pathogens that can be transmitted by direct or indirect contact.
2. Droplet Precautions. Droplet Precautions are used for particles that are larger than 5 m in diameter.
3. Airborne transmission involves either airborne droplet nuclei or dust particles containing a pathogen. Airborne
Precautions are used when particles are 5 m or less in diameter.
Airborne Infection Isolation Rooms
The preferred placement for patients who are infected with pathogens that are spread via airborne droplet nuclei and,
therefore, require Airborne Precautions, is in an airborne infection isolation room.
AIIRs are under negative pressure, and air that is evacuated from these rooms passes through high-efficiency
particulate air (HEPA).
Protective Environments
Protective Environments are rooms that are under positive pressure, and vented air that enters these rooms passes
through HEPA filters.
Certain patients are especially vulnerable to infection, particularly to invasive environmental fungal infections. Examples
of such patients are patients with severe burns, those who have leukemia, patients who have received a transplant (such
as a hematopoietic stem cell transplant), immunosuppressed persons, those receiving radiation treatments, leukopenic
patients (those having abnormally low white blood cell counts), and premature infants. These patients can be protected
by placing them in a Protective Environment (sometimes referred to as protective isolation or positive pressure isolation).
TAKE A QUICK BREAK. BREATHE SLOWLY. WRITE FREELY.
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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 30 minutes for this activity (20 points):
1. A HAI is one that:
a. develops during hospitalization or erupts within 14 days of hospital discharge.
b. develops while the patient is hospitalized.
c. is acquired in the community.
d. the patient has at the time of hospital
admission. ANSWER: B
RATIO: An HAI is an infection that arises from receiving medical attention. This could happen when receiving wound
care treatments, in a hospital, outpatient surgery center, nursing home, or rehabilitation institution.
2. An example of a fomite would be:
a. a drinking glass used by a patient.
b. bandages from an infected wound.
c. soiled bed linens.
d. all of the above.
ANSWER: D
RATIO: All of the choices above is correct.
3. Which of the following Gram-positive bacteria is most likely to be the cause of a HAI?
a. C. difficile
b. S. aureus
c. Streptococcus pneumoniae
d. S. pyogenes
ANSWER: B
RATIO: The cocci Staphylococcus aureus are gram-positive, catalase-positive, and coagulase-positive. Skin
infections, pneumonia, endocarditis, septic arthritis, osteomyelitis, and abscesses are inflammatory illnesses
that S. aureus can cause.
4. Which of the following Gram-negative bacteria is least likely to be the cause of a HAI?
a. a Klebsiella species
b. a Salmonella species
c. E. coli
d. P. aeruginosa
ANSWER: B
RATIO: A genus of rod-shaped (bacillus) Gram-negative bacteria belonging to the Enterobacteriaceae family is
called Salmonella. Salmonella enterica and Salmonella bongori are the two types of Salmonella.
5. A Protective Environment would be appropriate for a patient:
a. infected with MRSA.
b. with leukopenia.
c. with pneumonic plague.
d. with tuberculosis.
ANSWER: B
RATIO: A patient with leukopenia would benefit from being in a protective environment.
6. Which of the following is not part of Standard Precautions?
a. handwashing between patient contacts
b. placing a patient in a private room having negative air pressure
c. properly disposing of needles, scalpels, and other sharps
d. wearing gloves, masks, eye protection, and gowns when
appropriate
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ANSWER: B
RATIO: Placing a patient in a private room having negative air pressure is not part of routine precautions.
7. A patient suspected of having tuberculosis has been admitted to the hospital. Which one of the following is
not appropriate?
a. Droplet Precautions
b. an AIIR
c. Standard Precautions
d. use of a type N95 respirator by healthcare professional who are caring for the
patient ANSWER: A
RATIO: The use of droplet precautions on a patient with tuberculosis is inappropriate.
8. Which of the following statements about medical asepsis is false?
a. Disinfection is a medical aseptic technique.
b. Handwashing is a medical aseptic technique.
c. Medical asepsis is considered a clean technique.
d. The goal of medical asepsis is to exclude all microorganisms from an
area. ANSWER: D
RATIO: The goal of medical asepsis is to exclude pathogens from an area.
9. Which of the following statements about an AIIR is false?
a. Air entering the room is passed through HEPA filters.
b. The room is under negative air pressure.
c. An AIIR is appropriate for patients with meningococcal meningitis, whooping cough, or influenza.
d. Transmission-Based Precautions will be
necessary. ANSWER: A
RATIO: An inaccurate statement about an AIIR is that the HEPA filters are used to pass air into the
space.
10. Contact Precautions are required for patients with:
a. C. difficile-associated diseases.
b. infections caused by multidrug-resistant bacteria.
c. viral hemorrhagic fevers.
d. all of the above.
ANSWER: D
RATIO: All of the choices above is correct.
RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER:
RATIO:
2. ANSWER:
RATIO:
3. ANSWER:
RATIO:
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4. ANSWER:
RATIO:
5. ANSWER:
RATIO:
6. ANSWER:
RATIO:
7. ANSWER:
RATIO:
8. ANSWER:
RATIO:
9. ANSWER:
RATIO:
10. ANSWER:
RATIO:
LESSON WRAP-UP (5 minutes)
You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help
you track how much work you have accomplished and how much work there is left to do.
You are done with the session! Let’s track your progress.
Exit Ticket: One-minute paper
a. How do you feel about today’s session? __ Happy __ Satisfied __ Sad __ Confused
b. What question(s) do you have as we end this session? NONE
th
Reading Assignment: For the next session, read chapter 15 of Burton’s Microbiology for the Health Siences, 10 Ed.
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