**3. HAI : Types by site**


all types of HAIs occur in HAP [26] and roughly the mortality range from 24 to 76 % in different health care settings [27]. Ventilator associated pneumonia (VAP) is the commonest cause of HAP which occurs after 48 hours of initiating mechanical ventilation [25], [28]. VAP occurs 25% of all ICU infections and caused by multidrug resistantbacteriae.g.Pseudomonasaeruginosa,AcinetobacterbaummaniorCarbepe‐ nemaseproducingEnterobacteriaceae,MRSA,VREetc.Burkholderiasp.andStenotro‐ phomonas maltophila both have a tendancy to colonize respiratory tract rather than to cause invasive disease and are mostly resistant to Carbapenems, because of produc‐ tion of metallobetalactamase(MBL). The high mortality, prolonged ICU stay and excessive cost associated with VAP is a real challenge to medical fraternity.

The terms Multidrug resistance and Extreme drug resistance in Gram negative bacteria was introduced by Falagas in 2011 [18]. Multidrug resistance (MDR) is indicated by non-suscept‐ ibility to one or more antibiotics belonging to 3 or more antibiotic classes, whereas Extreme

10-12 % of all HAIs are caused by Enterococci which is the 3rd most common cause of blood stream infection in hospitalized patients. Vancomycin resistant Enterococci (VRE) was first isolated in vitro in 1969 and was described clinically in 1988. The main mechanism is alteration of cell wall precursors. Several resistant genotypes have been detected, of which vanA and vanB are most clinically significant. Vancomycin resistance is transferable to Staphylococcus aureus in vitro. As a life saving measure, treatment option with MDRO is very selective. MRSA strains can be treated by Vancomycin and Linezolid, VRE can be treated by Linezolid; ESBL producers can be treated by β – lactamase inhibitors; both ESBL and AmpC producers can be treated by Carbapenems. But Carbapenem resistant organisms can be treated by Colistin.

Recent studies in India have reported ESBL in 70 – 90% of Enterobacteriaceae, 29% Pseudo‐ monas aeruginosa and 26% of Acinetobacter spp. which is a serious problem [20]. Recently from our hospital prevalence of AmpC β – lactamase and metallobetalactamase (MBL) producing P.aeruginosa strains have been reported as 19.3% in 2009 and 11.4% in 2010

**i.** Unary tract infections (UTI) – UTI are mostly catheter associated which are called CA

**ii.** Hospital acquired pneumonia (HAP) – is the second most common hospital acquired

infectionandaccounts for 15%of HAIs [25].Highestmorbidityandmortalityamongst

– UTI. CA – UTI are the second most common cause of health care associated Blood stream infections. As per National Health care Safety Network [23], CA – UTIs are defined as the patient having indwelling urinary catheter or 48 hours before onset of UTI. No time period is fixed that the patient must be having catheter to call UTI as CA – UTIs. Richards et al have reported in 1999 that 95% of UTIs in hospitals are CA – UTI. In CA – UTI not only bacteruria occurs but Candida albicans and Candida nonalbicansspeciesarealsoisolatedandsoanewtermmicroburiahasbeenintroduced[24].

In 2009, Peterson et al used the acronym ESCAPE for MDR organism causing HAI [19].

drug resistance (XDR) is indicated by resistance to all available antibiotics.

E : Enterococcus faecium/E.faecalis

S : Staphylococcus aureus C : Clostridium difficile A : Acinetobacter baumani P : Pseudomonas aeruginosa

8 Infection Control

E : Enterobacteriaceae

respectively [21], [22].

**3. HAI : Types by site**


Amphotericin B has made antifungal treatment more difficult for neonates. The new azole drug Voriconazole is used for invasive aspergillosis but this drug has not been studied in neonates and possibility of its effect on developing retina which is observed in adults and older children cannot be ruled out [34].

From 2008 to 2010, out of total 250 Pseudomonas aeruginosa strains studied 40%, 42% and 11.2% were ESBL, AmpC β – lactamases and MBL producers respectively [40]. Amongst these ESBL and AmpC β – lactamase producers 27.2% P.aeruginosa strains produced both ESBL as well as AmpC β – lactamases. ESBL producing strains were detected by Combined disc method [41] and ESBL E - test strips [42]. AmpC β – lactamase was detected by Double disc synergy test and Disk potentiation test using 3 – aminophenyl boronic acid [43]. Metallobetalactamase (MBL) were detected by Imipenem – EDTA Double disc synergy test [44], Disk potentiation

From different ICUs 59.4%MRSA strains were isolated and amongst Gram negative MDROs 21.5% only ESBL producers, 9.6% were only AmpC β – lactamase producers, 13.3% were both ESBL and AmpC β – lactamase producers and 15.6% strains were MBL producers [47]. 90.5% MBL producing strains were resistant to all 08 antibiotics used as per CLSI guidelines [37] and

In one of our study, 56 E.coli strains were isolated from different ICUs (Fig.1). 26(46.4%) strains isolated from different ICUs, produced both ESBL and AmpC β – lactamases(Fig.2). Maximum MBL producing E.coli strains 4 (7.8%) were isolated from Medicine ICU and High Dependency Unit(HDU). Only 01 E.coli strain was isolated from patient of HDU which produced all 3 types of β – lactamases i.e. ESBL, MBL and AmpC β – lactamases. The unpaired t test was performed with MBL producing and non – MBL producing E.coli stains isolated from MICU and HDU, NICU, PICU and OT – ICU and the probability of the result assuming null hypothesis was

**25**

Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and

MICU NICU PICU OT‐ICU

Infection Control Practices in Health Care Set-Up

http://dx.doi.org/10.5772/55029

11

**OT‐ICU PICU NICU MICU**

test [45] and were further confirmed by MBL E – test (AB bioMerieux) [46].

all 100% MBL producers were sensitive to Colistin [47].

Figure 1. Isolation of *E.coli* strains from different ICUs (n = 56)

**4. Infection control programme: Need of the hour**

**14**

**7**

**10**

**Figure 1.** Isolation of *E.coli* strains from different ICUs (n = 56)

Figure 2. Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56)

Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care

**4. Infection control programme: Need of the hour** 

to patients and prevention of infections for patients and staffs.

0.043 and hence was significant.

0

5

10

15

20

25

30

#### **3.1. Scenario in our hospital, in last 5 years**

Our hospital is a tertiary care hospital in a rural set up. Though actual incidence of HAI is difficult to calculate, mostly because of improper reporting system, in last 5 years, there is definitely an increase in isolation of Multiple drug resistant organisms (MDRO) from different clinical specimens.

In a study conducted from September 2007 to June 2008, out of 366 Staphylococcus aureus strains studied 189 (51.6%) strains were MRSA. Because of changing patterns of antibiotic resistance and emergence of MRSA, renewed interest in macrolides lincosamides and Strep‐ tograminB (MLSB) have been developed. Clindamycin, a semisynthetic derivative of Lincosa‐ mides has excellent tissue penetration (except in central nervous system), rapid oral absorption and no dose adjustment is required in renal insufficiency and it is one of the most efficient antibiotics in treating skin and soft tissue infections including osteomyelitis. Though the chemical structure of macrolide, lincosamides and streptograminB are very different, their mechanism of action is identical i.e. to block protein synthesis by inhibiting peptidyl transfer‐ ase. Bacteria develop cross resistance due to overlapping binding sites in 23 SrRNA. Three types of MLSB resistance are observed -


For detection of iMLSB phenotype, D – zone test as per National Committee for Clinical Laboratory Standards (NCCLS) guideline 2004 is done [34]. In our study, out of 366 Staphy‐ lococcus aureus strains iMLSB (18.6%), cMLSB (3.8%) and MSB(0.8%) phenotypes were detected respectively [35].

In another study, out of 280 Staphylococcus aureus strains 51.8% strains were MRSA. Out of these MRSA strains 61.4% were isolated from pus and wound swab and 13.8% MRSA strains were isolated from different ICUs (Medicine ICU, Neonatal ICU, Pediatric ICU, OT – ICU etc). 35.2% MRSA strains were iMLSB phenotype [36]. The MRSA strains were detected by Cetoxitin (30μg) disc diffusion test as per Clinical and Laboratory standards Institute guidelines [37]. These MRSA strains were further confirmed by doing PCR to detect mec A gene for MRSA and fem A gene for Staphylococcus aureus [38]. The increasing incidence of MRSA strains in our hospital could be compared with our study done in 1997 and at that time only 30.6% MRSA strains were isolated [39].

Presently, MDROs isolated from health care set up are mostly caused by different Gram negative organisms, which produce newer β – lactamases like ESBL, AmpC β – lactamases and metallobetalactamases(MBL).

From 2008 to 2010, out of total 250 Pseudomonas aeruginosa strains studied 40%, 42% and 11.2% were ESBL, AmpC β – lactamases and MBL producers respectively [40]. Amongst these ESBL and AmpC β – lactamase producers 27.2% P.aeruginosa strains produced both ESBL as well as AmpC β – lactamases. ESBL producing strains were detected by Combined disc method [41] and ESBL E - test strips [42]. AmpC β – lactamase was detected by Double disc synergy test and Disk potentiation test using 3 – aminophenyl boronic acid [43]. Metallobetalactamase (MBL) were detected by Imipenem – EDTA Double disc synergy test [44], Disk potentiation test [45] and were further confirmed by MBL E – test (AB bioMerieux) [46].

From different ICUs 59.4%MRSA strains were isolated and amongst Gram negative MDROs 21.5% only ESBL producers, 9.6% were only AmpC β – lactamase producers, 13.3% were both ESBL and AmpC β – lactamase producers and 15.6% strains were MBL producers [47]. 90.5% MBL producing strains were resistant to all 08 antibiotics used as per CLSI guidelines [37] and all 100% MBL producers were sensitive to Colistin [47].

In one of our study, 56 E.coli strains were isolated from different ICUs (Fig.1). 26(46.4%) strains isolated from different ICUs, produced both ESBL and AmpC β – lactamases(Fig.2). Maximum MBL producing E.coli strains 4 (7.8%) were isolated from Medicine ICU and High Dependency Unit(HDU). Only 01 E.coli strain was isolated from patient of HDU which produced all 3 types of β – lactamases i.e. ESBL, MBL and AmpC β – lactamases. The unpaired t test was performed with MBL producing and non – MBL producing E.coli stains isolated from MICU and HDU, NICU, PICU and OT – ICU and the probability of the result assuming null hypothesis was 0.043 and hence was significant.

**Figure 1.** Isolation of *E.coli* strains from different ICUs (n = 56)

0

5

10

15

Amphotericin B has made antifungal treatment more difficult for neonates. The new azole drug Voriconazole is used for invasive aspergillosis but this drug has not been studied in neonates and possibility of its effect on developing retina which is observed

Our hospital is a tertiary care hospital in a rural set up. Though actual incidence of HAI is difficult to calculate, mostly because of improper reporting system, in last 5 years, there is definitely an increase in isolation of Multiple drug resistant organisms (MDRO) from different

In a study conducted from September 2007 to June 2008, out of 366 Staphylococcus aureus strains studied 189 (51.6%) strains were MRSA. Because of changing patterns of antibiotic resistance and emergence of MRSA, renewed interest in macrolides lincosamides and Strep‐ tograminB (MLSB) have been developed. Clindamycin, a semisynthetic derivative of Lincosa‐ mides has excellent tissue penetration (except in central nervous system), rapid oral absorption and no dose adjustment is required in renal insufficiency and it is one of the most efficient antibiotics in treating skin and soft tissue infections including osteomyelitis. Though the chemical structure of macrolide, lincosamides and streptograminB are very different, their mechanism of action is identical i.e. to block protein synthesis by inhibiting peptidyl transfer‐ ase. Bacteria develop cross resistance due to overlapping binding sites in 23 SrRNA. Three

For detection of iMLSB phenotype, D – zone test as per National Committee for Clinical Laboratory Standards (NCCLS) guideline 2004 is done [34]. In our study, out of 366 Staphy‐ lococcus aureus strains iMLSB (18.6%), cMLSB (3.8%) and MSB(0.8%) phenotypes were detected

In another study, out of 280 Staphylococcus aureus strains 51.8% strains were MRSA. Out of these MRSA strains 61.4% were isolated from pus and wound swab and 13.8% MRSA strains were isolated from different ICUs (Medicine ICU, Neonatal ICU, Pediatric ICU, OT – ICU etc). 35.2% MRSA strains were iMLSB phenotype [36]. The MRSA strains were detected by Cetoxitin (30μg) disc diffusion test as per Clinical and Laboratory standards Institute guidelines [37]. These MRSA strains were further confirmed by doing PCR to detect mec A gene for MRSA and fem A gene for Staphylococcus aureus [38]. The increasing incidence of MRSA strains in our hospital could be compared with our study done in 1997 and at that time only 30.6% MRSA

Presently, MDROs isolated from health care set up are mostly caused by different Gram negative organisms, which produce newer β – lactamases like ESBL, AmpC β – lactamases and

in adults and older children cannot be ruled out [34].

**3.1. Scenario in our hospital, in last 5 years**

types of MLSB resistance are observed **i.** Constitutive MLSB (cMLSB) **ii.** Inducible MLSB (iMLSB) and

**iii.** MSB phenotype

strains were isolated [39].

metallobetalactamases(MBL).

respectively [35].

clinical specimens.

10 Infection Control

#### Figure 1. Isolation of *E.coli* strains from different ICUs (n = 56) **4. Infection control programme: Need of the hour**

20 25 30 Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and

Figure 2. Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56)

Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care

**OT‐ICU PICU NICU MICU**

**4. Infection control programme: Need of the hour** 

to patients and prevention of infections for patients and staffs.

**25**

MICU NICU PICU OT‐ICU

policies, to manage critical incidents, to conduct training activities and to review the impact

Infection Control Practices in Health Care Set-Up

http://dx.doi.org/10.5772/55029

13

Every Health care facilities should have their own Infection Control Manual which is usually prepared by Infection Control Team and approved by HICC and updated. The manual should

Standard Precautions include basic infection control practices which must be applied to all patients at all times without taking consideration of diagnosis or infection status. Standard precautions are essential to provide a high level of protection to patients, HCWs and visitors

Hand hygiene is the most important simplest practice to reduce the transmission of HAI, which has been described in early 19th century by Ignaz Semmelweiss, a 2nd year medical student that puerperal sepsis was mainly transmitted by the contaminated hands of clinicians who conducted delivery just after performing autopsy without washing their hands [49], [50]. Semmelweiss also proved in 1847 that incidence of puerperal sepsis, fever and maternal

In 2005, WHO introduced first Global safety challenge 'Clean care is Safer care' for patient safety [51]. In 2006, guidelines on Hand Hygiene in Health care were published. The first Global hand washing day was observed on 15th October 2008. In April 2009, 3.6 million HCWs worldwide, registered themselves to comply with WHO's global challenge on Hand Hygiene. On 5th May 2009, WHO launched guidelines on Hand Hygiene and the theme was 'Save lives : Clean Your Hands' [52], [53]. There may be resident flora and transient flora which can colonize

mortality due to puerperal sepsis could be greatly reduced by washing hands.

of training amongst Health Care Workers (HCWs).

always be accessible to Health Care Workers (HCWs).

**4.4. Infection Control Practices : are grouped into 2 catagories [48] –**

**i.** Standard precautions – i.e. basic infection control precautions

**ii.** Additional precautions – i.e. transmission based precautions

**4.3. Infection control manual**

(relatives of patients).

**•** Hand hygiene

*4.4.2. Hand hygiene*

*4.4.1. Standard precautions include*

**•** Biomedical waste management

**•** Use of personal protective equipments (PPE)

**•** Precaution of needle stick / sharp injuries

**•** Proper handling of patient care equipments

**•** Environmental cleaning and spills management

Figure 2. Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56) **Figure 2.** Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56)

to patients and prevention of infections for patients and staffs.

**4. Infection control programme: Need of the hour** 

Figure 1. Isolation of *E.coli* strains from different ICUs (n = 56)

**14**

**7**

**10**

surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care to patients and prevention of infections for patients and staffs. Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care

#### **4.1. Hospital Infection Control Committee (HICC)**

To have need based Infection Control Programme every Health Care facility should form a Hospital Infection Control Committee (HICC) which provides a forum for multidiscipli‐ nary input and cooperation and information sharing and include administrators, Clinical Microbiologists, Pharmacologists, HCWs specially ICU and OT incharges, housekeeping, maintenance staffs etc.

#### *4.1.1. HICC must have*


HICC should meet regularly in every months but not less than 3 times a year.

#### **4.2. Infection control team**

Infection Control Team is responsible for day to day activities of HICC in a health care facilities. It usually should have Infection Control Practitioner and other members who give scientific and technical support to carry out surveillance programme and to implement infection control policies, to manage critical incidents, to conduct training activities and to review the impact of training amongst Health Care Workers (HCWs).

## **4.3. Infection control manual**

Every Health care facilities should have their own Infection Control Manual which is usually prepared by Infection Control Team and approved by HICC and updated. The manual should always be accessible to Health Care Workers (HCWs).

## **4.4. Infection Control Practices : are grouped into 2 catagories [48] –**

**i.** Standard precautions – i.e. basic infection control precautions

## **ii.** Additional precautions – i.e. transmission based precautions

Standard Precautions include basic infection control practices which must be applied to all patients at all times without taking consideration of diagnosis or infection status. Standard precautions are essential to provide a high level of protection to patients, HCWs and visitors (relatives of patients).

## *4.4.1. Standard precautions include*

**•** Hand hygiene

surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care to patients and prevention of

Every country develops a National Infection Control Programme to reduce the risk of Health Care Associated Infections (HAI) and thereby to achieve the national health care objectives with the help of a National Expert Committee. Each health care facility is required to develop an infection control programme to chalk out the annual work plan for monitoring and surveillance of HAI, for educating, training health care workers (HCWs) in infection control practices, for controlling out breaks to ensure good health care

Figure 2. Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56)

**4. Infection control programme: Need of the hour** 

**Figure 2.** Isolation of ESBL, AmpC & MBL producing E.coli strains from different ICUs (n = 56)

to patients and prevention of infections for patients and staffs.

To have need based Infection Control Programme every Health Care facility should form a Hospital Infection Control Committee (HICC) which provides a forum for multidiscipli‐ nary input and cooperation and information sharing and include administrators, Clinical Microbiologists, Pharmacologists, HCWs specially ICU and OT incharges, housekeeping,

HICC should meet regularly in every months but not less than 3 times a year.

Infection Control Team is responsible for day to day activities of HICC in a health care facilities. It usually should have Infection Control Practitioner and other members who give scientific and technical support to carry out surveillance programme and to implement infection control

infections for patients and staffs.

0

5

10

15

20

25

30

12 Infection Control

maintenance staffs etc.

*4.1.1. HICC must have*

**•** Infection Control Nurse

**4.2. Infection control team**

**•** A chairperson from administrators

**•** Infection Control Practitioner / Officer

**4.1. Hospital Infection Control Committee (HICC)**

Figure 1. Isolation of *E.coli* strains from different ICUs (n = 56)

**14**

**7**

**10**

**25**

MICU NICU PICU OT‐ICU

> **OT‐ICU PICU NICU MICU**


#### *4.4.2. Hand hygiene*

Hand hygiene is the most important simplest practice to reduce the transmission of HAI, which has been described in early 19th century by Ignaz Semmelweiss, a 2nd year medical student that puerperal sepsis was mainly transmitted by the contaminated hands of clinicians who conducted delivery just after performing autopsy without washing their hands [49], [50]. Semmelweiss also proved in 1847 that incidence of puerperal sepsis, fever and maternal mortality due to puerperal sepsis could be greatly reduced by washing hands.

In 2005, WHO introduced first Global safety challenge 'Clean care is Safer care' for patient safety [51]. In 2006, guidelines on Hand Hygiene in Health care were published. The first Global hand washing day was observed on 15th October 2008. In April 2009, 3.6 million HCWs worldwide, registered themselves to comply with WHO's global challenge on Hand Hygiene. On 5th May 2009, WHO launched guidelines on Hand Hygiene and the theme was 'Save lives : Clean Your Hands' [52], [53]. There may be resident flora and transient flora which can colonize the hands of HCW. The transient flora colonizes the superficial layer of skin and are removed by hand hygiene. The pathogens like MRSA, VRE, Multidrug resistant Gram negative bacilli, Candida species causing HAI colonize hands of HCW during patient care simply while taking blood pressure or taking temperature etc. or from environment like the uniform, patient's locker, bed rail, bed linens, furnitures etc. The organisms like Staphylococcus aureus, MRSA, VRE can survive for months on inanimate objects.

*4.4.3. Personal Protective Equipment (PPE)*

PPE includes gloves, protective eye wear (goggles), masks, cap, apron, gown, shoe covers etc. PPE should be used when there is a chance to have contact with patient's blood, body fluids, excretion or secretion while giving patient care by – HCWs, support staffs including attend‐ ants, sweeper, laundry staffs, laboratory staffs and family members. Masks alongwith goggles or a face shield may be used for complete protection of the face [58]. PPE should be chosen according to the risk of exposure and always where contact with blood and body fluid may occur. HCWs may be well trained when and how to use PPE and should be explained properly that use of PPE does not replace hand hygiene. Disposable PPEs e.g. gloves, masks, protective eyewear, gowns should never be reused. PPEs should always be changed between patients. All HCWs should follow hand hygiene after removal of PPE. Single use PPE must be discarded

Infection Control Practices in Health Care Set-Up

http://dx.doi.org/10.5772/55029

15

or reusable PPE may be put in a bin to send it to laundry and then for sterilization.

SARS CO-V, influenza, Swine flu etc occurs or suspected.

*4.4.5. Infection control practices for lumbar puncture procedure [59]*

*4.4.4. Safe injection practices*

*4.4.6. Patient care equipment*

the vials.

after use.

The recommendations include :

Respiratory protection : To prevent inhalation of microorganism the respirator with N-95 or higher filtration can be used. These are recommended if exposure to patients with tuberculosis,

In the current CDC guidelines regarding isolation precaution Respiratory Hygiene / Cough Etiquette are recommended for HCWs, patients and their relatives. Spatially separation (>3 foot) should be followed in persons with respiratory infection in common waiting areas of health care set up. To avoid inhalation of droplet nuclei, droplet precautions e.g. wearing mask are to be implemented for HCWs. Masks should never be confused with particulate respirators which are used to prevent inhalation of small particles contaminated with infectious agent.

**•** Always sterile, single use disposable needle and syringe for each injection is to be used.

**•** CDC recommends single dose vials instead of multiple dose vials, when used for multiple patients. Multidose vials are always discouraged, because HCWs commonly contaminate

**•** The intravenous fluid infusion sets are to be used for one patient only and discarded

The health Care Infection Control Practices Advisory Committee (HICPAC) in 2005 recom‐ mended that the HCW placing a catheter or injecting material into the spinal or epidural space

To prevent patient to patient transmission, instruments must be cleaned and sterilized. All patient care equipment soiled with blood, body fluids, secretions or excretions must be

must use a facemasks to prevent droplet transmission of oropharyngeal flora.

Hand hygiene includes washing hands with soap and water, antimicrobial soap, antiseptic agents, alcohol – based hand rub or surgical hand scrub. Hepatitis C virus (HCV), Rhinovi‐ ruses, Adenoviruses and Rotavirus nucleic acid can be found on hands of HCW [52].

If hands of HCWs are visibly dirty or contaminated with proteinaceous material, blood or other body fluids of patients, the hands are to be washed with soap and water. An alcohol based hand rub must be used by HCWs when hands are not visibly soiled such as before having any direct contact with patients including taking pulse or blood pressure or lifting a patient, before donning sterile gloves and also after removing gloves, after contact with inanimate objects in patient's immediate environment or if moving from a contaminated body site to a clean body site of the patient etc.

The maximum incidence of hand contaminations are reported from critical care areas. Hence, to prevent cross transmission, motivation, training, availability of alcohol based hand rubs and repeated reminders are required for HCWs. In most Health care set up, actually following the hand hygiene practice is below 40% where it is indicated [54]. The most important cause for poor hand hygiene compliance is lack of knowledge of guidelines of protocols on hand hygiene, lack of institution priority, lack of role model among the colleagues or superiors (specially clinicians), lack of HCWs etc [55].

The HCWs are to be specifically explained that wearing gloves does not replace hand hygiene and contamination may occur while removing the gloves. Actually, hand hygiene should be a habit of HCW while giving patient care.

Selection of hand hygiene products and its easy availability is one the most important step to promote hand hygiene practices during patient care. The new CDC guidelines does not suggest any specific spectrum for a hand hygiene agent and any health care set up can select an agent depending on cost spectrum and the common causative organisms of HAI [56]. Hand hygiene agent used for post contamination must be bactericidal, fungicidal (yeast), virucidal. The agent having activity against unenveloped viruses should be used in peadiatrics (rotavirus) or in oncology units (parvovirus) etc. The agent with mycobactericidal activity should be used in tuberculosis and chest wards, fungicidal activity (moulds) in organ transplant units or AIDS patients are to be considered. Preoperative hand hygiene agent should at least contain bactericidal and fungicidal (yeasts) to reduce the risk of SSIs. Any hand hygiene agent should not cause skin irritation and should dry on its own. WHO advocates to follow formula for resource poor settings [57].

**Formulation I** contains ethanol 80% v/v, glycerol 1.45% v/v and hydrogen peroxide 0.125% v/v.

**Formulation II** contains isopropyl alcohol 75% v/v, glycerol 1.45% v/v and hydrogen peroxide 0.125% v/v.
