Essentials of Hospital Infection Control Apurba S Sastry, Deepashree R
Page numbers followed by f refer to figure and t refer to table.
ABC Calc 507
Accelerate Pheno system 483
Active MDRO surveillance 375
Active surveillance 70
Adult ventilator associated event algorithm 90
Aerosol-generating procedures 232
particle counter 361
surveillance 356
Airborne precautions 159
Alcohol 263
Alkaline hydrolysis 412
American Society of Anesthesiologists score of patient physical status 55
Antibiotic cycling 497
Antimicrobial lock therapy 34
Antimicrobial resistance
in India 514
outcome indicator 507
surveillance 511
research network 512
Antimicrobial skin sealants 62
Antimicrobial stewardship 476
Antimicrobial-coated sutures 66
Aprons 152
fistula 173
graft 173
Automated blood culture systems 479
Automated cart washers 310
Automated endoscope reprocessors 276
Automated healthcare-associated infection surveillance 119
Automated washers 309
Awareness on infection control 6
Baclink 513
Bacterial endotoxin test 349
Baseline period of stability 92
Biological indicator 327
Biomedical waste 399
Biomethanation 420
Biosafety levels 207
Burn center 218
Burnout syndrome 457
Capacity tests 296
Carbapenem-resistant enterobacteriaceae 379
Care bundle
approach 24
for central line 39
for urinary catheter 24
Carrier tests 297
asymptomatic bacteriuria 15
urinary tract infection 15
surveillance 80
Catheter-related bloodstream infection 26
CDC NHSN common terminologies 74
Central line 26, 83
venous catheter 26
Central sterile supply department 301
Central venous catheter 26
Centrifugal sampler impactor 360
Chemical disinfectants 257
Chemical indicator 326
Chemical spill
kit 424
management 424
Chemical sterilant 259
Chennai declaration—roadmap to tackle challenge of AMR 515
Chick-martin test 296
Chlorhexidine 266
Chlorine 264
Cleanroom standards 362
Cold water jet guns 305f
Common source outbreaks 462
Composting 419
Computer physician order entry 493
Computerized decision support systems 493
Contact precautions 155
Contaminated linen 382
Continuous common source outbreak 463
Cumulative antibiograms 507
Cytotoxic drug waste management 415
Daily minimum PEEP 92
Date of event 75
Days of therapy 507
Decontamination sinks 305f
Deep burial 410
Defined daily dose 505
criteria 77
reinsertion criteria 78
utilization ratio 115
Differential coliform count 340
Dirty linen 382
Disinfectant testing 295
Disinfection policy 256
Disinfectors 309
Doffing sequence 153
Donning sequence 153
Double gloves 145
Droplet precautions 157
Dumb waiter 305f
Effluent treatment plant 420
Eijkman test 340
Electronic waste management 417
Embalming 252
Encapsulation 411
Endoscopy reprocessing 272
Endotoxin detection 349
Enhanced antibiograms 508
Envelope wrapping method 316
surface surveillance 364
surveillance 329
Enzymatic cleaners 307
Epidemic curve 461
Epidemiological chain of healthcare-associated infection 2
Eskape pathogens 4
Ethidium bromide disposal 427
Ethylene oxide 321
E-waste disposal 418
Exposed person 432
Facemasks 146
checking 150
testing 151
Formaldehyde 262
Formulary restriction with preauthorization 496
Fraction of inspired oxygen 91
Framing antimicrobial policy 494
Glassware management 414
Glo germ 135
Global action plan on antimicrobial resistance 515
Global antimicrobial resistance surveillance system 511
Gloves 144
Glutaraldehyde 260
Gowns 152
Guidewire exchange 38
Hand hygiene 121, 123
adherence rate 136
measurement methods 131
methods 123
partial adherence rate 136
products 124
Hazard analysis and critical control point system 397
Healthcare-associated infection 1, 75
surveillance cycle 115
Hemodialysis equipment 174
High-level disinfectants 259
Hospital antibiogram 507
Hospital infection control
committee 9
team 10
Hospital information system 492
Hospital-wide healthcare-associated infection surveillance 72
Housekeeping policy 281
Hydrogen peroxide 263
Hygiene preparation in funeral parlor 252
Hypochlorite 264
ICD-10-PCS category mapping 113
Ideal disinfectant 259
Immediate use system 321
Improvement of PEEP 92
Index of microbial air 357
Indian Public Health Standards 525
Indicators used for monitoring the sterilization 326
Indwelling catheter 17
Indwelling urinary catheter 81
Inertization 411
Infection control
during bioterrorism attack 242
for influenza 230
for legionellosis 234
for prion contaminated items 237
for tuberculosis 219
for viral hemorrhagic fever 244
in blood bank 212
in burns unit 216
in C. difficile infection 224
in dialysis units 172
in ICU 195
in kitchen and food safety 390
in laboratory 206
in laundry 382
in operation theater 199
in outpatient setting 203
in transplant units 183
nurse 12
officer 11
policy for after death 250
requirements for accreditation 520
Infection present at time of surgery 103
Infection window period 75
Intermittent common source outbreak 463
International patient safety goal 525
Iodophors 264
Jaipur declaration on antimicrobial resistance 515
Joint Commission International 525
Kayakalp Swachta guidelines 525
Kelsey-Sykes test 296
Kerala Accreditation Standards for Hospitals 526
Laboratory confirmed bloodstream infection 85
Laboratory stewardship 478
surveillance 72
ward liaison surveillance 72
ward surveillance 72
Landfilling 420
Laqshya 525
Line listing of cases 470
Liquid waste management 420
Location of attribution 78
Low-temperature steam formaldehyde 324
Luminometer 134
Maintenance care bundle for mechanical ventilator 53t
Mechanical bowel preparation 60
Mechanical ventilation 161
Medical care devices 256
Medicines with the red line 517
Medicolegal aspects of healthcare-associated infection 13
Membrane filtration method 340
Mercury spill kit 425
Mercury spillage management 425
Metal sharp management 414
Methicillin-resistant Staphylococcus aureus
surveillance 375
tagging 376
Microwaving 410
Mode of transmission of healthcare-associated pathogens. 5
Monitoring the efficacy of sterilization 325
Mucosal barrier injury laboratory confirmed bloodstream infection 88
Multiple-tube method 336
N95 respirator 150
National accreditation board for hospitals 520
National action plan on antimicrobial resistance 515
National healthcare safety network 73
National Program for Containment of Antimicrobial Resistance 511
Needle stick injury management 432
Needleless intravascular catheter systems 39
Nosocomial legionellosis 234
Occupational exposure 432
Ortho-phthalaldehyde 261
Outbreak control team 467
Outbreak investigation 461
Outcome surveillance 71
Parcel fold wrapping method 315
Pareto charts 507
Passive surveillance 70
PED VAE surveillance 98
Pelletization 420
Peracetic acid 262
Personal protective equipment 143
Phenolics 266
Physical or mechanical indicator 326
Physiochemical analysis of water 355
Pioneers in infection prevention and control 7
PK-PD monitoring of antimicrobials 487
pyrolysis 411
sterilization 323
PNEU/VAP surveillance 99
Point prevalence survey 73
Point source outbreak 462
Population-based surveillance 70
Positive end-expiratory pressure 92
Practical tests 298
Present on admission 75
Presumptive coliform 333
Procalcitonin 484
Process challenge device 327
Process surveillance 71
Promession 412
Propagated outbreak 464
Prophylactic negative pressure wound therapy 65
Prospective audit and feedback 498
Prospective incidence surveys 73
Protective isolation 165
Proteolytic cleaners 307
Qualifying antimicrobial days 94
Quality indicators in infection control 521
Quaternary ammonium compound 267
Radioactive waste management 417
Red line 517f
Repeat infection timeframe 75
Resident flora 122
Respirators 147
Respiratory protection equipment 220
Reverse isolation 165
Screening for multidrug-resistant organisms 371
Secondary blood stream infection 87
attribution period 75
Selective digestive decontamination 52, 61
Selective or cascade reporting 479
Selective oropharyngeal decontamination 51
Semirecumbent position 50
Sentinel event-based surveillance 70
Sharp pit 411
Shredder 410
Sieve impactor 358
Single-use devices 277
Skin reactions related to hand hygiene product 129
Slit-to-agar impactor 359
Sodium dichloroisocyanurate 265
Soiled linen 382
Solid general waste management 419
Source person 432
Sources of infection 3
Spaulding's classification of medical devices 257
Spill kit 424
Spillage management 422
Sputum collection booth 221
SSI bundle (adapted from WHO) 67
Staff clinic 450
Standard precautions 121
Standardized infection ratio 115
Steam sterilizer (autoclaves) 319
Subtraction antibiogram 508
Superoxide water 265
Surface disinfection test 298
Surgical antimicrobial prophylaxis 59
Surgical hand preparation 62
Surgical site infection 53
surveillance 103
Surveillance of healthcare-associated infections 70
Targeted healthcare-associated infection surveillance 72
Test of Kelsey and Maurer 298
Theatre sterile service unit 301
Thermotolerant coliform 334
Three bucket trolleys 288
Transfer rule 78
Transient flora 122
Transmission-based precautions 155
Trolley washer 310
Turn-around time 490
Ultrasonic cleaner 308, 309f
Ultraviolet germicidal irradiation 162
Urinary catheter insertion technique 21
Vancomycin-resistant enterococci 377
events and pneumonia surveillance 90
events window period 94
pneumonia 40
Vermicomposting 420
Ward liaison surveillance 72
Washer 309
management in healthcare facility 399
receptacle 404
segregation 401
Water surveillance 330
Waterborne pathogens 330
WHO priority pathogens 510
WHO's proposed core components for infection prevention and control 5
Work restriction 450
for healthcare worker 453
Workflow of blood culture laboratory 488
class type 54
protector devices 64
Chapter Notes

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Introduction to Healthcare-associated InfectionsCHAPTER 1

Healthcare-associated infections (HAIs) can be defined as, (i) the infections acquired in hospital by a patient admitted for a reason other than the infection in context, (ii) the infection should not be present or incubating at the time of admission, and (iii) the symptoms should appear at least after 48 hours of admission. This also include:
  • Infections acquired in the hospital but symptoms appearing after discharge.
  • Occupational infections among staff of the healthcare facility (e.g. needle stick injury transmitted infections).
  • Infection in a neonate that results while passage through the birth canal (in contrast to congenital infections due to transplacental transmission, which are not HAIs).
As the healthcare delivery system has increasingly shifted from inpatient hospital care based service to the ambulatory setting, the relevance of traditional terminologies such as “hospital-associated or nosocomial” infections has diminished.
Centre for Disease Control and Prevention (CDC), Atlanta recommends to use “Healthcare-associated infections” as a more accepted terminology, because it represents all type of healthcare delivery systems such as hospitals, nursing homes, rehabilitation facility, outpatient clinics, day care and other clinical settings.
Healthcare-associated infections (HAIs) are one of the most common adverse events in the care delivery system. Both the endemic burden and the occurrence of epidemics of HAI are a major public health problem, posing a significant impact on morbidity, mortality, quality of life and also present an economic burden at the societal level. In 2011, World Health Organization (WHO) reported that:
  • On average at any given time 7% of patients in developed and 10% in developing countries acquire at least one HAI.
  • Mortality from HAI occurs in about 10% of affected patients.
  • In Europe, more than 4 million patients are affected by approximately 4.5 million episodes of HAI annually, leading to 16 million extra days of hospital stay and 37,000 attributable deaths; contributing to an annual financial burden of approximately €7 billion.
  • In United States of America (USA), it was estimated that around 1.7 million patients are affected by HAI each year, representing a prevalence of 4.5% and accounting for 99,000 deaths with an annual economic impact of approximately US $ 6.5 billion.
Low and Middle-income Countries (LMIC)
Limited data are available from LMICs, but the prevalence of HAI is estimated to be between 5.7% and 19.1%.2
  • The increased burden of HAI in LMICs affects especially high-risk populations, such as patients admitted to intensive care units (ICUs) and neonates.
    • The HAI frequency is several-fold higher in LMIC than in high-income countries, notably for device-associated infections.
    • For example, the proportion of patients with an ICU-acquired infection can be as high as one in three in LMICs.
  • Increased length of hospital stay associated with HAI in developing countries ranges between 5 days and 29.5 days and excess mortality due to these infections in adult patients in Latin America, Asia and Africa were 18.5%, 23.6% and 29.3% for catheter-associated urinary tract infections, central line associated bloodstream infections and ventilator-associated pneumonia, respectively.
Economic Impact1,2
HAIs pose a significant (and largely avoidable) economic impact both at the patient and healthcare facility level. This includes both direct hospital costs, indirect and intangible costs to both patient and healthcare services.
  • Direct cost to health services due to the increased length of hospital stay and the overall impact on the facility, as well as unnecessary investigations, procedures and treatment.
  • Indirect costs to patients & caregivers due to:
    • Loss of job or paid working days or diminished worker productivity on the job.
    • Income lost by family members.
  • Intangible cost due to:
    • Psychological costs, (i.e. anxiety, grief, disability, job loss).
    • Pain and suffering.
    • Foregone leisure time.
    • Time spent by family or friends for hospital visits, travel costs, home care.
    • Change in social functioning or daily activities.
Traditional epidemiologic triad model shows that infectious diseases result from the interaction of agent, host, and environment. More specifically, transmission occurs when the agent leaves its reservoir or host through a portal of exit, is conveyed by some mode of transmission, and enters through an appropriate portal of entry to infect a susceptible host (Table 1.1 and Fig. 1.1).
At this context, an understanding of source of infection, mode of transmission and etiological agents causing HAI is essential.
Host Susceptibility
Host susceptibility plays an important role in acquiring HAIs.
  • Immunity: Majority of the hospitalized patients has impaired immunity either as a part of their preexisting disease processes or, in some instances, due to the treatment they have received in the hospital.
    Table 1.1   Epidemiological chain of healthcare-associated infections.
    Infectious agent
    Infectious agent is the microbial pathogen that establishes a disease process
    Reservoir includes environmental sources which harbor the infectious agent, (e.g. floor, surfaces, medical equipment, and devices)
    Portal of exit
    It is the means by which an infectious agent leaves the reservoir (through open wounds, aerosols, and splatter of body fluids including coughing, sneezing, and saliva)
    Mode of transmission
    It is the route by which the infectious agent can be passed on (through direct or indirect contact, ingestion, or inhalation) (explained in detail later in the text)
    Portal of entry
    It is the route by which an infectious agent enters a new host (through broken skin, the respiratory tract, mucous membranes, and external devices)
    Susceptible host
    Includes any person susceptible to acquire HAI; the most vulnerable are immunocompromised, or those on invasive medical devices
    zoom view
    Fig. 1.1: Epidemiological chain of healthcare-associated infection.
    Impaired immunity poses the patients to increased risk of acquiring HAI. Healthcare workers (HCWs) exposed to the same hospital environment are at lesser risk of acquiring HAI because of their stronger immunity.
  • Age: Neonates and elderly patients are more susceptible than adults.
  • Underlying comorbidities such as diabetes, increases the risk of acquiring HAIs.
  • Patient undergoing diagnostic or therapeutic interventions: Patients on devices such as intravenous (IV) or urinary catheters, or endotracheal tube are at increased risk of acquiring infection.
  • Patient receiving transfusion: Blood, blood products and IV fluids used for transfusion, if not properly screened, can transmit many blood borne infections (BBI) such as HIV, hepatitis B and C viral infections.
Sources of Infection
The source of HAI may be either endogenous or exogenous.
Endogenous Source
  • The majority of nosocomial infections are endogenous in origin, i.e. they involve patient's own microbial flora which may invade the patient's body during some surgical or instrumental manipulations.
  • For endogenous infections, the patient admitted to the facility was either priorly colonized with these microorganisms or became colonized at some point during the stay at the facility after admission.
  • It may not be possible to determine whether an organism isolated from a patient with a HAI is exogenous or endogenous in origin and in such situations, the term autogenous should be used.
  • Autogenous infection indicates that the infection was derived from the flora of the patient, whether or not the infecting organism became part of the patient's flora subsequent to admission.
Exogenous Source
Exogenous sources are from hospital environment, staff, or patients.
  • Environmental source: The hospital environment harbors a greater magnitude of microorganisms than that of community.
    • Transmission of these organisms to the patients can cause nosocomial outbreaks of infection.
    • The various environmental sources include inanimate objects, air, water and food in the hospital. Inanimate objects in the hospital are medical equipment (endoscopes, catheters, etc.) bed pans, surfaces contaminated by patients’ secretions, excretions, blood and body fluids.
  • Healthcare workers may be potential carriers, harboring many organisms; which may be multidrug resistant, e.g. nasal carriers of methicillin-resistant Staphylococcus aureus (MRSA).
  • Other patients of the hospital may also be the source of infection.4
Microorganisms Implicated1,2
Most of HAI causing pathogens are multi-drug resistant. This is due to the increased antibiotic usage in the hospital environment, which leads to the minor population of resistant organisms present initially to flourish under the influence of contact and selective antibiotic pressure. These drug resistant bugs slowly replace the susceptible strains.
ESKAPE Pathogens
The vast majority of HAI are caused by ESKAPE pathogens. This is an acronym proposed by the Infectious Disease Society of America (IDSA), which represent a list of pathogens that are capable of “escaping” the biocidal action of antibiotics and mutually representing new paradigms in pathogenesis, transmission and resistance:
  • Enterococcus faecium
  • Staphylococcus aureus
  • Klebsiella pneumoniae
  • Acinetobacter baumannii
  • Pseudomonas aeruginosa
  • Enterobacter species
This list has been expanded to “ESKAPES” to include Stenotrophomonas maltophilia. Although not enlisted by IDSA, Escherichia coli is also an important agent of multidrug-resistant organism (MDRO) causing HAI especially in Indian settings.
Other less common infections that can be transmitted in hospitals include:
  • Healthcare associated M. tuberculosis
  • Legionella pneumophila
  • Candida albicans
  • Clostridioides difficile diarrhea
  • Blood borne viruses (BBVs) such as HIV, hepatitis B and C viruses transmitted through contaminated needle prick injury or mucocutaneous exposure to blood and body fluids.
Mode of Transmission
Microorganisms spread in the hospital through several modes (Table 1.2).
Though several types of HAIs exist, there are four most common types (listed below) which are often monitored to estimate the burden of HAI in a hospital. Out of these, the first three together are termed as device associated infections (DAIs):
  • Catheter-associated urinary tract infection (CAUTI)
  • Central line-associated blood stream infection (CLABSI)
  • Ventilator-associated pneumonia (VAP)
  • Surgical site infection (SSI).
The pathogenesis, laboratory diagnosis, treatment and prevention of these major HAI types have been described in detail in Chapter 3 and the surveillance aspects has been described in Chapter 4.
The preventive measures for HAIs can be broadly categorized into:
  • Standard precautions
  • Transmission-based or specific precautions.
Standard (Routine) Precautions
It refers to a set of infection control practices used to prevent transmission of diseases, that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membrane.
  • These measures should be followed when providing care to all individuals, while handling all specimens and sharps regardless of their infectious status.
  • Components of standard precautions include hand hygiene, personal protective equipment, handling of sharps, biomedical waste management, environmental disinfection practices, etc. which have been described in detail subsequently in further chapters.
Transmission-based or Specific Precautions
These are the additional precautions taken over and above the standard precautions when a disease of a specific transmission is suspected and when standard precautions may not be sufficient enough to prevent the transmission of infection.5
Table 1.2   Mode of transmission of healthcare-associated pathogens.
Contact transmission
Direct contact
Skin to skin contact and thereby physical transfer of microorganisms between a susceptible host and an infected or colonized person (usually healthcare workers, rarely other patients)
This is the most important and frequent mode of transmission
Indirect contact
This involves contact of a susceptible host with contaminated inanimate objects such as:
  • Dressings, or gloves, instruments, (e.g. stethoscope)
  • Parenteral transmission through:
    • Needle or sharp prick injury
    • Splashes of blood or body fluids or excretions
    • Contaminated saline flush, syringes, etc.
Inhalational mode
Droplet transmission
Droplets of >5 µm size can travel for shorter distance (<3 feet)
  • Droplets generated from the infected person while coughing, sneezing, and talking are propelled for a short distance through the air and deposited on the host's body
  • This is an important mode of transmission for bacterial meningitis, diphtheria, respiratory syncytial virus, etc.
Airborne transmission
This refers to the airborne droplet nuclei (≤ 5 µm size) or dust particles that remain suspended in the air for long time and can travel longer distance:
  • This is more efficient mode than droplet transmission
  • Microorganisms transmitted by airborne transmission include Legionella, Mycobacterium tuberculosis, measles and varicella viruses
Vector borne transmission
Transmission via vectors such as mosquitoes, flies, etc. carrying the microorganisms
This is a rare mode of transmission in hospital
Common vehicle transmission
This mode includes food, water, medications, devices, and equipment
Based on the specific modes of transmission as discussed earlier in Table 1.2; there are three types of transmission-based precautions:
  1. Contact precautions
  2. Droplet precautions
  3. Airborne precautions.
The detail discussion of transmission based precautions has been described in Chapter 7.
The WHO has recently published the “core components for infection prevention and control (IPC)” in 2016. It has recommended eight evidence-based core components which need to be implemented both at healthcare facility level and at national level. All the core components are equally important and crucial for the establishment and effective functioning of IPC practices.
  1. Infection prevention and control program with a dedicated, trained team should be in place for the purpose of preventing HAI and combating antimicrobial resistance (AMR).
  2. Infection prevention and control guidelines: Evidence-based IPC guidelines should be developed and implemented for the purpose of reducing HAI and AMR.
  3. Infection prevention and control education and training: IPC related education and training facility should be in place for all HCWs by utilizing team and task based strategies that are participatory and 6include bedside and simulation training to reduce the risk of HAI and AMR.
  4. Surveillance: Facility-based HAI surveillance should be performed to guide IPC interventions and detect outbreaks, including AMR surveillance with timely feedback of results to HCWs, stakeholders and to national networks. National HAI surveillance program and networks should be established for the purpose of creating a national benchmark of HAI rates which can be used as standard for inter-hospital comparison.
  5. Multimodal strategies: IPC activities using multimodal strategies should be implemented to improve practices and reduce HAI and AMR. The 5 most common components of WHO's multimodal strategies include:
    1. System change (that is, availability of the appropriate infrastructure and supplies to enable good IPC practices).
    2. Education and training of HCWs and key players.
    3. Monitoring infrastructures, practices, processes, outcomes and providing data feedback.
    4. Reminders in the workplace or visual communication posters.
    5. Cultural change with the establishment and strengthening of a safety climate.
  6. Monitoring or audit of IPC practices and feedback: Regular monitoring or audit of healthcare practices according to IPC standards should be performed to prevent and control HAI and AMR at the healthcare facility level. Feedback should be provided to all audited persons and relevant staff.
    • A national IPC monitoring and evaluation program should be established to assess the extent to which standards are being met and activities are being performed.
    • Hand hygiene monitoring with feedback should be considered as a key performance indicator at the national level.
  7. Workload, staffing and bed occupancy: Bed occupancy should not exceed the standard capacity of the facility; HCWs staffing levels should be adequately assigned according to patient workload.
  8. Built environment, materials and equipment for IPC at the facility level: Patient care activities should be undertaken in a clean and/or hygienic environment that facilitates practices related to the prevention and control of HAI, as well as AMR. Materials and equipment to perform appropriate hand hygiene should be readily available at the point of care.
For the purpose of increase in awareness, there are several infection control events which are observed worldwide.
  • World Hand Hygiene Day: 5th May is observed every year as world hand hygiene day.
  • WHO theme on hand hygiene: The WHO theme on hand hygiene in last three years were:
    • 2018: It's in your hands—“prevent sepsis in healthcare”
    • 2017: Fight antibiotic resistance—It's in your hands.
    • 2016: See your hands—hand hygiene supports safe surgical care.
  • Global Handwashing Day: 15th October is observed as Global Handwashing Day. It is a campaign to motivate and mobilize people around the world to improve their handwashing habits.
  • International Infection Prevention Week: 3rd week in October is designated as International Infection Prevention Week. For 2018, it was observed during 14th to 20th October with a theme of “protecting patients everywhere.”
  • World Antibiotic Awareness Week: World Antibiotic Awareness Week aims to increase awareness of global antibiotic resistance 7and to encourage best practices among the general public, healthcare workers and policy makers to avoid further emergence of antimicrobial resistance. 2nd or 3rd week of November is celebrated every year as antibiotic awareness week. The theme used in last three years were:
    • In 2018, it was observed during 12th to 18th November with a theme of “Learn on how to handle antibiotics with care.”
    • In 2017, it was observed during 13th to 19th November with a theme of “Think twice, seek advice.”
    • In 2016, it was observed during 14th to 20th November with a theme of “Antibiotics: handle with care.”
Since time immemorial, many scientists, medical and surgical physicians have contributed largely to infection control and prevention. The historical context of hospital infection control has been briefly summarized in Table 1.3.
Table 1.3   Pioneers in infection prevention and control.911
Pioneer (Year)
Contributions in infection prevention and control
Joseph Lister
British surgeon and scientist
  • Father of antiseptic surgery
  • First to use an antiseptic, carbolic acid to treat the infected wound
  • Advocated hand washing and cleansing of the wounds prior to surgery
  • Also, initiated concept of spraying of the entire operation theatre with carbolic acid preoperatively and continued to spray the wound intraoperatively
Florence Nightingale
  • Founder of modern nursing
  • She campaigned for hospital cleanliness and sanitation during the Crimean War and advanced hospital asepsis through her work and convictions
Ignaz Philipp Semmelweis
Hungarian physician
  • Pioneer of antiseptic policy and hand hygiene
  • He observed that the incidence of puerperal fever could be drastically reduced by using hand disinfection in obstetric clinics
  • He instituted a policy of hand washing between autopsy work and obstetrics, with a solution of chlorinated lime (calcium hypochlorite)
Oliver Wendell Holmes
American physician
  • Around the same time of Semmelweis, in another part of the world, OW Holmes also proposed contaminated hand as a root cause of puerperal fever
John Snow
General practitioner, London
  • Founder of epidemiology
  • He analyzed the distribution of cholera cases in the 1848 epidemic in relation to the purity of the water supply in London
  • He hypothesized that, cholera was spread by contaminated water
Louis Pasteur
French chemist and microbiologist
  • Germ theory of disease
  • Contribution in sterilization—pasteurization
  • In 1862, French chemist and microbiologist Louis Pasteur published his findings on how germs cause disease, which he later used to develop the pasteurization process
Robert Koch
German microbiologist
  • Demonstrated disinfecting properties of steam and hot air
William Stewart Halsted
American surgeon
  • Invented rubber gloves in order to prevent medical staff from developing dermatitis from surgical chemicals8
Charles Chamberland
French microbiologist
  • Developed the first pressure steam sterilizer or autoclave in 1876
Earle Spaulding
American Physician
  • Proposed “Spaulding's classification of medical devices.” All the medical instruments can be classified into noncritical, semicritical and critical devices based on whether the device comes in contact with intact skin, mucous membranes, or sterile cavity of the body respectively
  1. World Health Organization. Guidelines on core components of infection prevention and control program at the national and acute healthcare facility level. World Health Organization;  2016.
  1. Scott RD. (2009). The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. [online] Available from [Accessed October 2018].
  1. Ling ML, Apisarnthanarak A, Madriaga G. The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis. Clin Infect Dis. 2015;60(11):1690–9.
  1. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309–32.
  1. World Health Organization. (2018). Save Lives: Clean Your Hands 5 May 2018. [online] Available from [Accessed October 2018].
  1. Global Handwashing Day. (2018). October 15 is Global Handwashing Day. [online] Available from [Accessed October 2018].
  1. Infection Prevention and You. (2018). Member Toolkit.  [online] Available from [Accessed October 2018].
  1. World Health Organization. (2018). World Antibiotic Awareness Week, 12–18 November 2018. [online] Available from [Accessed October 2018].
  1. Sunavala A, Singhal T, Soman R. Pioneers in Infection Prevention-Part 1. J Assoc Physicians India. 2015;63(11):71–2.
  1. Sunavala A, Singhal T, Soman R. Pioneers in Infection Prevention-Part 2. J Assoc Physicians India. 2015;63(12):90–1.
  1. Smith PW, Watkins K, Hewlett A. Infection control through the ages. Am J Infect Control. 2012;40(1):35–42.