Breaking the Chain of Infection

Thinking in terms of interrupting transmission of infectious agents in everyday situations is known as 
Breaking the Chain of Infection. 

This term uses a metaphor to create a visual interpretation; each link depends on the last and the next, in order to continue. Break one link and there is no longer a connection. An example might be:

The 1st link is the Infectious Agent or pathogen, let’s use MRSA 

The 2nd link is the Reservoir or house the pathogen lives in. In this case it’s living in the nares (nose) of a nurse but not causing any clinical signs of infection  

The 3rd link is the Portal of Exit, or the path the pathogen takes out of the reservoir (the nurse rubs her nose, now the pathogen is on her hands)

The 4th link is the Mode of Transmission or the way the pathogen is passed. This can be direct, indirect, ingesting or inhaling. In this case the Mode of Transmission is direct, because the nurse rubs her nose, the MRSA is on her hands and she then touches the patient’s skin

The 5th link is the new host, her patient

The 6th link is the portal of entry. The nurse does not take time to wash her hands and transmits the MRSA to her patient’s skin while taking her blood pressure. 

The patient is a susceptible host because her immune status is impaired by her chronic medical conditions and diabetes. Her arm itches, she scratches it, the MRSA she picked up from the nurse is carried directly into her open skin (portal of entry) and she develops an MRSA wound infection.

In reviewing the situation, we see one of the links could have been broken at any time, to prevent this infection. The only barrier needed was simple, effective hand washing or the use of an alcohol sanitizer, which could have prevented transmission at every link. 

Here is a good link to a visual interpretation of Breaking the Chain of Infection: Break-the-Chain-of-Infection

Courtesy of APIC.ORG


Why Are You Wearing Gloves?


Glove use is essential in acute care facilities, skilled nursing, long term care or any environment where there is a need to maintain a barrier from one person, place or thing to another person, place or thing. We know glove use is the mainstay of Standard Precautions  (Standard Precautions First)

As often as we observe the correct use of gloves, there’s the real probability we are witness to the opposite. The use of gloves during Phlebotomy procedures comes to mind.

  • The phlebotomist puts on a pair of non-sterile gloves, places the tourniquet, prepares the syringe, runs an alcohol wipe over the anticubital fossa, then palpates the vein with the gloved finger after the alcohol wipe and before inserting the needle into the now re-contaminated skin.  Well in any case, that quick dab with an alcohol wipe wasn’t really going to do the job anyway. But it was something. My guess is the phlebotomist is attempting to protect themselves from the patient’s blood and body fluids (and that’s appropriate) but they aren’t considering protecting the patient from the act of the procedure or the environment. But they had on gloves.
  • During a dressing change. The nurse dons’ non-sterile gloves to remove the old dressing and then removes them. Once ready to clean the wound and apply sterile dressings, the nurse dons’ sterile gloves but doesn’t wash her hands first. Unwashed hands and sterile gloves isn’t good practice, why? Washing hands, when done well, removes most of the bacteria/pathogens found on our hands. Good handwashing practices are really the best preventative measures we can take to prevent cross contamination.  If there is a microscopic tear or hole in the gloves, the bacteria escape in to the wound, introducing the nurse’s bacteria to the patient’s wound. But she had on gloves. 
  • Food preparation in the kitchen. Not only do we see this in hospital kitchens, but this can be observed in any deli section of your favorite grocery store or restaurant, as well. The employee dons’ non-sterile gloves in anticipation of food preparation, then goes about touching any and all items in the environment before returning to finish preparing the sandwich, the salad or the arranging of fruit or garnishes on the plate. But they had on gloves.
  • At the grocery deli counter. An unaware employee might be seen wiping gloved hands on their apron, going to the cash register and handling money, or returning the bundles of meat or cheese to their rightful place, before handling the last slice of meat or cheese, wrapping it up and handing it to the customer. But they had on gloves. 

To be fair, gloves can be confusing to many employees and for good reason. In many cases they give one a false sense of security; the person may honestly believe they are doing the right thing by placing them on their hands, but they haven’t been educated properly or frequently enough to their best use. Do they understand how, why, where and when they should be using gloves? If not, they are of no use at all.

This is a great visual for glove use; it can be printed and used as a guide:

Do’s & Don’ts For Wearing Gloves In the Healthcare Environment

 Courtesy of APIC.ORG


Standard Precautions First

Standard Precautions First

The term Standard Precautions speaks for itself. These are basic precautions taken to reduce the possibility of coming in contact with infectious body fluids including blood, secretions, excretions, non-intact skin and mucous membranes. In other words, anything that is warm and wet, except for sweat.

Standard Precautions include hand washing, using alcohol hand sanitizers when there are no visible signs of soiling, and barriers such as gloves, gowns, masks and goggles, depending on the situation. Use Standard Precautions all the time with every patient. Often the term just isn’t understood and is overlooked, instead healthcare workers scramble to determine “What kind of precautions the patient is on.” Barriers are included as part of Standard Precautions, leaving the use of them to be determined by assessing the patient situation. It would make sense to use gloves if there is a possibility of soiling your hands, gowns and goggles if splashing or contact with bodily fluids is anticipated. 

When you think of Standard Precautions, think insurance policy. Why do we use Standard Precautions? Precaution is the key word here. We use precautions in advance of coming upon a situation that might lead to an undesired outcome, one leading to possible transmission of infectious organisms from patient to patient, patient to healthcare worker and what of the visitors? Let us not overlook role of the visitors in the mix.  

We can’t always know who among our patients, employees, physicians, or visitors, may be carrying an infectious or potentially infectious organism. It’s safe to say not only do we not always know, we usually do not know.  So, in order to avoid an unwanted outcome, such as the spread of infectious disease, we use barriers such as gloves, gowns and masks, when indicated. This means we need to rely on our own assessment of a situation when it comes to caring for patients who have not yet been diagnosed with any particular infectious organism. 

Example: A patient has been coughing; do any of us want to inhale droplets sprayed into the air by a coughing or sneezing person? Don’t we usually avoid those situations anyway? So before any tests are completed, before a particular organism is cultured, identified and reported, put a mask on yourself and one on your patient if they are leaving the room.  That’s Standard Precautions.  

Example: A patient has complained of sudden upset stomach and diarrhea. Do any of us want to touch anyone’s feces? Do we want to touch the same places the person with the diarrhea has touched?  So before any tests, cultures and diagnoses are made, put on gloves and even a gown if there is a chance your clothes could become contaminated. That’s Standard Precautions.

Example: A newly admitted patient complains of intense itching, especially bothersome at night. Before you think Scabies, before skin scrapings and identification of mites occurs, put on gloves before touching the patient. That’s Standard Precautions.

Let’s not forget. Patients, just like you and me, touch their bodies, their noses, mouths and their skin. Hopefully we all wash our hands, but we don’t know for sure. We all live in a unique cloud of our own organisms and touch things in the environment over and over again, leaving our own unique brand of micro-organisms behind us. See Microbiome

Fortunately, or unfortunately, we don’t see what is on our hands, our skin or in the environment. When we’re distracted we forget, overlook or postpone doing what we know is the right thing to do; after all, we are very busy. But, if we could actually see the organisms on our hands, our patient’s hands and the environment we might never stop washing, cleaning and sanitizing. At the very least, using Standard Precautions all of the time dilutes the potential number of organisms we transmit to one another. 

To be sure: Every time you enter a patient’s room, sanitize your hands. Every time you care for a patient, and go to another patient, sanitize your hands.  Every time you leave a patient’s room sanitize your hands. That’s Standard Precautions.



Multi-drug Resistant Organisms

The CDC defines Multidrug-resistant Organisms (MDRO’s) as microorganisms that have developed resistance to multiple antimicrobial drugs; two MDRO’s we are most familiar with in Long-term Care are MRSA (Methicillin-Resistant Staphylococcus Aureus) and VRE (Vancomycin Resistant Enterococcus). Patients, healthcare workers and visitors are potential sources of MDRO’s. They may be colonized, infected, and unknowingly transmitting resistant organisms to one another.

Colonization is defined as the presence of an organism in or on the body but with no clinical signs and symptoms of infection. Infection is defined as tissue invasion by a microorganism accompanied by positive clinical signs and symptoms.

Since health care workers, patients and family alike, could potentially be unaware they are colonized with Multi-Drug Resistant Organisms, it follows they could easily be transmitted from one person to another. Inadequate hand hygiene is the root cause for transmission of pathogens in Long-Term Care and in all other health care settings as well. Health care workers, patients and visitors must do all they can to interrupt the cycle of transmission by consciously and conscientiously washing their hands. 

Multi-drug Resistant organisms are not more virulent than their non-resistant predecessors, but they may be more difficult to treat because they are resistant to many classes of antimicrobials.  Reducing exposure to MDRO’s is accomplished by using the same  approach to preventing transmission of all pathogens found in health care facilities.  

  • Use Standard Precautions at all times and Transmission Based Precautions for known or suspected infections. Standard Precautions
  • Always practice responsible Hand Hygiene
  • Use optimum Room Placement of patients with known infections;  co-hort those with like infectious organisms.  
  • PPE (Personal Protective Equipment) use gloves, gowns and masks appropriately. Give frequent demonstrations on the correct procedures for donning, removing and disposing of PPE,  followed by staff return demonstrations. Donning and Removing PPE

Assess patients for group activities. In general, if a patient’s wounds are covered and contained, if they are not exhibiting signs and symptoms of infection, and if they are able to demonstrate responsible hygiene practices, it is usually acceptable for them to leave their room. Check the Policies & Procedures for your facility. Conversely, if wounds cannot be covered and drainage contained, if the patient is confused or unable to engage in good hygiene practices, if they demonstrate clinical signs of infection such as fever, active vomiting/diarrhea or if they are coughing productively, they should remain in their rooms until their signs and symptoms have subsided. Again, review and educate your staff to your facility Policy & Procedures, which should be updated as needed for federal, state and local Standards of Care and Best Practice Guidelines.

C. Difficile

C. Difficile Infection (CDI); what it is, how it is transmitted and what can be done to prevent its spread.

Clostridium Difficile is an Antibiotic- Associated Diarrhea Disease (AAD) found in hospitals, skilled nursing facilities and long-term care settings subsequent to antibiotic treatment.  It is a tough little anaerobic, gram-positive, spore forming bacillus that produces two exotoxins which attack  the mucosal lining of the colon, usually subsequent to antibiotic usage; the action  neutralizes the normal flora of the bowel, allowing for C. Dif proliferation.

The clinical signs and symptoms of C. Difficile are abdominal pain, watery diarrhea, nausea and fever. The bacillus is shed in the feces and transmission is by oral ingestion. How does this occur? Contamination of the environment by an infected patient allows for transmission from feces to hands, to surfaces, and then to others, when adequate precautions are not followed.

C. Difficile spores are capable of living in the environment for days, weeks and even months.  Severe cases of C. Difficile carry the potential for colon perforation, mega-colon, sepsis and even death.

Treatment of C. Difficile may consist of physician ordered Vancomycin and/or Flagyl but about 23 percent of patients recover within a few days if the offending antibiotics have been discontinued. Of special note: The CDC does not recommend re-culturing of patients who have completed treatment or have resolved on their own and remain asymptomatic because they may be colonized.   

  • Always use Standard precautions for all patients in Long-term Care and use Transmission Based Precautions for known or suspected infections. With symptomatic C. Difficile   patients with watery diarrhea may be placed on contact precautions until asymptomatic, which means no further diarrhea.
  • The CDC recommendations for hand hygiene when caring for patients with C. Difficile consist of hand washing; alcohol sanitizers are not effective against C. Difficile spores. Hand washing does not kill the spores but the friction with soap and running water allows for them to be washed down the drain.
  • Environmental cleaning consists of Hypochlorite/bleach solutions with careful attention to protocols for contact time. Information can be found in the CDC’S Frequently Asked Questions about C. Difficile for professionals: CDC/C.Dif / Hand Hygiene and C. Dif

Reference picture: CDC PHIL.

Becoming Preventionists

Infection Prevention and Control is not a new specialty but it is one that has gained attention locally, nationally and globally, in light of the emergence and re-emergence of childhood diseases, such as measles and pertussis and the Pandemic H1N1 Influenza outbreaks, not to mention Ebola. Nurses are educated to be familiar with basic Infection Control principles whether they work in acute care settings, long-term care, home health, clinics or physician’s offices.

The term Infection Control has recently been changed to Infection Prevention and Control with an emphasis on prevention. It follows that nurses and other medical professionals who work closely within the specialty, are now referred to as Infection Preventionists. After all, preventing healthcare associated infections should be the primary concern. Controlling them implies there is already a problem.

Infection Prevention and Control in Skilled Nursing, Long-term and Long-term Acute Care begins with developing a strong Infection Prevention and Control program designed to prevent transmission of infection from resident to staff, staff to patient and patient to patient. In Long-term Care the job typically, but not always, falls to the Staff Developer. Often times there is a sudden vacancy, for whatever reason, and an urgent assignment is made to a nurse who may have no measurable experience in the specialty. Before the appointee begins to feel overwhelmed, it is very important that the Infection Preventionist have the support of physicians, nursing, administration and ancillary services.

To those nurses who find themselves feeling unprepared for the new role suddenly thrust upon them, please consider becoming a member of our National Professional Association, the Association for Professionals in Infection Control and Epidemiology (APIC). There you will find classes, seminars, videos, podcasts, manuals, books, magazines and information regarding certification in Infection Control. A visit to the website is well worthwhile. 



What are OSHA and The CDC?

What is OSHA?

OSHA is the acronym for the Occupational Safety and Health Administration, an agency of the Federal Government created by Congress in 1970 under The Department of Labor. OSHA mandates  compliance with standards set for employee safety in the workplace. In 1991 OSHA developed the Bloodborne Pathogens Standard to protect workers from the risk associated with sharps injuries, HIV/AIDS, and Hepatitis B & C. Congress developed The Needle stick Safety and Prevention Act in 2000 and OSHA revised the Standard to include the modifications in 2001.

OSHA developed Universal Precautions to protect health care workers from coming in contact with all potentially infected blood and body fluids during patient care. This includes hand washing and the use of bariers such as gloves, gowns and masks when indicated.   

What is the CDC?

CDC is the acronym for the Centers for Disease Prevention and Control, an agency of the Federal Government under the Department of Health and Human Services. The CDC is concerned with Public Health, safety and the prevention and control of disease.

Based on the fact that we cannot know a patient’s status with certainty, The CDC recommends Standard Precautions for the care of all patients no matter their diagnosis.

Standard Precautions include the use of Personal Protective Equipment (PPE) to provide a barrier to blood and body fluids. PPE consists of gloves, gowns, masks.

Hand washing and alcohol hand sanitizers are used appropriately before and after contact with each patient, before and after donning gloves, passing medications, using the restroom, eating, inserting contacts or applying makeup.  

Transmission Based Precautions are recommended to provide additional precautions when it is known or suspected a patient is infected or colonized with a significant pathogen. These precautions are based on the pathogen and their mode of transmission.

They include:

Airborne Precautions for pathogens that travel through small particles in the air such as  Tuberculosis. Airborne Precautions usually require the use of N-95 respirators and negative pressure rooms for patient care, options not normally available in Long-term Care.   

Droplet Precautions are indicated for pathogens traveling on large droplet’s propelled in the air through respiratory secretions while sneezing, coughing or talking. These droplets travel about 3 feet; if it is expected the worker will come within 3 feet of the patient  they wear a mask. If the patient is transported from the room, they wear a mask. Examples of droplet isolation include the influenza viruses, Pneumonias, and Meningitis. (See Appendix A of The CDC Guidelines for Isolation Precautions 2007 for a complete list.

Contact Precautions are used for infectious pathogens that are transmitted from skin to skin and by contact with a contaminated environment. Examples are C. Difficile, Noro Viruses, MRSA, and VRE. 


Adult Vaccine Schedule

Every year at this time, we as Infection Preventionist, preach the importance of getting the Influenza Vaccine, but what of the other adult vaccines? Is your staff compliant? Do you keep track of your vaccinations? Are you up to date with your own adult vaccines? What about these:

  • Influenza (Flu) every year
  • Tetanus, diphtheria, pertussis (Td/Tdap)
  • Varicella (Chickenpox)
  • HPV Vaccine for Women
  • HPV Vaccine for Men
  • Zoster (Shingles)
  • Measles, mumps, rubella (MMR)
  • Pneumococcal (pneumonia)
  • Meningococcal
  • Hepatitis A
  • Hepatitis B

Here are some great links to the CDC Adult Vaccine Schedules

CDC Adult Vaccines

Adult Vaccine Schedule

Picture courtesy of CDC:PHIL


Healthcare Acquired Infection Prevention (HAI) in Long-term Care

The term Nosocomial Infection has more recently been changed to Health Care Acquired Infection or HAI, but I find Health Care Workers continue to default to using Nosocomial. In any case, a HAI or Nosocomial Infection, is one that develops 48 to 72 hours after admission to a healthcare facility, according to McGeer’s Criteria (McGeer’s, 1991)

Multiple factors contribute to the transmission of infectious organisms in hospitals, long-term care facilities and rehabilitation centers; they include the type of infectious organism, the patient’s proximity to the source of infection, the means by which the organism could potentially be transmitted  and the status of the patient’s immune system.

Ultimately, it is the responsibility of the facility to develop policies and procedures designed to interrupt the transmission of infectious organisms from the source to the patient and to maintain a strong Infection Control Surveillance program. That is where you, the DSD, Infection Preventionist, or DON, and your Infection Control Committee, come in. Preventing HAI in Healthcare Facilities CDC


McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang E. Definitions of Infection for Surveillance in Long Term Care Facilities. American Journal of Infection Control 1991; 19(1):1-7.

PHIL ID # 10068
Photo Credit: Janice Haney Carr, Centers for Disease Control and Prevention

PHIL ID # 10045
Photo Credit: Janice Carr, Centers for Disease Control and Prevention

CDC Newsroom Image Library




is the acronym for Extended Spectrum Beta Lactamase. If it sounds somewhat complicated it is; basically, ESBLs are bacteria that produce an enzyme capable of neutralizing the effectiveness of certain classes of Beta-lactam antibiotics such as, carbapenems, cephalosporins and certain penicillin derivatives. The end result is yet another type of Multi-drug resistant Organism (MDRO).

The bacteria are spread in the same way all organisms are transmitted depending on their site.  Those at highest risk are usually hospitalized patients who have been on extensive antimicrobial therapy and have already compromised immune systems.

What should be done about ESBLs in long-term care?

  • If you are new to infection prevention, be sure to locate your facility policy for MDROS in your Infection Control Manual.  Hopefully, the policy will be up to date and based on the evidence based guidelines and recommendations available to long-term care facilities in your state.
  • The CDC, your state Department of Public Health and APIC (Association for Professionals in Infection Control and Epidemiology) are the Big 3 support systems for Infection Preventionists. Visit their websites frequently.
  • If you aren’t sure or have questions, seek out the support of your DON, and the Infection Control Committee.
  • Together, you can review, update and sign off on a current policy.  As soon as appropriate, announce the presence of an updated policy for MDROs (including ESBLS) to the staff and educate them to its definition, treatment and potential precautions.
  • Standard Precautions are THE place to start; utilize Transmission Based Precautions for infections that cannot be contained. Think about that.

Is an ESBL in the urine contained in a Foley bag, a diaper or as a continent patient?

If the source of the organism is contained, the patient’s hands are clean, they are wearing clean clothes and want to socialize, could they be managed with Standard Precautions?  

What is the policy for your facility? Is your staff educated frequently to the principles of Standard Precautions?