INFECTION

CONCEPT

Humans may hold dominance over most other life-forms on Earth, but a few varieties of organism have long held mastery over us. Ironically, these life-forms, including bacteria and viruses, are so small that they cannot be seen, and this, in fact, has contributed to their disproportionate influence in human history. For thousands of years, people attributed infection to spiritual causes or, at the very least, to imbalances of "humors," or fluids, in the human body. Today germ theory and antisepsis—the ideas that microbes cause infection and that a clean body and environment can prevent infections—are ingrained so deeply that we almost take them for granted. Yet these concepts are very recent in origin, and for a much longer span of human history people quite literally wallowed in filth—with predictable consequences.

HOW IT WORKS

What Is Infection?

The term infection refers to a state in which parasitic organisms attach themselves to the body, or to the inside of the body, of another organism, causing contamination and disease in the host organism. Parasite refers generally to any organism that lives at the expense of another organism, on which it depends for support. Numerous parasites and the diseases they cause are discussed in the essay Parasites and Parasitology; in the present context, we are concerned primarily with infections that relate to bacteria and viruses.

Almost all infections contracted by humans are passed along by other humans or animals.

Infections fall into two general categories: exogenous, or those that originate outside the body, and endogenous, which occur when the body's resistance is lowered. Examples of exogenous infection include catching a cold by drinking after someone else from the same glass; coming down with salmonella after ingesting under-cooked eggs, meat, or poultry; getting rabies from a dog bite; or contracting syphilis, AIDS (acquired immunodeficiency syndrome), or some other sexually transmitted disease from an infected partner.

Any number of factors—lack of sleep, prolonged exposure to extreme cold or moisture, and so on—can lower the body's resistance, opening the way for an endogenous infection. Malnutrition, illness, and trauma also can be factors in endogenous infection. Substance abuse, whether it be the use of tobacco in its many forms, excessive drinking, or drug use, lowers the body's resistance. Furthermore, all of these behaviors tend to be coupled with poor eating habits, which invite infection by denying the body the nutrients it needs.

Some Terms

A whole array of terminology attends the study of infection and infectious diseases, a subject that is touched upon in the present context but explored at length in its own essay as well. Among these terms are the names for the different branches of study relating to infection, its agents, and the resulting diseases. Although germ theory is a term (defined later) that is used widely in the context of infection, germ itself—a common word in everyday life—is not used as much as microorganism or pathogen. The latter word refers to disease-carrying parasites, which are usually microorganisms. Two of the principal types of pathogen, bacteria and viruses, are discussed later in this essay.

Words relating to the effects of infectious agents include epidemic, an adjective meaning "affecting or potentially affecting a large proportion of a population"; as a noun, the word refers to an epidemic disease. Pandemic also doubles as an adjective, meaning "affecting an extremely high proportion of a population over a wide geographic area," and a noun, referring to a disease of pandemic proportions. Areas of study relating to pathogens, their effects, and the prevention of those effects include the following.

• Bacteriology: An area of the biological sciences concerned with bacteria, including their importance in medicine, industry, and agriculture)
• Epidemiology: An area of the medical sciences devoted to the study of disease, including its incidence, distribution, and control within a population)
• Etiology: A branch of medical study concerned with the causes and origins of disease. Also, a general term referring to all the causes of a particular disease or condition)
• Immunology: The study of the immune system, immunity, and immune responses)
• Pathology: The study of the essential nature of diseases)
• Virology: The study of viruses

In addition, there are several terms relating to the prevention of infection.

• Antibiotic: A substance produced by, or derived from, a microorganism, which in diluted form is capable of killing or at least inhibiting the action of another microorganism. Antibiotics typically are not effective against viruses.
• Antisepsis: The practice of inhibiting the growth and multiplication of microorganisms)
• Germ theory: A theory in medicine, widely accepted today, that infections, contagious diseases, and other conditions are caused by the actions of microorganisms)
• Immunity: A condition of being able to resist a particular disease, particularly through means that prevent the growth and development of pathogens or counteract their effects
• Inoculation: The prevention of a disease by the introduction to the body, in small quantities, of the virus or other microorganism that causes the disease
• Vaccine: A preparation containing microorganisms, usually either weakened or dead, which are administered as a means of increasing immunity to the disease caused by those microorganisms

Some of these words appear in this essay and others in related essays on infectious diseases and immunity.

Bacteria

Five major groups of microorganisms are responsible for the majority of infections. They include protozoa and helminths, or worms—both of which are considered in Parasites and Parasitology—as well as bacteria and viruses. Bacteria and viruses often are discussed, along with fungi (the fifth major group), in the context of infection and infectious diseases. In the present context, however, we limit our inquiry to viruses and bacteria.

Bacteria are very small organisms, typically consisting of one cell. They are prokaryotes, a term referring to a type of cell that has no nucleus. In eukaryotic cells, such as those of plants and animals, the nucleus controls the cell's functions and contains its genes. Genes carry deoxyribonucleic acid (DNA), which determines the characteristics that are passed on from one generation to the next. The genetic material of bacteria is contained instead within a single, circular chain of DNA.

Members of kingdom Monera, which also includes blue-green algae (see Taxonomy), bacteria generally are classified into three groups based on their shape: spherical (coccus), rodlike (bacillus), or spiralor corkscrew-shaped (spirochete). Some bacteria also have a shape like that of a comma and are known as vibrio. Spirochetes, which are linked to such diseases as syphilis, sometimes are considered a separate type of creature; hence, Monera occasionally is defined as consisting of blue-green algae, bacteria, and spirochetes.

The cytoplasm (material in the cell interior) of all bacteria is enclosed within a cell membrane that itself is surrounded by a rigid cell wall. Bacteria produce a thick, jellylike material on the surface of the cell wall, and when that material forms a distinct outer layer, it is known as a capsule. Many rod, spiral, and comma-shaped bacteria have whiplike limbs, known as flagella, attached to the outside of their cells. They use these flagella for movement by waving them back and forth. Other bacteria move simply by wiggling the whole cell back and forth, whereas still others are unable to move at all.

Bacteria most commonly reproduce by fission, the process by which a single cell divides to produce two new cells. The process of fission may take anywhere from 15 minutes to 16 hours, depending on the type of bacterium. Several factors influence the rate at which bacterial growth occurs, the most important being moisture, temperature, and pH, or the relative acidity or alkalinity of the substance in which they are placed.

Bacterial preferences in all of these areas vary: for example, there are bacteria that live in hydrothermal vents, or cracks in the ocean floor, where the temperature is about 660°F (350°C), and some species survive at a pH more severe than that of battery acid. Most bacteria, however, favor temperatures close to that of the human body—98.6°F (37°C)—and pH levels only slightly more or less acidic than water. Since they are composed primarily of water, they thrive in a moist environment.

Viruses

One of the interesting things about bacteria is their simplicity, coupled with the extraordinary complexity of their interactions with other organisms. As simple as bacteria are, however, viruses are vastly more simple. Furthermore, the diseases they can cause in other organisms are at least as complex as those of bacteria, and usually much more difficult to defeat. Whereas there are "good" bacteria, as we shall see, scientists have yet to discover a virus whose impact on the world of living things is beneficial. There is something downright creepy about viruses, which are not exactly classifiable as living things; in fact, a virus is really nothing more than a core of either DNA or RNA (ribonucleic acid), surrounded by a shell of protein.

Two facts separate viruses from the world of the truly living. First, unlike all living things (even bacteria), viruses are not composed of even a single cell, and, second, a virus has no life if it cannot infect a host cell. When we say "no life" in this context, we truly mean no life. Although parasites, including bacteria and those species discussed in Parasites and Parasitology, depend on other organisms to serve as hosts, they can live when they are between hosts. They are rather like a person between jobs: without other means of support, the person eventually will go broke or starve, but typically such a person can hang on for a few months until he or she finds a new job. A virus without a host, on the other hand, is simply not alive—not dead, like a formerly living thing, but more like a machine that has been switched off.

Once a virus enters the body of a host, it switches on, and the result is truly terrifying. In order to produce new copies of itself, a virus must use the host cell's reproductive "machinery"—that is, the DNA. The newly made viruses then leave the host cell, sometimes killing it in the process, and proceed to infect other cells within the organism. As for the organisms that viruses target, their potential victims include the whole world of living things: plants, animals, and bacteria. Viruses that affect bacteria are called bacteriophages, or simply phages. Phages are of special importance, because they have been studied much more thoroughly than most viruses; in fact, much of what virologists now know about viruses is based on the study of phages.

REAL-LIFE APPLICATIONS

Bacteria and Humans

Not all bacteria are harmful; in fact, some even are involved in the production of foods consumed by humans. For example, bacteria that cause milk to become sour are used in making cottage cheese, buttermilk, and yogurt. Vinegar and sauerkraut also are produced by the action of bacteria on ethyl alcohol and cabbage, respectively. Other bacteria, most notably Escherichia coli (E. coli ) in the human intestines, make it possible for animals to digest foods and even form vitamins in the course of their work. (See Digestion for more on these subjects.) Others function as decomposers (see Food Webs), aiding in the chemical breakdown of organic materials, while still others help keep the world a cleaner place by consuming waste materials, such as feces.

Despite its helpful role in the body, certain strains of E. coli are dangerous pathogens that can cause diarrhea, bloody stools, and severe abdominal cramping and pain. The affliction is rarely fatal, though in late 1992 and 1993 four people died during the course of an E. coli outbreak in Washington, Idaho, California, and Nevada. More often the outcome is severe illness that may bring on other conditions; for example, two teenagers among a group of 11 who became sick while attending a Texas cheerleading camp had to receive emergency appendectomies. The pathogen is usually transmitted through under-cooked foods, and sometimes through other means; for example, a small outbreak in the Atlanta area in the late 1990s occurred in a recreational water park.

BACTERIAL INFECTIONS.

Many bacteria attack the skin, eyes, ears, and various systems in the body, including the nervous, cardiovascular, respiratory, digestive, and genitourinary (i.e., reproductive and urinary) systems. The skin is the body's first line of defense against infection by bacteria and other microorganisms, although it supports enormous numbers of bacteria itself. Bacteria play a major role in a skin condition that is the bane of many a young man's (and, less frequently, a young woman's) existence: acne. Pimples or "zits," known scientifically as Acne vulgaris, constitute one of about 50 varieties of acne, or skin inflammation, which are caused by a combination of heredity, hormones, and bacteria—particularly a species known as Propionibacterium acnes. When a hair follicle becomes plugged by sebum, a fatty substance secreted by the sebaceous, or oil, glands, this forms what we know as a blackhead; a pimple, on the other hand, results when a bacterial infection, brought about by P. acnes, inflames the blackhead and turns it red. For this reason, antibiotics may sometimes cure acne or at least alleviate the worst symptoms.

Acne may seem like a life-and-death issue to a teenager, but it goes away eventually. On the other hand, toxic shock syndrome (TSS), caused by other bacteria at the surface of the skin—species of Staphylococcus and Streptococcus —can be extremely dangerous. The early stages of TSS are characterized by flulike symptoms, such as sudden fever, fatigue, diarrhea, and dizziness, but in a matter of a few hours or days the blood pressure drops dangerously, and a sunburn-like rash forms on the body. Circulatory problems arise as a result of low blood pressure, and some extremities, such as the fingers and toes, are deprived of blood as the body tries to shunt blood to vital organs. If the syndrome is severe enough, gangrene may develop in the fingers and toes.

In 1980, several women in the United States died from TSS, and several others were diagnosed with the condition. As researchers discovered, all of them had been menstruating and using high-absorbency tampons. It appears that such tampons provide an environment in which TSS-causing bacteria can grow, and this led to recommendations that women use lower-absorbency tampons if possible, and change them every two to four hours. Since these guidelines were instituted, the incidence of toxic shock has dropped significantly, to between 1 and 17 cases per 100,000 menstruating women.

Many bacteria produce toxins, poisonous substances that have effects in specific areas of the body. An example is Clostridium tetani, responsible for the disease known as tetanus, in which one's muscles become paralyzed. A related bacterium, C. botulinum, releases a toxin that causes the most severe form of food poisoning, botulism. Salmonella poisoning comes from another genus, Salmonella, which includes S. typhi, the cause of typhoid fever.

Viral Infections

With viruses, as we have noted, there is no need even to discuss "good" kinds, because there is no such thing—all viruses are harmful, and most are killers. The particular strains of virus that attack animals have introduced the world to a variety of ailments, ranging from the common cold to AIDS and some types of cancer. Other diseases related to viral infections are hepatitis, chicken pox, smallpox, polio, measles, and rabies.

One reason why physicians and scientists have never found a cure for the common cold is that it can be caused by any one of about 200 viruses, including rhinoviruses, adenoviruses, influenza viruses, parainfluenza viruses, syncytial viruses, echoviruses, and coxsackie viruses. Each has its own characteristics, its favored method of transmission, and its own developmental period. These viruses can be transmitted from one person to another by sneezing on the person, shaking hands, or handling an object previously touched by the infected person. Surprisingly, some more direct forms of contact with an infected person, as in kissing, seldom spread viruses.

A group of viruses called the orthomyxoviruses transmit influenza, an illness usually characterized by fever, muscle aches, fatigue, and upper respiratory obstruction and inflammation. The most common complication of influenza is pneumonia, a disease of the lungs that may be viral or bacterial. The viral form of pneumonia that goes hand in hand with influenza can be very severe, with a high mortality (death) rate; by contrast, bacterial pneumonia, which typically appears five to ten days after the onset of flu, can be treated with antibiotics.

THE EVER ELUSIVE VIRUS.

Viruses are tricky. Because their generations are very short and their structures extremely simple, they are constantly mutating (altering their DNA and hence their heritable traits) and thus becoming less susceptible to vaccines. This is the reason why flu vaccine has to be prepared a new each year to target the current strains, and even then the vaccine is far less than universally effective. On the other hand, vaccination has a high rate of success for strains of virus that undergo little mutation—for example, the smallpox virus.

One particularly elusive type of virus is known as a retrovirus, which reverses the normal process by which living organisms produce proteins. Ordinarily, DNA in the cell's nucleus carries directions for the production of new protein. Coded messages in the DNA molecules are copied into RNA molecules, which direct the manufacture of new protein. In retroviruses, that process is reversed, with viral RNA used to make new viral DNA, which then is incorporated into host cell DNA, where it is used to direct the manufacture of new viral protein. Among the diseases caused by retroviruses is AIDS, discussed in Infectious Diseases and The Immune System.

Fighting the Invisible War

Every day of our lives, we are at war with microorganisms, both individually and as a species. It is a war that has lasted for several million years, with billions of lives in the balance, yet it is an invisible war. Up until a few centuries ago, in fact, we had no idea what we were fighting. Before the advent of germ theory, the most scientific theories of disease blamed them either on an imbalance of "humors" (blood, phlegm, yellow bile, and green bile), or on inhaling bad air. These were the most advanced ideas, the ones held by men of learning; most of the populace, by contrast, believed that disease was caused by evil spirits, cast upon individuals or populations by an angry God as punishment for disobedience.

Personal hygiene and public health were completely foreign concepts: not only did people bathe infrequently, but they also thought nothing of throwing trash—including rotting food and even human excrement—into the city streets. This image of trash in the streets may call to mind a city of medieval Western Europe, a place and time widely known for its filth, squalor, and ignorance. Yet such an image also describes Athens during the fifth century b.c., when human imagination, wisdom, and appreciation for beauty reached perhaps their highest points in all of history. In the Athens of Socrates, Herodotus, Hippocrates, and Sophocles, the streets were piled with trash and crawling with vermin. In fact, this lack of concern for cleanliness contributed directly to the end of the Greek golden age, sometimes known as the Age of Pericles, after Athens's great leader (495-425 b.c.)—who died in a great plague that swept the germ-ridden city.

BACTERIOLOGY AND ANTI-SEPSIS.

The first inkling of any etiology other than that of imbalanced humors and demons was the work of the Italian physician Girolamo Fracastoro (ca. 1483-1553), who put forth the theory that disease is caused by particles so small they are almost imperceptible. The invention of the microscope in 1590 made it possible to glimpse those particles, which Holland's Anton van Leeuwenhoek (1632-1723)—the first human being to observe bacteria and other microorganisms—dubbed animalcules, or "tiny animals." The German scholar Athanasius Kircher (1601-1680) also observed "tiny worms" in the blood and pus of plague victims and theorized that they were the source of the infection. This was the first theory that dealt with microbial agents as infectious organisms.

In 1848 Ignaz P. Semmelweis (1818-1865), a Hungarian physician working in German hospitals, came up with a novel idea: after examining the bodies of women who had died of puerperal (childbed) fever, he suggested that doctors should wash their hands in a solution of chlorinated lime water before touching a pregnant patient. Semmelweis's idea resulted in a drastic reduction of puerperal fever cases, but his colleagues denounced his outlandish notion as a useless and foolish waste of time. Six years later, in 1854, modern epidemiology was born when the English physician John Snow (1813-1858) determined that the source of a cholera epidemic in London could be traced to the contaminated water of the Broad Street pump. After he ordered the pump closed, the epidemic ebbed—and still many physicians refused to believe that invisible organisms could spread disease.

GERM THEORY.

A major turning point came just three years later, in 1857, when the great French chemist and microbiologist Louis Pasteur (1822-1895) discovered that heating beer and wine to a certain temperature killed bacteria that caused these liquids to spoil or turn into vinegar. Thus was born the process of pasteurization, still used today to purify such foods as milk, because, as Pasteur observed, "There are similarities between the diseases of animals or man and the diseases of beer and wine." Pasteur also dealt the final blow to spontaneous generation, a centuries-old belief that living organisms could originate from nonliving matter. As he showed in 1861, microorganisms present in the air can contaminate solutions that seem sterile.

Then, in 1876, the German physician Robert Koch (1843-1910) proved what Kircher had postulated two centuries earlier: that bacteria can cause diseases. Koch showed that the bacterium Bacillus anthracis was the source of anthrax in cattle and sheep and generalized the methodology he had used in that situation to form a specific set of guidelines for determining the cause of infectious diseases. Known as Koch's postulates, these guidelines define a truly infectious agent as one that can be isolated from an infected animal, cultured in a laboratory setting, introduced into a healthy animal to produce the same infection as in the first animal, and isolated again from the second animal. These ideas formed the basis of research into bacterial diseases and are still dominant in the sciences devoted to the study of disease.

Koch's postulates helped usher in what has been called the golden era of medical bacteriology. Between 1879 and 1889 German microbiologists isolated the organisms that cause cholera, typhoid fever, diphtheria, pneumonia, tetanus, meningitis, and gonorrhea as well the Staphylococcus and Streptococcus organisms. Even as Koch's work was influencing the development of the germ theory, the influence of the English physician Joseph Lister (1827-1912) was being felt in operating rooms. Building on the work of both Semmelweis and Pasteur, Lister—for whom the well-known antiseptic mouthwash Listerine was named—began soaking surgical dressings in carbolic acid, or phenol, to prevent postoperative infection.

ANTIBIOTICS.

Whereas antisepsis was the great battleground of the invisible war during the nineteenth century, in the twentieth century the most important struggle concerned the development of antibiotics. The first effective medications to fight bacterial infection in humans were sulfa drugs, developed in the 1930s. They work by blocking the growth and multiplication of bacteria and were initially effective against a broad range of bacteria, but many strains of bacteria have evolved resistance to them. Today, sulfa drugs are used most commonly in the treatment of urinary tract infections and for preventing infection of burn wounds.

The importance of sulfa drugs was eclipsed by that of penicillin, first discovered in 1928 by the British bacteriologist Alexander Fleming (1881-1955). Working in his laboratory, Fleming noticed that a mold that had fallen accidentally into a bacterial culture killed the bacteria. Having identified the mold as the fungus Penicillium notatum, Fleming made a juice with it that he called penicillin. He administered it to laboratory mice and discovered that it killed bacteria in the mice without harming healthy body cells.

It would be more than a decade before the development of a form of penicillin that could be synthesized easily. This drug arrived on the scene in 1941—just in time for the years of heaviest fighting in World War II—and after the war pharmaceutical companies began to manufacture numerous varieties of antibiotic. By the last decade of the twentieth century, however, a new problem emerged: bacteria were becoming resistant to antibiotics. This has been the case with medications used to treat conditions ranging from children's ear infections to tuberculosis.

An example is amoxicillin, a penicillin derivative developed in the late twentieth century. Many pediatricians found it a better treatment than penicillin for ear infections, because it did not tend to cause allergic reactions sometimes associated with the other antibiotic. However, by the late 1990s evidence surfaced indicating that certain types of bacteria had developed a protein that rendered amoxicillin ineffective against ear infections. Critics of amoxicillin (or of antibiotic treatments in general) maintained that widespread prescription of the antibiotic actually helped create that situation, because the bacteria developed the protein mutation defensively. Because of these and similar concerns associated with antibiotics, doctors have begun taking measures toward controlling the spread of antibiotic-resistant diseases, for instance by prescribing antibiotics only when absolutely necessary. Research into newer types and combinations of drugs is ongoing, as is research regarding the development of vaccines to prevent bacterial infections.

WHERE TO LEARN MORE

Biddle, Wayne. A Field Guide to Germs. New York: Henry Holt, 1995.

The Big Picture Book of Viruses. Tulane University (Web site). <http://www.tulane.edu/~dmsander/Big_Virology/BVHomePage.html>.

Cells Alive! (Web site). <http://www.cellsalive.com/>.

Centers for Disease Control and Prevention (Web site). <http://www.cdc.gov/>.

Infection Index. Spencer S. Eccles Health Sciences Library, University of Utah (Web site). <http://medlib.med.utah.edu/WebPath/INFEHTML/INFECIDX.html>.

"Oral Health Topic: Infection Control." American Dental Association (Web site). <http://www.ada.org/public/topics/infection.html>.

The Race Against Lethal Microbes: Learning to Outwit the Shifty Bacteria, Viruses, and Parasites That Cause Infectious Diseases. Chevy Chase, MD: Howard Hughes Medical Institute, 1996.

Virtual Museum of Bacteria. Bacteria Information from the Foundation for Bacteriology (Web site). <http://www.bacteriamuseum.org/>.

Weinberg, Winkler G. No Germs Allowed!: How to Avoid Infectious Diseases at Home and on the Road. New Brunswick, NJ: Rutgers University Press, 1996.

KEY TERMS

ANTIBIOTIC:

A substance produced by or derived from a microorganism, which in diluted form is capable of killing or at least inhibiting the action of another microor ganism. Antibiotics are not usually effective against viruses.

ANTISEPSIS:

The practice of inhibiting the growth and multiplication of microorganisms, generally by ensuring the cleanliness of the environment.

BACTERIOLOGY:

An area of the bio logical sciences concerned with bacteria, including their importance in medicine, industry, and agriculture.

DNA:

Deoxyribonucleic acid, a molecule in all cells, and many viruses, containing genetic codes for inheritance.

ENDOGENOUS:

A term for an infection that occurs when the body's resistance is lowered. Compare with exogenous.

EPIDEMIC:

Affecting or potentially affecting a large proportion of a popula tion (adj. ) or an epidemic disease (n. )

EPIDEMIOLOGY:

An area of the medical sciences devoted to the study of disease, including its incidence, distribution, and control within a population.

ETIOLOGY:

A branch of medical study concerned with the causes and origins of disease; also, a general term referring to all the causes of a particular disease or condition.

EXOGENOUS:

A term for an infection that originates outside the body. Compare with endogenous.

GENE:

A unit of information about a particular heritable (capable of being inherited) trait that is passed from parent to offspring, stored in DNA molecules called chromosomes.

GERM THEORY:

A theory in medicine, widely accepted today, that infections, contagious diseases, and other conditions are caused by the actions of microorganisms.

IMMUNITY:

The condition of being able to resist a particular disease, particularly through means that prevent the growth and development of pathogens or counteract their effects.

IMMUNOLOGY:

The study of the immune system, immunity, and immune responses.

INFECTION:

A state or condition in which parasitic organisms attach them selves to the body or to the inside of the body of another organism, producing contamination and disease in the host.

INOCULATION:

The prevention of a disease by the introduction to the body, in small quantities, of the virus or other microorganism that causes the disease.

MUTATION:

Alteration in the physical structure of an organism's DNA, resulting in a genetic change that can be inherited.

PANDEMIC:

Affecting an extremely high proportion of a population over a wide geographic area (adj. ) or a disease of pandemic proportions (n. )

PARASITE:

A general term for any organism that depends on another organism for support, which it receives at the expense of the other organism.

PARASITOLOGY:

A biological discipline devoted to the study of parasites, primarily those among the animal and protist kingdoms. Parasitic bacteria, fungi, and viruses usually are studied within the context of infectious diseases.

PATHOGEN:

A disease-carrying para site, typically a microorganism.

PATHOLOGY:

The study of the essential nature of diseases.

PUBLIC HEALTH:

A set of policies and methods for protecting and improving the health of a community through efforts that include disease prevention, health education, and sanitation.

RNA:

Ribonucleic acid, the molecule translated from DNA in the cell nucleus, the control center of the cell, that directs protein synthesis in the cytoplasm, or the space between cells.

VACCINE:

A preparation containing microorganisms, usually either weakened or dead, which is administered as a means of increasing immunity to the disease caused by those microorganisms.

VECTOR:

An organism, such as an insect, that transmits a pathogen to the body of a host.

Infection Control

Definition

Infection control refers to policies and procedures used to minimize the risk of spreading infections, especially in hospitals and human or animal health care facilities.

Purpose

The purpose of infection control is to reduce the occurrence of infectious diseases. These diseases are usually caused by bacteria or viruses and can be spread by human to human contact, animal to human contact, human contact with an infected surface, airborne transmission through tiny droplets of infectious agents suspended in the air, and, finally, by such common vehicles as food or water. Diseases that are spread from animals to humans are known as zoonoses; animals that carry disease agents from one host to another are known as vectors.

Infection control in hospitals and other health care settings

Infections contracted in hospitals are also called nosocomial infections. They occur in approximately 5% of all hospital patients. These infections result in increased time spent in the hospital and, in some cases, death. There are many reasons nosocomial infections are common, one of which is that many hospital patients have a weakened immune system which makes them more susceptible to infections. This weakened immune system can be caused either by the patient's diseases or by treatments given to the patient. Second, many medical procedures can increase the risk of infection by introducing infectious agents into the patient. Thirdly, many patients are admitted to hospitals because of infectious disease. These infectious agents can then be transferred from patient to patient by hospital workers or visitors.

Infection control has become a formal discipline in the United States since the 1950s, due to the spread of staphylococcal infections in hospitals. Because there is both the risk of health care providers acquiring infections themselves, and of them passing infections on to patients, the Centers for Disease Control and Prevention (CDC) established guidelines for infection control procedures. In addition to hospitals, infection control is important in nursing homes, clinics, child care centers, and restaurants, as well as in the home.

To lower the risk of nosocomial infections, the CDC began a national program of hospital inspection in 1970 known as the National Nosocomial Infections Surveillance system, or NNIS. The CDC reported that over 300 hospitals participate in the NNIS system as of the early 2000s. Data collected from the participating hospitals show that infection control programs can siginificantly improve patient safety, lower infection rates, and lower patient mortality.

Dental health care settings are similar to hospitals in that both personnel and equipment can transmit infection if proper safeguards are not observed. The CDC issued new guidelines in 2003 for the proper maintenance and sterilization of dental equipment, hand hygiene for dentists and dental hygienists, dental radiology, medications, and oral surgery, environmental infection control, and standards for dental laboratories.

The newest addition to the infection control specialist's resources is molecular typing, which speeds up the identification of a disease agent. Rapid identification in turn allows for timely containment of a disease outbreak.

ELIZABETH LEE HAZEN (1885–1975)

Elizabeth Lee Hazen was born on August 24, 1885, in Rich, Mississippi. Hazen, born the middle of three children to Maggie (Harper) and William Edgar Hazen, was orphaned before she turned four. She and her sister went to live with their aunt and uncle shorly after her younger brother died. Hazen attended the Mississippi Industrial Institute and College at Columbus, receiving her B.S. degree in 1910. During college, Hazen became interested in science and she studied biology at Columbia University, earning her M.S. in 1917. After working in the U.S. Army laboratories during World War I, she returned to Columbia where she received her Ph.D. in microbiology in 1927. Following her work as an instructor at Columbia, Hazen accepted a position with the New York Department of Health where she researched bacterial diseases.

In 1948, Hazen and Rachel Brown began researching fungal infections found in humans due to antibiotic treatments and diseases. Some of the antibiotics they discovered did indeed kill the fungus; however, they also killed the test mice. Finally, Hazen located a micro-organism on a farm in Virginia, and Brown's tests indicated that the microorganism produced two antibiotics, one of which proved effective for treating fungus and candidiasis in humans. Brown purified the antibiotic which was patented under the name nystatin. In 1954, the antibiotic became available in pill form. Hazen and Brown continued their research and discovered two other antibiotics. Hazen received numerous awards individually and with her research partner, Rachel Brown. Elizabeth Hazen passed away on June 24, 1975.

Threat of emerging infectious diseases

Due to constant changes in our lifestyles and environments, new diseases are constantly appearing that people are susceptible to, making protection from the threat of infectious disease urgent. Many new contagious diseases have been identified in the past 30 years, such as AIDS, Ebola, and hantavirus. Increased travel between continents makes the worldwide spread of disease a bigger concern than it once was. Additionally, many common infectious diseases have become resistant to known treatments.

The emergence of the severe acute respiratory syndrome (SARS) epidemic in Asia in February 2003 was a classic instance of an emerging disease that spread rapidly because of the increased frequency of international and intercontinental travel. In addition, the SARS outbreak demonstrated the vulnerability of hospitals and health care workers to emerging diseases. Clusters of cases within hospitals occurred in the early weeks of the epidemic when the disease had not yet been recognized and the first SARS patients were admitted without isolation precautions.

The SARS epidemic also raised a number of ethical and legal questions regarding current attitudes toward infection control.

Problems of antibiotic resistance

Because of the overuse of antibiotics, many bacteria have developed a resistance to common antibiotics. This means that newer antibiotics must continually be developed in order to treat an infection. However, further resistance seems to come about almost simultaneously. This indicates to many scientists that it might become more and more difficult to treat infectious diseases. The use of antibiotics outside of medicine also contributes to increased antibiotic resistance. One example of this is the use of antibiotics in animal husbandry. These negative trends can only be reversed by establishing a more rational use of antibiotics through treatment guidelines.

Bioterrorism

The events of September 11, 2001, and the anthrax scare that followed in October 2001 alerted public health officials as well as the general public to the possible use of infectious disease agents as weapons of terrorism. The Centers for Disease Control and Prevention (CDC) now has a list of topics and resources related to bioterrorism on its web site.

Description

The goals of infection control programs are: immunizing against preventable diseases, defining precautions that can prevent exposure to infectious agents, and restricting the exposure of health care workers to an infectious agent. An infection control practitioner is a specially trained professional, oftentimes a nurse, who oversees infection control programs.

Commonly recommended precautions to avoid and control the spread of infections include:

• Vaccinate people and pets against diseases for which a vaccine is available. As of 2003, the vaccines used against infectious diseases are very safe compared to most drugs.
• Wash hands often.
• Cook food thoroughly.
• Use antibiotics only as directed.
• See a doctor for infections that do not heal.
• Avoid areas with a lot of insects.
• Be cautious around wild or unfamiliar animals, or any animals that are unusually aggressive. Do not purchase exotic animals as pets.
• Do not engage in unprotected sex or in intravenous drug use.
• Find out about infectious diseases when you make travel plans. Travelers' advisories and adult vaccination recommendations are available on the CDC web site or by calling the CDC's telephone service at 404-332-4559.

Because of the higher risk of spreading infectious disease in a hospital setting, higher levels of precautions are taken there. Typically, health care workers wear gloves with all patients, since it is difficult to know whether a transmittable disease is present or not. Patients who have a known infectious disease are isolated to decrease the risk of transmitting the infectious agent to another person. Hospital workers who come in contact with infected patients must wear gloves and gowns to decrease the risk of carrying the infectious agent to other patients. All articles of equipment that are used in an isolation room are decontaminated before reuse. Patients who are immunocompromised may be put in protective isolation to decrease the risk of infectious agents being brought into their room. Any hospital worker with infections, including colds, are restricted from that room.

Hospital infections can also be transmitted through the air. Thus care must be taken when handling infected materials so as to decrease the numbers of infectious agents that become airborne. Special care should also taken with hospital ventilation systems to prevent recirculation of contaminated air.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Immunizations for Adults." Section 13, Chapter 152. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Ashford, D. A., R. M. Kaiser, M. E. Bales, et al. "Planning Against Biological Terrorism: Lessons from Outbreak Investigations." Emerging Infectious Diseases 9 (May 2003): 515-519.

Gostin, L. O., R. Bayer, and A. L. Fairchild. "Ethical and Legal Challenges Posed by Severe Acute Respiratory Syndrome: Implications for the Control of Severe Infectious Disease Threats." Journal of the American Medical Association 290 (December 24, 2003): 3229-3237.

Ho, P. L., X. P. Tang, and W. H. Seto. "SARS: Hospital Infection Control and Admission Strategies." Respirology 8, Supplement (November 2003): S41-S45.

Jacobson, R. M., K. S. Zabel, and G. A. Poland. "The Overall Safety Profile of Currently Available Vaccines Directed Against Infectious Diseases." Expert Opinion on Drug Safety 2 (May 2003): 215-223.

Jarvis, W. R. "Benchmarking for Prevention: the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance (NNIS) System Experience." Infection 31, Supplement 2 (December 2003): 44-48.

Kohn, W. G., A. S. Collins, J. L. Cleveland, et al. "Guidelines for Infection Control in Dental Health-Care Settings—2003." Morbidity and Mortality Weekly Reports: Reports and Recommendations 52, RR-17 (December 19, 2003): 1-61.

Peng, P. W., D. T. Wong, D. Bevan, and M. Gardam. "Infection Control and Anesthesia: Lessons Learned from the Toronto SARS Outbreak." Canadian Journal of Anaesthesiology 50 (December 2003): 989-997.

Petrak, R. M., D. J. Sexton, M. L. Butera, et al. "The Value of an Infectious Diseases Specialist." Clinical Infectious Diseases 36 (April 15, 2003): 1013-1017.

Sehulster, L., and R. Y. Chinn. "Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)." Morbidity and Mortality Recommendations and Reports 52, RR-10 (June 6, 2003): 1-42.

Subramanian, D., J. A. Sandoe, V. Keer, and M. H. Wilcox. "Rapid Spread of Penicillin-Resistant Streptococcus pneumoniae Among High-Risk Hospital Inpatients and the Role of Molecular Typing in Outbreak Confirmation." Journal of Hospital Infection 54 (June 2003): 99-103.

KEY TERMS

Acquired immune deficiency syndrome (AIDS)— A disease that weakens the body's immune system. It is also known as HIV infection.

Antibiotic— A substance, such as a drug, that can stop a bacteria from growing or destroy the bacteria.

Antibiotic resistance— The ability of infectious agents to change their biochemistry in such a way as to make an antibiotic no longer effective.

Bioterrorism— The intentional use of disease-causing microbes or other biologic agents to intimidate or terrorize a civilian population for political or military reasons.

Ebola— The disease caused by the newly described and very deadly Ebola virus found in Africa.

Epidemiology— The branch of medicine that deals with the transmission of infectious diseases in large populations and with detection of the sources and causes of epidemics.

Hantavirus— A group of arboviruses that cause hemorrhagic fever (characterized by sudden onset, fever, aching and bleeding in the internal organs).

Immunization— Immunity refers to the body's ability to protect itself from a certain disease after it has been exposed to that disease. Through immunization, also known as vaccination, a small amount of an infectious agent is injected into the body to stimulate the body to develop immunity.

Immunocompromized— Refers to the condition of having a weakened immune system. This can happen due to genetic factors, drugs, or disease.

Nosocomial infection— An infection acquired in a hospital setting.

Staphylococcal infection— An infection caused by the organism Staphlococcus. Infection by this agent is common and is often resistant to antibiotics.

Vector— An animal carrier that transfers an infectious organism from one host to another.

Zoonosis (plural, zoonoses)— Any disease of animals that can be transmitted to humans under natural conditions. Lyme disease, rabies, psittacosis (parrot fever), cat-scratch fever, and monkeypox are examples of zoonoses.

ORGANIZATIONS

American College of Epidemiology. 1500 Sunday Drive, Suite 102, Raleigh, NC 27607. (919) 861-5573. 〈http://www.acepidemiology.org〉.

American Public Health Association (APHA). 800 I Street NW, Washington, DC 20001-3710. (202) 777-APHA. 〈http://www.apha.org〉.

American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173-4360. 〈http://www.avma.org〉.

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. 〈http://www.cdc.gov〉.

National Institute of Allergy and Infectious Diseases (NIAID). 31 Center Drive, Room 7A50 MSC 2520, Bethesda, MD, 20892. (301) 496-5717. 〈http://www.niaid.nih.gov〉.

Infection Control

Definition

Infection control is the protection of patients and health care workers by the prevention of infection in the health care setting in a cost-efficient manner.

Purpose

The purpose of infection control is to reduce the risk of health care worker exposure and infection and nosocomial (hospital-acquired) infections, which can complicate existing diseases or injuries.

Description

Organized efforts at infection control began in the United States in the 1950s, along with the increase in intensive care units to care for critically ill patients and the emergence of nonsocomial staphylococcal infections. Many hospitals implemented programs in the 1960s and 1970s at the insistence of various organizations. In the 1980s, state and federal agencies, along with professional organizations, began to make recommendations for infection control and require adherence to regulations.

Infection control procedures are followed in hospitals, long term care facilities, rehabilitation units, outpatient facilities, and home care. All infection control programs should encourage actions that limit the spread of nosocomial infections. All healthcare institutions are mandated by the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) to "develop specific objectives and outcome measures to determine whether or not its infection control goals have been achieved" (AJIC, 1998). Infection control programs must include the means to measure the effectiveness of procedures, policies, or programs to protect patients and health care providers and to determine if these activities are cost-effective.

Health care organizations must be in compliance with regulations and accreditation requirements by various federal and state agencies and governing bodies. JCAHO, for instance, has standards that are incorporated into many state licensing, as well as Medicare and Medicaid, regulations. The facility's administration is responsible for ensuring compliance. Ongoing education and training are an important part of an effective infection control program. Also, the monitoring of patient-care activities can identify areas of concern, and the data obtained is vital to improving the program and ensuring successes.

The Hospital Infections Program (HIP) of the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), is the focus for information, surveillance, investigation, prevention, and control of nosocomial infections for the U.S. Public Health Service, state and local health departments, hospitals, and professional organizations in the United States and around the world. Studies indicate that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only 6-9% are actually prevented. The Study of Efficacy of Nosocomial Infection Control (SENIC) carried out by HIP over ten years showed that, to be effective, nosocomial infection programs must include the following: 1) organized surveillance and control activities, 2) a ratio of one infection control practitioner for every 250 acute care beds, 3) a trained hospital epidemiologist, and 4) a system for reporting surgical wound infection rates back to surgeons (NNIS, 1996). The National Nosocomial Infections Surveillance (NNIS) System has been gathering information for 20 years regarding nosocomial infections. This information is being used to assist hospitals in conducting successful surveillance of these infections.

In 1987, the Centers for Disease Control (CDC) expanded previous recommendations to prevent the spread of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. Previously, certain isolation precautions were recommended only for those patients who were known or suspected to have bloodborne infectious diseases. Because of the growing number of persons infected with HIV and the high mortality rates associated with AIDS, Universal Blood and Body Fluids Precautions were developed. Under these new recommendations, all patients are considered potentially infectious for bloodborne infections. In 1991, the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogen Standard required the use of universal precautions and dictated that all staff must be trained annually on the risk of exposure to bloodborne pathogens. Preventing exposure is the best and safest way to reduce infection.

The effectiveness of infection control programs are evaluated in several ways: lower rates of infection for the patient, shorter periods of hospital stays, decreased morbidity, and reduction of on-the-job exposure of health care workers to infection and contamination from patients. To do this, infection control policies focus on strategies for isolation, barrier precautions, case investigation, health care worker education, immunization services, and employee health programs. When healthcare institutions are successful in their infection control programs, it decreases the cost of care and has a positive impact on the institution's image within the community.

It is the responsibility of infection control to identify problems, collect and analyze data, change policies and procedures when necessary, and monitor data. The specific functions of an infection control program should be based on the needs of the individual healthcare institution. It is most important to monitor infection activity. Data is collected and disseminated based on the principles of epidemiology to implement quality-improvement activities and improve patient outcomes. Policies and procedures of the facility must be based on scientific and valid infection control prevention and be reviewed and updated frequently to reflect practice guidelines and standards.

Transmission of infection within a health care organization requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism. The skin of patients and personnel can function as a reservoir for infectious agents and as a vehicle for transfer of infectious agents to susceptible persons. The microbial flora of the skin consists of resident and transient microorganisms. Resident microorganisms persist and multiply on the skin. Transient microorganisms are contaminants that can survive for only a limited period of time. Most resident microorganisms are found in superficial skin layers, but about 10-20% inhabit deep epidermal layers. Handwashing with plain soaps is effective in removing many transient microorganisms. Resident microorganisms in the deep layers may not be removed by handwashing with plain soaps, but usually can be killed or inhibited by antimicrobial products. Handwashing is the single most important measure for preventing nosocomial infections.

Hand-washing indications

Health care workers should wash their hands:

• after removing gloves
• when coming on duty
• when hands are soiled, including after sneezing, coughing, or blowing the nose
• between patient contacts
• before medication preparation
• after personal use of the toilet
• before performing invasive procedures
• before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns
• before and after touching wounds
• before and after eating
• after touching inanimate objects that are likely to be contaminated with pathogenic microorganisms, such as urine-measuring devices and secretion collection apparatuses
• after taking care of infected patients or patients who are likely to be colonized with microorganisms of special clinical or epidemiologic significance; for example, bacteria that are resistant to multiple antibiotics

Preparation

Routine hand-washing is accomplished by vigorously rubbing together all surfaces of lathered hands followed by thorough rinsing under a stream of water. This should take 10-15 seconds to complete. The hands should be dried with a paper towel. Immediate recontamination of the hands by touching sink fixtures may be avoided by using a paper towel to turn off faucets.

Universal precautions recommend that all health care workers who come into contact with a patient's blood or body fluids that contain visible blood should wear an appropriate type of barrier to prevent the spread of blood-borne pathogens. Other body fluids for which barrier protection is recommended include semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, pericardial fluid, and amniotic fluid. The type of exposure determines the specific barrier that should be used. Universal precautions are designed to augment, not replace, standard infection control procedures such as hand washing and the use of gloves when touching obviously infected materials.

Adequate routine cleaning and removal of soil should be the environmental sanitation procedure for all healthcare facilities. Microorganisms are normal contaminants of the environment. A healthcare facility's environmental services department should maintain schedules for routine cleaning in all rooms and include equipment and working surfaces. General and infectious wastes are disposed of on a regular schedule. All departments, though, are responsible for implementing infection control policies.

Complications

Health care workers must not be complacent about implementing their facility's infection control policies. Perhaps due to long time-exposure to occupationally acquired infections, they have the tendency to minimize or ignore the ramifications. Infections oftentimes go undetected, underreported, or overlooked by health care workers.

Results

If infection control programs are successful, the result will be a reduction in the risk of infection and related adverse outcomes in the healthcare setting, achieved in a cost-efficient manner.

Health care team roles

Much of the responsibility for infection control rests on the shoulders of the clinical staff providing care at the bedside. Because nurses are close to the patient physically, they are able to prevent the spread of infection, but they can also be a means of transmitting infection. Therefore they need to foster compliance with infection control policies to ensure a high quality outcome for the patient. Infection control practices should have a positive effect on not only the clinical staff, but the patient as well.

Resources

BOOKS

Jennings, J., and F. Manian. APIC Handbook of Infection Control. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology, 1999.

PERIODICALS

Barrs, A. "Infection Control Across the Board." Nursing Homes Long Term Care Management 49, Issue 11 (November 2000):38.

Henderson, D. "Raising the Bar: The Need for Standardizing the Use of 'Standard Precautions' as a Primary Intervention to Prevent Occupational Exposures to Bloodborne Pathogens." Infection Control and Hospital Epidemiology 22 (February 2001):6.

Heseltine, P. "Why Don't Doctors and Nurses Wash Their Hands?" Infection Control and Hospital Epidemiology 22 (April 2001):4.

Hood, R., and D. Olesen. "Re-evaluating the Role of the Clinical Nurse in Minimizing Health Care Related Infection." Australian Nursing Journal 8 (October 2000):1.

Rello, J. "Impact of Nosocomial Infections on Outcome: Myths and Evidence." Infection Control and Hospital Epidemiology 20 (June 1999):6.

"Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report." Infection Control and Epidemiology 19 (1998):114-124.

Shimkins, J. "Making the Grade." Health Facilities Management 1 (January 1999):18.

Stratton, C. "Occupationally Acquired Infections: A Timely Reminder." Infection Control and Hospital Epidemiology (January 2001):22.

ORGANIZATIONS

Hospital Infections Program. Centers for Disease Control and Prevention. 1600 Clifton Road, Atlanta, GA 30333. 〈http://www.cdc.gov/ncidod/publications/brochures/hip.htm〉.

OTHER

Infection Control: Hand-Washing and Antisepsis. Johns Hopkins University. 2001.

Infection control

Definition

Infection control is the protection of patients and health care workers by the prevention of infection in the health care setting in a cost-efficient manner.

Purpose

The purpose of infection control is to reduce the risk of health care worker exposure and infection and nosocomial (hospital-acquired) infections, which can complicate existing diseases or injuries.

Description

Organized efforts at infection control began in the United States in the 1950s, along with the increase in intensive care units to care for critically ill patients and the emergence of nonsocomial staphylococcal infections . Many hospitals implemented programs in the 1960s and 1970s at the insistence of various organizations. In the 1980s, state and federal agencies, along with professional organizations, began to make recommendations for infection control and require adherence to regulations.

Infection control procedures are followed in hospitals, long term care facilities, rehabilitation units, outpatient facilities, and home care . All infection control programs should encourage actions that limit the spread of nosocomial infections. All healthcare institutions are mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to "develop specific objectives and outcome measures to determine whether or not its infection control goals have been achieved" (AJIC, 1998). Infection control programs must include the means to measure the effectiveness of procedures, policies, or programs to protect patients and health care providers and to determine if these activities are cost-effective.

Health care organizations must be in compliance with regulations and accreditation requirements by various federal and state agencies and governing bodies. JCAHO, for instance, has standards that are incorporated into many state licensing, as well as Medicare and Medicaid , regulations. The facility's administration is responsible for ensuring compliance. Ongoing education and training are an important part of an effective infection control program. Also, the monitoring of patient-care activities can identify areas of concern, and the data obtained is vital to improving the program and ensuring successes.

The Hospital Infections Program (HIP) of the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), is the focus for information, surveillance, investigation, prevention, and control of nosocomial infections for the U.S. Public Health Service, state and local health departments, hospitals, and professional organizations in the United States and around the world. Studies indicate that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only 6-9% are actually prevented. The Study of Efficacy of Nosocomial Infection Control (SENIC) carried out by HIP over ten years showed that, to be effective, nosocomial infection programs must include the following: 1) organized surveillance and control activities, 2) a ratio of one infection control practitioner for every 250 acute care beds, 3) a trained hospital epidemiologist, and 4) a system for reporting surgical wound infection rates back to surgeons (NNIS, 1996). The National Nosocomial Infections Surveillance (NNIS) System has been gathering information for 20 years regarding nosocomial infections. This information is being used to assist hospitals in conducting successful surveillance of these infections.

In 1987, the Centers for Disease Control (CDC) expanded previous recommendations to prevent the spread of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. Previously, certain isolation precautions were recommended only for those patients who were known or suspected to have bloodborne infectious diseases. Because of the growing number of persons infected with HIV and the high mortality rates associated with AIDS , Universal Blood and Body Fluids Precautions were developed. Under these new recommendations, all patients are considered potentially infectious for bloodborne infections. In 1991, the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogen Standard required the use of universal precautions and dictated that all staff must be trained annually on the risk of exposure to bloodborne pathogens. Preventing exposure is the best and safest way to reduce infection.

The effectiveness of infection control programs are evaluated in several ways: lower rates of infection for the patient, shorter periods of hospital stays, decreased morbidity, and reduction of on-the-job exposure of health

care workers to infection and contamination from patients. To do this, infection control policies focus on strategies for isolation, barrier precautions, case investigation, health care worker education, immunization services, and employee health programs. When healthcare institutions are successful in their infection control programs, it decreases the cost of care and has a positive impact on the institution's image within the community.

It is the responsibility of infection control to identify problems, collect and analyze data, change policies and procedures when necessary, and monitor data. The specific functions of an infection control program should be based on the needs of the individual healthcare institution. It is most important to monitor infection activity. Data is collected and disseminated based on the principles of epidemiology to implement quality-improvement activities and improve patient outcomes. Policies and procedures of the facility must be based on scientific and valid infection control prevention and be reviewed and updated frequently to reflect practice guidelines and standards.

(Public Domain.)

Transmission of infection within a health care organization requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism. The skin of patients and personnel can function as a reservoir for infectious agents and as a vehicle for transfer of infectious agents to susceptible persons. The microbial flora of the skin consists of resident and transient microorganisms. Resident microorganisms persist and multiply on the skin. Transient microorganisms are contaminants that can survive for only a limited period of time. Most resident microorganisms are found in superficial skin layers, but about 10-20% inhabit deep epidermal layers. Handwashing with plain soaps is effective in removing many transient microorganisms. Resident microorganisms in the deep layers may not be removed by hand-washing with plain soaps, but usually can be killed or inhibited by antimicrobial products. Handwashing is the single most important measure for preventing nosocomial infections.

Hand-washing indications

Health care workers should wash their hands:

• after removing gloves
• when coming on duty
• when hands are soiled, including after sneezing, coughing, or blowing the nose
• between patient contacts
• before medication preparation
• after personal use of the toilet
• before performing invasive procedures
• before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns
• before and after touching wounds
• before and after eating
• after touching inanimate objects that are likely to be contaminated with pathogenic microorganisms, such as urine-measuring devices and secretion collection apparatuses
• after taking care of infected patients or patients who are likely to be colonized with microorganisms of special clinical or epidemiologic significance; for example, bacteria that are resistant to multiple antibiotics

Preparation

Routine hand-washing is accomplished by vigorously rubbing together all surfaces of lathered hands followed by thorough rinsing under a stream of water. This should take 10-15 seconds to complete. The hands should be dried with a paper towel. Immediate recontamination of the hands by touching sink fixtures may be avoided by using a paper towel to turn off faucets.

Universal precautions recommend that all health care workers who come into contact with a patient's blood or body fluids that contain visible blood should wear an appropriate type of barrier to prevent the spread of blood-borne pathogens. Other body fluids for which barrier protection is recommended include semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, pericardial fluid, and amniotic fluid. The type of exposure determines the specific barrier that should be used. Universal precautions are designed to augment, not replace, standard infection control procedures such as hand washing and the use of gloves when touching obviously infected materials.

Adequate routine cleaning and removal of soil should be the environmental sanitation procedure for all healthcare facilities. Microorganisms are normal contaminants of the environment. A healthcare facility's environmental services department should maintain schedules for routine cleaning in all rooms and include equipment and working surfaces. General and infectious wastes are disposed of on a regular schedule. All departments, though, are responsible for implementing infection control policies.

Complications

Health care workers must not be complacent about implementing their facility's infection control policies. Perhaps due to long-time exposure to occupationally acquired infections, they have the tendency to minimize or ignore the ramifications. Infections oftentimes go undetected, underreported, or overlooked by health care workers.

Results

If infection control programs are successful, the result will be a reduction in the risk of infection and related adverse outcomes in the healthcare setting, achieved in a cost-efficient manner.

Health care team roles

Much of the responsibility for infection control rests on the shoulders of the clinical staff providing care at the bedside. Because nurses are close to the patient physically, they are able to prevent the spread of infection, but they can also be a means of transmitting infection. Therefore they need to foster compliance with infection control policies to ensure a high quality outcome for the patient. Infection control practices should have a positive effect on not only the clinical staff, but the patient as well.

Resources

BOOKS

Jennings, J., and F. Manian. APIC Handbook of Infection Control. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology, 1999.

PERIODICALS

Barrs, A. "Infection Control Across the Board." Nursing Homes Long Term Care Management 49, Issue 11 (November 2000):38.

Henderson, D. "Raising the Bar: The Need for Standardizing the Use of "Standard Precautions" as a Primary Intervention to Prevent Occupational Exposures to Bloodborne Pathogens." Infection Control and Hospital Epidemiology 22 (February 2001):6.

Heseltine, P. "Why Don't Doctors and Nurses Wash Their Hands?" Infection Control and Hospital Epidemiology 22 (April 2001):4.

Hood, R., and D. Olesen. "Re-evaluating the Role of the Clinical Nurse in Minimizing Health Care Related Infection." Australian Nursing Journal (8 October 2000):1.

Rello, J. "Impact of Nosocomial Infections on Outcome: Myths and Evidence." Infection Control and Hospital Epidemiology 20 (June 1999):6.

"Requirements For Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report." Infection Control and Epidemiology 19 (1998):114-124.

Shimkins, J. "Making the Grade." Health Facilities Management 1 (January 1999):18.

Stratton, C. "Occupationally Acquired Infections: A Timely Reminder." Infection Control and Hospital Epidemiology (January 2001):22.

ORGANIZATIONS

Hospital Infections Program. Center for Disease Control and Prevention. 1600 Clifton Road, Atlanta, GA 30333. <http://www.cdc.gov/ncidod/publications/brochures/hip.htm>.

OTHER

Infection Control: Hand-Washing and Antisepsis. Johns Hopkins University. 2001.

René A. Jackson, RN

Infection control

Definition

Infection control is the protection of patients and health care workers by the prevention of infection in the health care setting in a cost-efficient manner.

Purpose

The purpose of infection control is to reduce the risk of health care worker exposure and infection and nosocomial (hospital-acquired) infections, which can complicate existing diseases or injuries.

Description

Organized efforts at infection control began in the United States in the 1950s, along with the increase in intensive care units to care for critically ill patients and the emergence of nonsocomial staphylococcal infections . Many hospitals implemented programs in the 1960s and 1970s at the insistence of various organizations. In the 1980s, state and federal agencies, along with professional organizations, began to make recommendations for infection control and require adherence to regulations.

Infection control procedures are followed in hospitals, long term care facilities, rehabilitation units, outpatient facilities, and home care . All infection control programs should encourage actions that limit the spread of nosocomial infections. All healthcare institutions are mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to “develop specific objectives and outcome measures to determine whether or not its infection control goals have been achieved” (AJIC, 1998). Infection control programs must include the means to measure the effectiveness of procedures, policies, or programs to protect patients and health care providers and to determine if these activities are cost-effective.

Health care organizations must be in compliance with regulations and accreditation requirements by various federal and state agencies and governing bodies. JCAHO, for instance, has standards that are incorporated into many state licensing, as well as Medicare and Medicaid , regulations. The facility's administration is responsible for ensuring compliance. Ongoing education and training are an important part of an effective infection control program. Also, the monitoring of patient-care activities can identify areas of concern, and the data obtained is vital to improving the program and ensuring successes.

The Hospital Infections Program (HIP) of the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC), is the focus for information, surveillance, investigation, prevention, and control of nosocomial infections for the U.S. Public Health Service, state and local health departments, hospitals, and professional organizations in the United States and around the world. Studies indicate that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only 6–9% are actually prevented. The Study of Efficacy of Nosocomial Infection Control (SENIC) carried out by HIP over ten years showed that, to be effective, nosocomial infection programs must include the following: 1) organized surveillance and control activities, 2) a ratio of one infection control practitioner for every 250 acute care beds, 3) a trained hospital epidemiologist, and 4) a system for reporting surgical wound infection rates back to surgeons (NNIS, 1996). The National Nosocomial Infections Surveillance (NNIS) System has been gathering information for 20 years regarding nosocomial infections. This information is being used to assist hospitals in conducting successful surveillance of these infections.

In 1987, the Centers for Disease Control (CDC) expanded previous recommendations to prevent the spread of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. Previously, certain isolation precautions were recommended only for those patients who were known or suspected to have bloodborne infectious diseases. Because of the growing number of persons infected with HIV and the high mortality rates associated with AIDS , Universal Blood and Body Fluids Precautions were developed. Under these new recommendations, all patients are considered potentially infectious for bloodborne infections. In 1991, the Occupational Safety and Health Administration's (OSHA) Bloodborne Pathogen Standard required the use of universal precautions and dictated that all staff must be trained annually on the risk of exposure to bloodborne pathogens. Preventing exposure is the best and safest way to reduce infection.

The effectiveness of infection control programs are evaluated in several ways: lower rates of infection for the patient, shorter periods of hospital stays, decreased morbidity, and reduction of on-the-job exposure of health care workers to infection and contamination from patients. To do this, infection control policies focus on strategies for isolation, barrier precautions, case investigation, health care worker education, immunization services, and employee health programs. When healthcare institutions are successful in their infection control programs, it decreases the cost of care and has a positive impact on the institution's image within the community.

It is the responsibility of infection control to identify problems, collect and analyze data, change policies and procedures when necessary, and monitor data. The specific functions of an infection control program should be based on the needs of the individual healthcare institution. It is most important to monitor infection activity. Data is collected and disseminated based on the principles of epidemiology to implement quality-improvement activities and improve patient outcomes. Policies and procedures of the facility must be based on scientific and valid infection control prevention and be reviewed and updated frequently to reflect practice guidelines and standards.

Transmission of infection within a health care organization requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism. The skin of patients and personnel can function as a reservoir for infectious agents and as a vehicle for transfer of infectious agents to susceptible persons. The microbial flora of the skin consists of resident and transient microorganisms. Resident microorganisms persist and multiply on the skin. Transient microorganisms are contaminants that can survive for only a limited period of time. Most resident microorganisms are found in superficial skin layers, but about 10–20% inhabit deep epidermal layers. Handwashing with plain soaps is effective in removing many transient microorganisms. Resident microorganisms in the deep layers may not be removed by handwashing with plain soaps, but usually can be killed or inhibited by antimicrobial products. Handwashing is the single most important measure for preventing nosocomial infections.

Hand-washing indications

Health care workers should wash their hands:

• after removing gloves
• when coming on duty
• when hands are soiled, including after sneezing, coughing, or blowing the nose
• between patient contacts
• before medication preparation
• after personal use of the toilet
• before performing invasive procedures
• before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns
• before and after touching wounds
• before and after eating
• after touching inanimate objects that are likely to be contaminated with pathogenic microorganisms, such as urine-measuring devices and secretion collection apparatuses
• after taking care of infected patients or patients who are likely to be colonized with microorganisms of special clinical or epidemiologic significance; for example, bacteria that are resistant to multiple antibiotics

Preparation

Routine hand-washing is accomplished by vigorously rubbing together all surfaces of lathered hands followed by thorough rinsing under a stream of water. This should take 10-15 seconds to complete. The hands should be dried with a paper towel. Immediate recontamination of the hands by touching sink fixtures may be avoided by using a paper towel to turn off faucets.

Universal precautions recommend that all health care workers who come into contact with a patient's blood or body fluids that contain visible blood should wear an appropriate type of barrier to prevent the spread of blood-borne pathogens. Other body fluids for which barrier protection is recommended include semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, pericardial fluid, and amniotic fluid. The type of exposure determines the specific barrier that should be used. Universal precautions are designed to augment, not replace, standard infection control procedures such as hand washing and the use of gloves when touching obviously infected materials.

Adequate routine cleaning and removal of soil should be the environmental sanitation procedure for all healthcare facilities. Microorganisms are normal contaminants of the environment. A healthcare facility's environmental services department should maintain schedules for routine cleaning in all rooms and include equipment and working surfaces. General and infectious wastes are disposed of on a regular schedule. All departments, though, are responsible for implementing infection control policies.

Complications

Health care workers must not be complacent about implementing their facility's infection control policies. Perhaps due to long time-exposure to occupationally acquired infections, they have the tendency to minimize or ignore the ramifications. Infections oftentimes go undetected, underreported, or overlooked by health care workers.

Results

If infection control programs are successful, the result will be a reduction in the risk of infection and related adverse outcomes in the healthcare setting, achieved in a cost-efficient manner.

Caregiver concerns

Much of the responsibility for infection control rests on the shoulders of the clinical staff providing care at the bedside. Because nurses are close to the patient physically, they are able to prevent the spread of infection, but they can also be a means of transmitting infection. Therefore they need to foster compliance with infection control policies to ensure a high quality outcome for the patient. Infection control practices should have a positive effect on not only the clinical staff, but the patient as well.

Resources

BOOKS

Jennings, J., and F. Manian. APIC Handbook of Infection Control. Washington, D.C.: Association for Professionals in Infection Control and Epidemiology, 1999.

PERIODICALS

Barrs, A. “Infection Control Across the Board.” Nursing Homes Long Term Care Management 49, Issue 11 (November 2000):38.

Henderson, D. “Raising the Bar: The Need for Standardizing the Use of ‘Standard Precautions’ as a Primary Intervention to Prevent Occupational Exposures to Bloodborne Pathogens.” Infection Control and Hospital Epidemiology 22 (February 2001):6.

Heseltine, P. “Why Don't Doctors and Nurses Wash Their Hands?” Infection Control and Hospital Epidemiology 22 (April 2001):4.

Hood, R., and D. Olesen. “Re-evaluating the Role of the Clinical Nurse in Minimizing Health Care Related Infection.” Australian Nursing Journal 8 (October 2000):1.

Rello, J. “Impact of Nosocomial Infections on Outcome: Myths and Evidence.” Infection Control and Hospital Epidemiology 20 (June 1999):6.

“Requirements for Infrastructure and Essential Activities of Infection Control and Epidemiology in Hospitals: A Consensus Panel Report.” Infection Control and Epidemiology 19 (1998):114–124.

Shimkins, J. “Making the Grade.” Health Facilities Management 1 (January 1999):18.

Stratton, C. “Occupationally Acquired Infections: A Timely Reminder.” Infection Control and Hospital Epidemiology (January 2001):22.

ORGANIZATIONS

Hospital Infections Program. Centers for Disease Control and Prevention. 1600 Clifton Road, Atlanta, GA 30333. http://www.cdc.gov/ncidod/publications/brochures/hip.htm.

OTHER

Infection Control: Hand-Washing and Antisepsis. Johns Hopkins University. 2001.

René A. Jackson RN