Guide to Infection Control
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Guide to Infection Control in the Hospital, 3rd Edition

Guide to Infection Control cover The latest edition of A Guide to Infection Control in the Hospital is now available. This handy pocket-sized manual contains 50 chapters that explain key principles and guidelines for reducing the rate of nosocomial infections and practical measures intended to improve quality of care, minimize risk, save lives, and reduce costs.

In developed countries, about 5 to 10% of patients admitted to acute care hospitals acquire an infection which was not present or incubating on admission. The rate for developing countries can exceed 25%. Such hospital-acquired, or nosocomial, infections add to the morbidity, mortality, and costs expected from the patients' underlying diseases alone.

Because the illnesses, deaths, and added costs incurred by nosocomial infections are preventable, the field of infection control has grown in importance over the last 30 years. Although estimates of the proportion of preventable nosocomial infections vary, it may be as high as 20% in developed countries and as high as 40% or more in developing countries.

Furthermore, in developed countries 5 to 10% of infections acquired in the hospital occur as part of an epidemic or cluster. The figure is larger for developing countries. The major point, however, is that all epidemics or clusters are preventable, and the opportunities are excellent for limiting the occurrence of such infections. What is required is attention to the basic principles of infection control. In response, the Society's Infection Control Working Group has developed A Guide to Infection Control in the Hospital.

The English print version of the Guide may be purchased directly through the Society. The 2nd edition of the Guide is available in Spanish. Individuals from developing countries may receive the Guide free of charge upon request by contacting ISID directly.

To contact ISID about the Guide, please send an email to

How to order the English version of the Guide:

Purchase the Guide by mail by sending payment and correspondence to the address at the bottom of the webpage.

The Infection Control Working Group intends to revise and update the Guide every two years. Feedback and comments from users of the Guide are welcome and encouraged.
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Editors, 3rd edition
Richard P. Wenzel, MD, MS, Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia, USA

Timothy F. Brewer, MD, MPH, Division of Infectious Diseases, Mt. Auburn Hospital, Cambridge, Massachusetts, USA

Jean-Paul Butzler, MD, PhD, Department of Human Ecology, Faculty of Medicine, Vrije Universiteit Brussel, Brussels, Belgium

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Table of Contents, 3rd edition

Chapter 1: Importance of Infection Control
Richard P. Wenzel, MD, MSc
Health is a high priority for any society, and infections remain a leading cause of disease globally. Infections that occur among hospitalized patients and become manifest only after 48 hours of stay are called "nosocomial."

Chapter 2: Organization
Richard P. Wenzel, MD, MSc
A necessary feature for a successful program in infection control is dedicated leadership that creates a culture for excellence.

Chapter 3: Role of the Microbiology Laboratory in Infection Control
Mohamed Benbachir, PhD
The microbiology laboratory plays an important role in the surveillance, treatment, control, and prevention of nosocomial infections.

Chapter 4: The Hospital Environment
William A. Rutala, PhD, MPH and David J. Weber, MD, MPH
In the last 25 years, accumulating evidence shows that enviornmental sources within the hospital are the primary reservoirs of nosocomial pathogens for hospitalized patients.

Chapter 5: Waste Management
Mussaret Zaidi, MD
Infectious waste requires special procedures for handling, transport, and storage in order to prevent disease transmission to health care workers, waste management workers and the community.

Chapter 6: Reuse of Disposable Waste
Samuel Ponce de Leon R. MD, MSc
Reutilization of disposable devices is a common practice in most hospitals, but there are no well-founded standard guidelines to assure the quality and the safety of these procedures.

Chapter 7: Hand Hygiene
Professor Didier Pittet, MD, MS
Hand hygiene is the cornerstone of infection. Health-care workers' compliance with hand hygiene practices remains low. Enhanced compliance is associated with decreased transmission of infections.

Chapter 8: Isolation of Communicable Diseases
Bart Gordts, MD, MBA
The combination of standard precautions and isolation procedures represents an effective strategy in the fight against nosocomial transmission of infectious agents.

Chapter 9: Sterilization
Constanze Wendt, MD, MS
Critical medical devices must be sterilized and kept from being contaminated before use to avoid infections in patients exposed to them.

Chapter 10: Sterilization and Use of Sterile Products
Mussaret Zaidi, MD
Improperly disinfected medical equipment and devices can harbor microorganisms that cause infection. Environmental surfaces have been implicated in endemic as well as epidemic nosocomial infections.

Chapter 11: Is the Health Care Worker a Source of Transmission?
Margreet C. Vos, MD, Phd
Within the hospital, health care workers (HCWs) are often exposed to infections. Any transmissible disease can occur in the hospital setting and may affect HCWs. HCWs are not only at risk of acquiring infections but also of being a source of infection to patients. Therefore, both the patient and the HCW need to be protected from contracting or transmitting nosocomial infections by using recommended infection control measures.

Chapter 12: Antibiotic Resistance
Richard P. Wenzel, MD, MSc
Begun in the 1940's, the antibiotic era is only 60 years old, yet now is challenged by the worldwide incidence of resistance by microorganisms.

Chapter 13: Managing Antibiotic Resistance: What Works in the Hospital
Atef M. Shibl, MRCPath, PhD, and Ziad A. Memish, MD, CIC, FRCPC, FACP, FIDSA
Managing antibiotic resistance in hospitals requires a multifaceted prevention and control strategy. Antibiotic resistance is a primary concern for infectious diseases and infection control specialists and clinicians in hospitals around the world.

Chapter 14: Organizing and Recording Problems Including Epidemics
R. Samuel Ponce de Leon, MD, MSc
Surveillance is the foundation for organizing and maintaining an infection control program.

Chapter 15: Keeping the Environment Safe with Limited Resources
Adriano G. Duses, MT, MBBCh, DTM&H, MMed
Ever-increasing budgetary constraints and outsourcing of cleaning services have resulted in an overall deterioration in hospital hygiene practices in health-care facilities of many developing countries.

Chapter 16: Patient Areas
Constanze Wendt, MD, MS
The patient environment harbors a number of potential reservoirs for pathogens.

Chapter 17: Food
Frederick James Bolton, PhD, FRCPath
Outbreaks of foodborne infection continue to be a problem in healthcare settings, but they are preventable if all food handlers are trained to understand the sources and transmission routes of food-related pathogens and practice the basic principles of food hygiene from preparation to final serving of meals.

Chapter 18: Water
M. Sigfrido Rangel-Frausto, MD, MSc
Despite the fact that hospital water is not sterile, water sources are an uncommon source of nosocomial outbreaks.

Chapter 19: Laboratory Areas
Andreas Voss, MD, PhD, and Eric Nulens, MD
Laboratory workers are at occupational risk of exposure to microbiological pathogens that may cause inapparent to life-threatening infections. Laboratory-acquired infections are defined as all infections acquired through laboratory activities, regardless of their clinical/subclinical manifestations.

Chapter 20: The Pharmacy
Mary D. Nettleman, MD, MS and Ranjodh Gill, MD
The dissemination of infection from and to the pharmacy can be prevented. A pharmacist can play a pivotal role in reducing infection throughout the hospital.

Chapter 21: Operating Room
Marie-Claude Roy, MD, MSc
Surgical site infections (SSIs) continue to burden surgical patients with important morbidity, mortality and immense cost. Because SSIs are primarily acquired during the surgical procedure while the woulnd is opened, a number of infection control practices in the operating room merit scrutiny.

Chapter 22: Emergency Room and Receiving Areas
Heike von Baum, M,D and Richard P. Wenzel, MD, MSc
Health care workers in emergency rooms and receiving areas need to protect themselves from bloodborne infections and also recognize and attempt to isolate quickly all patients with infections posing a risk to nearby personnel, patients, and visitors.

Chapter 23: HIV Infection and AIDS in Developing Countries
Philippe Van de Perre, MD, PhD
Fewer thatn 20 years after it was first recognized in Africa, HIV infection is already the leading cause of adult deaths in many cities in developing countries and has significantly increased childhood mortality. Despite considerable efforts to control the epidemic, HIV continues to spread at a rapid pace in developing countries. Out of an estimated 42 million people infected with HIV worldwide as of December 2002, 70% of the adults and 90% of the children were living in developing countries.

Chapter 24: Tuberculosis
Timothy Brewer, MD, MPH
Tuberculosis (TB) remains one of the leading causes of preventable deaths in adults worldwide. The vast majority of TB cases and deaths occur in low-resource areas.

Chapter 25: Diarrhea
Made Sutjita, MD and Herbert L. DuPont, MD
A diarrheal disease outbreak in health care facilities may affect patients, health care workers, and visitors. Recognizing the risk factors, surveillance, and initiation of prompt infection control management practices will reduce the morbidity and mortality these diseases cause.

Chapter 26: Skin and Soft Tissue Infections
Antoni Trilla, MD, MSc
Skin and soft tissue (SST) infections are not uncommon in the hospital setting. In addition to localized complications, SST infections may cause life-threatening bacteremias or a sepsis syndrome.

Chapter 27: Bloodstream Infections
K Marhoum El Filali, and H. Himmich
Hospital acquired bloodstream infections (BSIs) are related to the underlying diagnoses and therapeutic invasive procedures. BSIs have been divided into two groups: primary BSIs, which occur without any other infectious site with the same organism at the time of BSI diagnosis (positive blood culture), and the secondary BSIs, which are subsequent to bacteremia from another infectious site.

Chapter 28: Managing Vascular Catheters
Andreas Widmer, MD, MS
Intravascular catheters are frequent sources of bloodstream infections. The prevention of these infections should be part of any infection control program. Surveillance for catheter-related bloodstream infections requires few resources compared to other nosomial infections, but has an important impact on the prevention of this most serious type of nosocomial infection.

Chapter 29: Hospital-Acquired Urinary Tract Infections
Emanuele Nicastri MD, PhD
"The decision to use the urinary catheter should be made with the knowledge that it involves risk of producing a serious disease." Even though this statement was made by Paul Beeson about fifty years ago, it is still relevant for both patients and health care workers.

Chapter 30: Pneumonia
Javier Ena, MD
Nosocomial pneumonia occures in 0.4 to 1.1% of hospitalized patients. It is the most common infection in intensive care units and the second most common cause of nosocomial infection overall.

Chapter 31: Diphtheria, Tetanus, Pertussis
Jack Levy, MD
Active immunization of the general population is effective both in controlling the transmission of these infections in the community and also of infection in the hospital.

Chapter 32: Measles
SPatrick De Mol, MD, PhD, and Phillippe Lepage, MD, PhD
Measles is caused by rubeola virus, one of the most contagious pathogenic agents known. Despite progress in global immunization, measles remains one of the major infectious causes of mortality in developing countries and is responsible for about 1 million deaths in children each year.

Chapter 33: Transfusions
Sigfrido Rangel Frausto MD, MSc, and Samuel Ponce de Leon R. MD, MSc
Although life-saving, transfusions are not infrequently associated with life-threatening complications. In the USA alone, between 10 and 12 million units are transfused every year with at least a 1% risk of complications ranging from allergic reactions to blood-borne infections.

Chapter 34: Mechanical Ventilation
Stephan Harbarth, MD and Didier Pittet, MD, MS
Mechanical ventilation is the main risk factor for nosocomial pneumonia in critically ill patients.

Chapter 35: Preparing the Patient for Surgery
Helen Giamarellou, MD
Appropriate skin preparation plus antimicrobial prophylaxis can decrease the incidence of both superficial and deep wound infections (surgical site infection) after certain operations.

Chapter 36: Infection Control in Obstetrics
J.A.J.W. Kluytmans, MD, PhD
Neonatal sepsis and postpartum endometritis can be largely prevented by simple infection control measuress. However, in developing countries, they still cause substantial morbidity and mortality. Most infections are caused by microorganisms of the mothers' vaginal flora.

Chapter 37: Infection Hazards of Human Cadavers
T.D. Healing, MCs, PhD, P.N. Hoffman , BSc, and S.E. J. Young, FRCP
Cadavers may pose hazards to those handling them. None of the organisms that caused mass death in the past (e.g., plague, cholera, typhoid, tuberculosis, anthrax, smallpox) is likely to survive long after the burial.

Chapter 38: Streptococcus Pyogenes (Group A Streptococcus) Infections
Belinda Ostrowsky, MD, MPH
Handwashing is one of the most important infection control practices for the prevention of the spread of infection with Streptococcus pyogenes (Group A Streptococcus).

Chapter 39: Staphylococcus Aureus
Bonzalo M.L.
Bearman, MD, MPH and Michael B. Edmond, MD, MPH, MPA

Staphylococcus aureus is a major human pathogen that commonly causes nosocomial and community-acquired infections. It is a highly virulent organism and is exhibiting increasing antibiotic resistance.

Chapter 40: Enterococcal Species
Michael B. Edmond, MD, MPH, MPA
Enterococci are important nosocomial pathogens because 1) they are the normal flora in the human gastrointestinal tract, 2) antimicrobial resistance allows for their survival in an environment with heavy antimicrobial usage, 3) they contaminate the hospital environment and survive for prolonged periods of time, and 4) contamination of the hands of health care workers coupled with poor handwashing compliance provides the potential for spread in the hospital.

Chapter 41: Pneumococcus
Roman Pallares, MD
Streptococcus pneumoniae (pneumococcus) remains a magor pathogen for human beings. In recent years, important changes in the epidemiology of pneumococcal infections have been observed.

Chapter 42: Legionella
Marc Struelens, MD, PhD
Nosocomial legionellosis (also called Legionnaires' disease) is a serious pneumonia caused by inhalation of Legionella in aerosols from a contaminated hospital water system. Prevention should be based on a risk management plan including targeted surveillance for cases, adequate design and manintenance of water distribution system, and adherence to appropriate respiratory care practices.

Chapter 43: Bacterial Enteric Pathogens: Salmonella, Shigella, Escherichia Coli, and Others
Awa Aidara Kane, PhD, Oliver Vandenberg, MD, Mahbubur Rahman, MD, PhD and Jean-Paul Butzler, MD, PhD
Clstridium difficile, Salmonella, Shigella, Escherichia coli, Campylobacter, Yersinia enterocolitica, Vibrio cholerae, and Vibrio parahaemolyticus are among the various agents which may cause acute gastrointestinal infections in long-term care facility residents and health care workers.

Chapter 44: Pertussis
Loreen A. Herwaldt, MD
Pertussis continues to cause significant morbidity and mortality worldwide. Several countries that stopped using the killed whole-cell vaccine suubsequently experienced large outbreaks of pertussis.

Chapter 45: Other Enterobacteriaceae
Heike von Baum, MD, Diane Franchi, MD, and Michael T. Wong, NM, MD
Enterobacteriaceae (other than enteropathogenic Salmonella, Shigella, and E. coli) are important nosocomial pathogens. More than 340 different types of beta-lactamases including extended spectrum beta-lactamases (ESBL) have been characterized in multidurg-resistant Enterobacteriaceae.

Chapter 46: Pseudomonas Aeruginosa
H. Wisplinghoff, MD, and Harald Seifert, MD
Pseudomonas aeruginosa is an important nosocomial pathogen that causes serious nosocomial infections and contributes significantly to morbidity and mortality.

Chapter 47: Helicobacter Pylori
Anne Dediste, MD, Jeanne-Marie Devaster, MD
Helicobacter pylori is the most prevalent chronic bacterial infectious agent in humans, colonizing approximately 60% of the world's population.

Chapter 48: Fungi
Sergio B. Wey, MD
The incidence of nosocomial fungal infections has increased in recent years.

Chapter 49: Viruses
M.W.H. Wulf, MD, C.M.A. Swanink, MD, PhD, and Andreas Voss, MD, PhD
Viral infections are common in the community and can cause a variety of symptoms.

Chapter 50: SARS
Richard P. Wenzel, MD, MSc
Severe acute respiratory syndrome (SARS) is the latest epidemic to challenge infection control experts. The etiology is a novel coronavirus execially capable of being transmitted in hospitals.

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