Top Prevention Protocols and Control Measures for Nosocomial Infections

Healthcare-associated infections (HAIs), also known as Nosocomial infections, hospital-associated infections, and hospital infections is currently one of the major issues for the mortality and morbidity rate to often increase. These are infections that are not present in the patient at the time of admission to the hospital but develop during the stay in the hospital. The reason for this could be due to the wide range of antibiotic uses, and the unhygienic environment of various medical clinics and hospitals. The mode of transfer of healthcare-associated infection can be either by direct or by indirect contact. The Intensive Care Unit (ICU), where doctors treat serious diseases is one of the most common wards where HAIs occur. About 1 in 10 of the people admitted to a hospital will contract an HAI, thus increasing the stay of the patient in the hospital for treatment. Nosocomial infections can be prevented by minimizing the spread of causative agents, maintaining well sanitary conditions in hospitals and the medical care unit, and isolation for the patient suffering from infectious disease.

Nosocomial diseases are those which are procured by the patient inside 48-72 h or 3 days of confirmation in the emergency clinic or medical care unit. Immuno-compromised and patients admitted to the Intensive Care Unit (ICU) are at high risk of acquiring the nosocomial infection.



Symptoms of Nosocomial Infection

The symptoms of healthcare-associated infections differ type by type. The most common types of HAIs are:

•    surgical site infections
•    pneumonia
•    urinary tract infections (UTIs)
•    meningitis
•    gastroenteritis

The symptoms of these infections may include -

•    fever
•    headache
•    discharge from a wound
•    nausea, vomiting, diarrhea
•    burning with urination or difficulty urinating
•    cough, shortness of breathing

Causes of Nosocomial Infections

Healthcare-associated infections can be caused by bacteria, fungus, and viruses. About 90% of these cases could be caused by bacteria alone. Most people have compromised immune systems during their hospital stay, so they are more likely to contract an infection. A few of the common bacteria that are responsible for HAIs are:

Bacteria Infection type
Staphylococcus aureus (S. aureus) blood
Escherichia coli (E. coli) UTI
Enterococci blood, UTI, wound
Pseudomonas aeruginosa (P. aeruginosa) kidney, UTI, respiratory


Of all the HAIs, P. aeruginosa accounts for 11% and has a high morbidity and mortality rate. The viruses, bacteria, and fungi spread mainly through person-to-person contact. This includes medical instruments such as respiratory machines, catheters, and other hospital tools, and unclean hands. Besides, there could be a surge of cases when there's excessive and improper usage of antibiotics. This can direct to bacteria that are resistant to multiple antibiotics.

Source of Nosocomial Infections

Nosocomial infections are caused by microbes originated in hospitals, clinics, and medical care centers. The mode of transfer of hospital-acquired infection can be either by direct or by indirect contact. The infection could transmit by touching an infected person, animals, or reservoir of infection count to be in direct contact. One of the principal routes of disease transmission is through contaminated hands. There could be an indirect disease transmission through communicable infectious agents, that does not require a direct connection of an infected person with a healthy one. The pathogens could be present in inmate objects and usage of these objects can lead to the spread of pathogens. The disease could also be transmitted through aerosols originated by sneezing and coughing of patients, which may carry pathogens ultimately.

The aerosol is the main cause of the respiratory tract infection to happen. It had been observed that the infectious agents are already present in the patient's body, but do not show any signs of the infection. But, the infection developed when the patients are admitted to the hospital. The immune system weakness and decreased resistance of the patient towards the infectious agent can lead to diseases. This kind of infection is known as Endogenous infection or autoinfection or self-infection. Another route of infection transmission is Cross-contamination followed by cross-infection. In such cases, the admitted patient can be exposed to a new infective agent leading to the development of another infection. Moreover, contaminated water can also be a source of nosocomial infection. For this, sterile water had been recommended for the patients more prone to infection and to avoid using hospital water. As these places are visited by patients suffering from illness, monitoring, and quality of air in the hospital, clinics, and medical care units is also an important aspect to deal with.
An essential role in the ecosystem is played by biofilm. Microbial growth can occur on different types of medical devices and this, in turn, favors microbial film growth. There's a high chance of microbial growth in implanted devices such as studs in the blood vessels, which can cause a severe infection if not treated timely.

Who's at risk of nosocomial infections?

Any person admitted to a healthcare facility is at risk of contracting an HAI. Your risks for bacteria may also depend on -

•    age, especially if you are more than 70 years old
•    any trauma you've experienced
•    your hospital roommate
•    your compromised immune system
•    prolonged ICU stay
•    how long you had been using antibiotics
•    if you had experienced shock
•    whether or not you have a urinary catheter
•    if you had been in a coma


Doctors can diagnose a healthcare-associated infection by sight and symptoms alone. It could be indicated by an inflammation and/or a rash at the site of infection. If the infections prior to your stay become complicated, they are generally not counted as HAIs. But, still, if any new symptoms appear during your stay, you should tell your doctor right away. Moreover, to identify the infection, you may also be required to take a blood and urine test also.


The treatment for these infections depends on the type of infection. Your doctor may likely recommend antibiotics and bed rest. Also, they would remove any foreign devices like catheters as soon as medically appropriate. Besides, a healthy diet, fluid intake, and rest would be encouraged by your doctor as a natural healing process and to prevent dehydration.

Prevention of Nosocomial Infections

The responsibility of HAI prevention lies with the healthcare facility. Healthcare staff and hospitals should follow the recommended guidelines for disinfection and sterilization. Taking appropriate steps to prevent healthcare-associated infections can reduce your risk of contracting them by 70% or more. However, due to the nature of healthcare facilities, it's not feasible to eliminate 100% of nosocomial infections. The nosocomial infections can be prevented by minimizing the spread of causative agents, maintaining well sanitary conditions in hospitals and medical care units, isolation for the patient suffering from infectious disease. Some of the common measures for infection control include -

•    Maintaining hand hygiene - Involves washing hands before and after touching people in the hospital
•    Sterilization of medical equipment - appropriate gloves, gear, gowns and face protection
•    Validation and cleaning of hospitals environment, with the recommended frequency
•    Avoid surgical site infection
•    An isolation unit for a patient infected by an infectious disease, which can help to protect others or decrease chances of further infection
•    Screen the ICU to see if people with HAIs need to be isolated
•    Make sure rooms are well ventilated

A) Maintaining hand hygiene

The most common vehicle for transmission of organisms is the hands. As per World Health Organization (WHO), the five moments for hand hygiene are - Before touching a patient, Before clean/aseptic procedure, after body fluid exposure risk, after touching a patient, after touching the patient's surroundings.

There's no complete eradication of germs with improper hand wash and it could be a reason for the infection. Lack of time, poor hygiene habits, lack of education, dry skin, perceived lack of importance, the absence of a suitable cleansing agent, skin irritation or dermatitis, and inadequate handwashing are some of the factors involved.

B) Avoid Surgical Site Infection (SSI)

This infection occurs within 30 days up to 1 year of the surgical process and is one of the major causes of mortality. Hence, it must be prevented and taken in critical concern. The different risk factors involved in surgical site infection are - age, health (obesity, diabetic, immunity), a habit like (smoking, drinking, etc), and immunity.

Preoperative Phase

•    Before any operative procedure, treat a remote infection from the site of surgery.
•    Remove only hair if they interfere in surgery and use an electric clipper with a single. It's best to avoid the use of a razor, as it may increase the SSI.
•    The blood sugar levels should be controlled prior to surgery.
•    Use intranasal mupirocin ointment for nasal decolonization in certain groups of patients to reduce staphylococcus infection.
•    The patient undergoing surgery must be given antibiotic prophylaxis, and it must be well defined. The antibiotic must not be given rottenly to the patient as it may have adverse effects also. Instead, it should be administered intravenously timely so that the serum and tissue contain bactericidal concentration at the time of incision and the concentration can be maintained after a few hours of surgery.
•    An appropriate skin antiseptic must be used for skin incision preparation.
•    Coming to the hand hygiene, nails should be short, no artificial nails to be applied, and using appropriate antiseptic perform preoperative scrub for 25 mins. Hands and forearms up to the elbow must be scrubbed and hands should be kept away from the body. After performing the surgical scrub, just flex the elbow and dry the side with a sterile towel.    

Intraoperative Phase

•    Ventilation - Compared to corridors, a positive pressure must be maintained, and fifteen air changes should be maintained every hour, and three should be of fresh air.  The recirculated air must be fresh and filtered through the appropriate filters. In the operation theater, UV radiation is prohibited and the door should be closed except for the passage of essential equipment, personnel, and patients.
•    Cleaning and Disinfection - Disinfection is a must after and before the operation procedure and clean visible soiling and blood/fluid spread contamination by appropriate disincentive agents. The use of a trace mat should be avoided at the entrance of the operation theater.
•    Microbiological sampling - Regular microbiological sampling is not required daily. But, as part of the epidemiological investigation of healthcare-associated infections, monitoring of operation theater surface and air sampling can be performed.
•    Sterilization of surgical instruments - All the surgical instruments must be sterilized. Flash sterilization can be used for the patient care instrument that will be used immediately.
•    Surgical attire and drapes - Wear a surgical mask that thoroughly covers the mouth and nose, before entering the operation theater. Wear surgical gowns and drapes for an effective barrier for a liquid that stops penetration. Change scrub suits infected with visibly soiled blood or other potentially infectious material.
•    Asepsis and Surgical technique - During the entire operative procedure, the aseptic condition should be maintained. Eradication of dead space, maintain hemostasis and minimize devitalized tissues. If the surgical site is found to be contaminated, it must leave to heal incision by the secondary intention.

Postoperative Incision Care

Post-operation for 24-48 hours, the incision must be closed by a sterile dressing. Wash hands with an appropriate antiseptic before and after changing dressing and surgical contact.

C) Isolation Unit for Patient Infected by Communicable Disease

Isolation here refers to the separation of the patient to control the infection or communicable disease. The patients are isolated as per the mode of transmission of the disease.

•    Strict Isolation - To prevent the spread of highly communicable diseases, prone to transfer through contact as well as airborne route. For eg: chickenpox and rabies.
•    Respiratory Isolation - To prevent the respiration transmission of organisms through droplets sneezed or breathed into by infected patients into the environment. Eg: Mycobacterium Tuberculosis.
•    Protective Isolation - To prevent contact between potentially pathogenic microbes and the unaffected person who is undergoing certain therapy resulting in suppression of immunity. Eg: Patient undergoing chemotherapy for leukemia treatment is more prone to infection.
•    Enteric Isolation - Disease spread through direct and indirect oral contact with infected feces/contaminated items. Eg: Dysentry and hepatitis.
•    Wound and Skin precautions - To prevent transmission of microorganisms found in infected wounds (burns, open sores), and contaminated articles. Safety measures should be taken in infected wounds, burns, and purulent discharge infections. It includes impetigo, herpes, and ringworm.
•    Blood Precaution - Prevention of the spread of blood-transmitted diseases which are due to the usage of infected blood-contaminated items. Eg: razor, use of a contaminated needle. HIV and HBV 19 are examples of this infection.

Sterilization of medical equipment - Any medical device or surgical instrument that comes in contact with the patient during treatment or operation procedure has a risk of disease transmission which is due to failure of sterilization or disinfection. The sterilization procedure is based on the objects to be sterilizing which can be classified into critical (surgical items, catheters (urinary and cardiac) and Ultrasound probes, semi-critical (endoscopes, laryngoscope blades, esophageal manometry probes, cystoscopes, anorectal manometry catheters, and diaphragm fitting rings) and non-critical objects (blood-pressure cuffs, crutches, bed rails, furniture, and floor).


It is concluded that immuno-compromised patients, old age people, and children are more prone to nosocomial infection and are advised to avoid unnecessary visits or exposure to the containment environment. Regular surveillance of the medical center should be monitored and necessary acti