Infection prevention and control general principles and role of microbiology laboratory

www.wjpr.net Vol 8, Issue 9, 2019.
Mohamed. World Journal of Pharmaceutical Research
68
INFECTION PREVENTION AND CONTROL: GENERAL PRINCIPLES
AND ROLE OF MICROBIOLOGY LABORATORY
Mohamed Khalid*
Kamal Medical Polyclinics Riyadh – Saudi Arabia – Zip Code 11461.
ABSTRACT
The healthcare-associated infections HAIs are international health
problem and its major cause of death worldwide with wide range
complications among healthcare workers, patients, and visitors, And
these complications are very expensive from the humanitarian and
economic aspects and cause increase in healthcare resources waste as
increase medications and medical supplies consumption, intensive uses
of diagnostic laboratory services, sharp rising hospital's admission
rates and other harmful effects on patient's life. As currently, medical
laboratory specialists are the cornerstones of diagnosis of infectious
diseases, the number of medical laboratories science colleges has increased, with a high
number of highly qualified specialists with a strong background on microbiology and
epidemiology of various disciplines that include clinical chemistry, microbiology,
hematology, immunology, and histopathology. Those specialists work in laboratories of
varying sizes and resources. Most of those specialists perform most tasks from different
disciplines, including the microbiological tests. Therefore, the junior laboratory specialist
must be fully familiar with the basic tasks and activities of infection control and prevention.
The aim of this review is to know the general principles of infection control and prevention
and the role of medical laboratory specialists, hoping that the medical laboratory specialists
will play a valuable and effective role in the field of infection control and prevention, thereby
preventing hospital infections and antibiotic resistance and providing a safe environment for
the patient, health care providers and the community.
INTRODUCTION
Healthcare-associated infections (HAIs), or nosocomial infections, affect patients in a
hospital or other healthcare facility, and are not present or incubating at the time of
World Journal of Pharmaceutical Research
SJIF Impact Factor 8.074
Volume 8, Issue 9, 68-91. Review Article ISSN 2277– 7105
*Corresponding Author
Mohamed Khalid
Kamal Medical Polyclinics
Riyadh – Saudi Arabia – Zip
Code 11461.
Article Received on
25 May 2019,
Revised on 16 June 2019,
Accepted on 07 July 2019
DOI: 10.20959/wjpr20199-15429

69
admission, HAIs are an important cause of morbidity and mortality of hospitalized
patients.[1,2,3]
Risk factors for healthcare-associated infection include intrinsic and extrinsic
factors. The major intrinsic factors are age, birth weight, underlying diseases, and immune
status. The major extrinsic factors are presence of invasive devices and procedures.[2]
HAIs
create additional suffering and come at a high cost for patients and their families. Infections
prolong hospital stays, create long-term disability, increase resistance to antimicrobials,
represent a massive additional financial burden for health systems, generate high costs for
patients and their family, and cause unnecessary deaths.[1]
Infection prevention and control
(IPC) is a discipline that aims to prevent or control the spread of infections in healthcare
facilities and the community.[1,4]
As each medical technologist/microbiologist needs to make
efforts to understand the characteristics of the examinations for infectious diseases and send
out information useful for clinical practices and they also need to be aware of themselves as
good practitioners of IPC measures to prevent hospital infections, the knowledge IPC
practices and role of microbiology laboratory are core scope beyond this review. Having
microbiology laboratory as a part of the hospital diagnostic laboratories is a huge advantage
for HAIs prevention and control. Ideally, a microbiology laboratory should be set up inside
the hospital and working every day on a 24-hour basis.[3]
Basic Principles of Infection Prevention and Control
The chain of infection: The process of infection can be represented as a chain, along which
microorganisms are passed from a source to a vulnerable person. Breaking a link at any point
in the chain will control the risk of infection by preventing the onward transmission of
microorganisms. The six links of chain of infection include: the infectious agent, reservoir,
portal of exit, mode of transmission, portal of entry, and susceptible host.[5]
Opportunities to break the chain of infection
Transmission may be interrupted when
 The infectious agent is eliminated, inactivated or cannot survive in the reservoir (E.g. rapid
identification and management of organisms, cleaning and disinfecting of the environment).
 The portal of exit is managed through good infection prevention and control practices (E.g.
Hand Hygiene, appropriate use of PPE, safe packaging and disposal of waste).
 Transmission does not occur due to good infection prevention and control practices (E.g.
Hand Hygiene, isolation of infected patients, air flow control where appropriate).

70
 The portal of entry is protected (E.g. Aseptic non-touch technique, safe catheter care,
wound care).
 Reducing the susceptibility of patients receiving healthcare (E.g. Treatment of underlying
disease, recognizing high risk patients).[5,6]
Infection Prevention and Control Program
Infection prevention and control program (IPCP) is scientific approach and practical solution
designed to prevent harm caused by infection to hospitalized patients and health care workers
(HAWs). The important components of the infection control program are (i) developing and
implementing guidelines/manual (ii) basic measures for infection control, i.e. standard
precautions (iii) education and training of HAWs (iv) protection of HAWs, e.g.
(immunization), identification of hazards and minimizing risks. (v) routine practices essential
to infection control such as aseptic techniques, reprocessing of instruments and
equipment, antibiotic usage, management of blood/body fluid exposure, handling and use of
blood and blood products, sound management of medical waste (vi) effective work practices
and procedures, such as environmental management practices including management of
hospital/clinical waste, support services (e.g., food, linen), use of therapeutic devices
(vii) surveillance (viii) incident monitoring (ix) outbreak investigation (x) infection control in
specific situations and research (xi) implementing IPC activities using multimodal
strategies (xii) Workload, staffing &bed occupancy management.[4,7]
Objectives of infection prevention and control program
 To have hospital IPC manual in place with clear role and responsibilities.
 To interpret and implement all activities according to hospital IPC manual.
 To conduct outbreak investigations of epidemics.
 To monitor the IPCP and promote improved practice, including inspection of waste
disposal, laundry and kitchen.
 Monitoring and advice on the safe use of antibiotics.
 Continuing education and training of staff in prevention and control of HAIs; and
 To sensitize patients on preventive aspects for control of airborne infections.[7,8,9,10]
Organization of an infection prevention and control program
Infection control committee: Infection control committee (ICC) members are for
multidisciplinary as medical, nursing, engineering, administration, pharmacy, central sterile
services department (CSSD) and microbiology laboratory. The ICC formulates the policies

71
for the IPC. The ICC meets regularly and not less than three times a year. ICC is responsible
for developing and updating HAIs prevention manual which should contain instructions and
practices for patient care and preparing the yearly work plan with adequate resources for the
effective functioning of the IPCP.[4,11]
Infection control team: The infection control team (ICT) consists of members of staff with
specialized knowledge and interest in IPC. The ICT will include the microbiologist who will
usually be the infection control officer, infection control nurses and members of the scientific
or technical staff with responsibilities in infection control. The role of the ICT is
to implement the annual program and policies and responsible for the following: (i)
Surveillance of infections and monitoring methods of control. (ii) Rapid identification and
investigation of outbreaks. (iii) Providing advice on the isolation of infected patients. (iv)
Giving advice, making day-to-day decisions and liaising with staff in all areas. (v) Providing,
monitoring and evaluating policies and procedures for prevention of infections and its spread.
(vi) A staff education program. (vii) Preparing the annual IPCP and reporting to the
ICC.[12,13,14]
Infection Control Officer (ICO): Infection Control Officer (ICO) is a senior member of the
medical staff with ready access to committees and sufficient authority to command respect
and suitably qualified and interested in IPC. The microbiologist is usually the logical choice.
The functions of the ICO with the other members of the team are to assess risks of infection,
to advise on preventive measures and to check their efficacy in all parts of the hospital
including catering, laundry and CSSD in domestic, pharmaceutical and engineering
departments, as well as clinical and other areas. ICO is carrying out targeted surveillance
of HAIs and act upon data obtained. ICO recommends antibiotics policy for different areas of
the hospital. ICO provide manual of policies and procedures for aseptic, isolation and
antiseptic technique; investigate outbreaks of infections and take corrective measures;
supervision of biomedical waste management activities; supervision of airborne
isolation procedures.[12,15]
Importance of instauration infection prevention and control manual
A HAIs prevention manual is an important tool due to instructions and practices used for
patient care. The policies and procedures for IPC manual (see Table 1) should be based on
national and international published best practices. The manual should be developed and
updated by the ICT and reviewed and approved by the ICC.[4]
Health care staff must adhere to

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IPC manual, guidelines and policies at all times and use critical thinking, risk assessment and
problem-solving in managing clinical situations.[16]
Table. 1: Components for Institution Infection Prevention and Control Manual.
Organization/institution details
Date formation of institutional ICC
Name and designation of ICC committee members
Name and designation of ICO
Name and designation of infection prevention and control nurse
Roles and responsibilities of each member
Details of version and date of amendment
Technical description of standard precautions and high risk area management
Policies and procedures for improvement of hand hygiene compliance
Policies and procedures for identification of high risk areas and establish steps to mitigate
risk of HAIs to patients, staff and visitor
Policies and procedures aseptic, isolation and antiseptic techniques
Policies and procedures for disinfection and sterilization of reusable equipments
Policies and procedures for biomedical waste management
Policies and procedures for laboratory based and ward based surveillance of infections
Policies and procedures with regards to staff health monitoring
Policies and procedures for patient visitors
Policies and procedures for staff training regarding IPC Measures
Policies and procedures for outbreak investigations
Policies and procedures for monitoring of emergence of antimicrobial resistance
Policies and procedures for hospital building renovation.[2,4,7,8,17]
Infection Prevention and Control Practice
The optimal defense against HAIs and antimicrobial resistance (AMR) is strict of HAWs,
patients and visitors adherence to IPC practices, which can significantly contribute to halting
the spread of untreatable infections and negate the need for antibiotics. Such practices include
the use of standard infection control precautions and transmission-based precautions.[18]
Components of standard precautions
Personal protective equipments (PPE): Healthcare facilities must have the necessary
equipment to implement the standard precautions for all HAWs, patients and visitors. PPE
used in healthcare include gloves, aprons, long-sleeved gowns, goggles, fluid-repellant
surgical masks, face visors, and respirator masks. The initial risk assessment of whether or
not PPE is required is based on the level of risk of transmission to and from the patients.[19]
Principles of PPE. (i) PPE should be chosen according to the risk of exposure. (ii) The skin
should not be exposed when PPE has worn; (iii) Step by step instructions regarding wearing

73
and removing off PPE to be displayed in all prominent areas in the hospital; (iv) PPE should
be stored to prevent contamination in a clean/dry area until required for use; (v) PPE should
be single-use only items unless specified by the manufacturer; (vi) PPE should be changed
immediately after each patient and/or following completion of a procedure or task; and (vii)
PPE should be disposed of after use into the correct waste stream i.e. healthcare waste or
domestic waste.[4]
The gloves. The wearing of gloves has two main purposes as they act as a protective barrier
for HAWs and they prevent the transmission of micro-organisms to patients during invasive
procedures. Gloves must be (i) worn when exposure to blood and/or other body fluids is
anticipated/likely; (ii) changed immediately after each patient and/or following completion of
a procedure or task; (iii) changed if a perforation or puncture is suspected; (iv) Appropriate
for use, fit for purpose and well-fitting.[20]
Gowns and Aprons. Gowns and aprons are to protect susceptible patients from infections
and protect the wearer from contamination. Gowns and aprons are worn to protect uniform or
clothes when contamination is anticipated/likely. Full body /Fluid repellent coveralls worn
when there is a risk of extensive splashing of blood and/or other body fluids, e.g. in the
operating theatre, also worn when a disposable apron provides inadequate cover for the
procedure/task being performed.[20,21]
Eye/face protection. Masks, visors, and goggles protect the mucous membranes of the eyes
and mouth from exposure to blood and body fluids in situations where splashes can
occur. Eye/face protection should not be touched by hand while being worn.[20]
Face
masks/surgical masks are loose fitting, single-use items that cover the nose and mouth.
They are used as part of standard precautions to keep splashes or sprays away from reaching
the mouth and nose of the person wearing them. All patients with cough and confirmed TB
patients should be encouraged to wear face masks all times to reduce the transmission
of infections to other patients, visitors, and HAWs.[22]
Preventions of injury from needles and sharps management
The use of sharp devices exposes HAWs to the risk of injury and potential exposure to
Bloodborne infectious agents, including hepatitis B virus, hepatitis C virus and human
immunodeficiency virus (HIV).[22]
Sharp injuries include regulatory requirements for
employers and contractors in the healthcare sector in relation to (i) arrangements for the safe

74
use and disposal of sharps. (ii) Provision of information and training to employees (iii)
Sharps handling must be assessed and kept to a minimum and eliminated if possible with the
use of approved safety devices. (v) Needles must not be re-sheathed/recapped.[21]
Reducing risks if a sharps injury occurred. (i) Seek care immediately if you sustain a
sharps injury. (ii) If the skin is penetrated, wash the affected area immediately with soap and
water. Alcohol-based hand rub can be used to clean the area if soap and water are not
available. (iii) Do not squeeze the affected area. (iv) Report the incident immediately to the
department supervisor. (v) Ask about follow-up care, including post-exposure prophylaxis,
which is most effective if implemented soon after the incident. (vi) Complete an
accident/incident report form, including the date and time of the exposure and how it
happened.[22]
Hand hygiene
Hand hygiene is the single most important way to prevent spread/transmission of
infections. It is important that hand hygiene should be performed before any procedure for
reason that places the patient at risk of infections; world health organization (WHO) defines
five moments when healthcare workers should perform hand hygiene
1. Before touching a patient;
2. Before clean/aseptic procedures. liquid soap should be used;
3. After body fluid exposure risk;
4. After touching a patient; and
5. After touching a patient’s immediate surroundings.[23]
Hand washing methods
Hand washes with soap and water. This method is usually used in case of hands are visibly
dirty or soiled with blood or other body fluid after using the toilet. Hand washes with soap
and water also used if exposure to potential spore-forming pathogens are strongly suspected
or proven.[23]
Alcohol-based hand rubs. Have become more widely used after contact with inanimate
surfaces or objects, before handling an invasive device for patient care, before and after
touching the patient, after contact with the body fluids and excretions, mucus membrane and
non-intact skin or wound dressing and if moving from a contaminated body side to another
body side during patient care and after removing sterile or non-sterile gloves.[23]

75
Respiratory hygiene and cough attitude: Is an infection control component of standard
precautions. Persons with respiratory symptoms should always practice respiratory hygiene
and cough attitude this can be achieved by providing a mask to those who are coughing.
Designate an area in the waiting room for patients with respiratory symptoms and consider
isolating symptomatic patients are highly recommended.[24]
Cleaning of patients care environment: Keeping the patient environment area clean is a
fundamental principle of preventing infection in the hospital setting and it is the
responsibility of the person in charge to ensure that the care environment is safe for practice.
The care environment to be (i) visibly clean, free from non-essential items and equipment
to facilitate effective cleaning. (ii) The environment should be well maintained and in a good
state. Staff should be educated on the use of the chemicals and annual competencies are
recommended for specific disinfection and sterilization procedures. All cleaning, disinfection,
and sterilization processes should comply with relevant guidelines.[24]
Disinfection and sterilization of patients care equipments
Any instrument or piece of equipment that is to be reused requires reprocessing/cleaning,
disinfection and/or sterilization. The system is based on instruments and items for patient care
being categorized into critical, semi-critical and non-critical, according to the degree of risk
for infection involved in the use of the items. Disinfection is a process that inactivates non-
sporing infectious agents, using either thermal (moist or dry heat) or chemical means. Items
need to be cleaned before being disinfected. Sterilization destroys all microorganisms on the
surface of an instrument or device, to prevent disease transmission associated with the use of
that an instrument or device.[6]
Biomedical waste management
Sharps waste. Sharps are items that could cause cuts or puncture wounds. Examples
of sharps, including needles, hypodermic needles, scalpels, and other blades, knives, infusion
sets, saws, broken glass, and pipettes. Whether or not they are infected such items are usually
considered highly hazardous healthcare waste and should be treated as if they were
potentially infected.[25]
Infectious waste. Is materials suspected to contain pathogens (bacteria, viruses, parasites or
fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This
category includes:

76
 Waste contaminated with blood or other body fluids;
 Cultures and stocks of infectious agents from laboratory work;
 Waste from infected patients in isolation wards.[25]
Domestic waste. Non-hazardous or general waste is waste that has not been in contact with
infectious agents, hazardous chemicals or radioactive substances and does not pose a sharps
hazard.[25]
Waste segregation systems
 Black Plastic bag – Trivial risk. Used for domestic waste and final disposal to Landfill.
 Yellow container – High risk. Used for highly infectious or contamination risks. Type of
container should be strong, leakproof plastic bag or container capable of being autoclaved.
 Brown container/plastic bag. Should be labeled with the appropriate hazard symbol and
used for chemical and pharmaceutical waste.
 Yellow. Should be marked “SHARPS” and with a biohazard symbol used for sharps. Type
of container must be Puncture-proof container.[25]
Hospital linen management
Clean linen should be stored in a clean and designated area, preferably an enclosed
cupboard. If clean linen is not stored in a cupboard, then the trolley used for storage must be
designated for this purpose and completely covered with an impervious covering that is able
to withstand decontamination.[6]
Soiled linen should be removed as close to the source as possible. Soiled linen should not (i)
rinse, shake or sort linen on removal from beds/trolleys (ii) place used linen on the floor or
any other surfaces e.g. a locker/table top (iii) re-handle used linen once bagged (iv) overfill
laundry receptacles.[6]
Transmission-based precautions
Transmission-based precautions are designed to reduce the risk of airborne, droplet and
contact transmission and always are used in addition to standard precautions to observe
patients known or suspected to have highly transmissible or epidemiologically important
pathogens.[26,27]
Airborne precautions are used to prevent transmission of infectious agents
that remain infectious across long distances when suspended in the air. Disease-causing
microorganisms may be suspended in the air as small particles, aerosols or dust and remain

77
infective over time and distance, for example, Mycobacterium tuberculosis
(pulmonary/laryngeal), varicella zoster virus (chickenpox), herpes zoster (shingles) and
measles. Patient placement should be in an airborne infection isolation room, which is a
single-patient room with special air-handling and ventilation capacity. Respiratory protection
must be employed when entering the isolation room using the disposable N-95 respirator
mask, which fits tightly around the nose and mouth to protect against both large and small
droplets. This should be worn by all persons entering the room, including visitors.[27]
Contact Precautions are intended to prevent transmission of infectious agents that are spread
by direct or indirect contact with the patient or the patient’s environment. For example,
Methicillin-Resistant Staphylococcus aureus (MRSA), respiratory syncytial virus infection,
varicella (chickenpox), herpes zoster, hepatitis A and rotavirus infections. Patient placement
is preferred to be in a single-patient room to limit the opportunities for transmission.
Transporting patients should be limited as much as possible to reduce opportunities for
disease transmission to staff members and other patients.[26,27]
Droplet precautions are
intended to prevent transmission of pathogens spread through close respiratory or mucous
membrane contact with respiratory secretions. Microorganisms are also transmitted by
droplets (large particles >5 μm in size) generated during coughing, sneezing and talking for
example, influenza virus, Bordetella pertussis, Mycoplasma pneumoniae, Severe acute
respiratory syndrome-associated corona virus, Group A Streptococcus, adenovirus and
rhinovirus. Patient placement is preferred to be in a single-patient room to limit the
opportunities for transmission. Transporting of patients who require droplet precautions
should be limited.[26,27]
Improving Healthcare Facility Infection Control
Using the Hierarchy of Control Technologies: Controlling exposures to occupational
hazards is the fundamental method of protecting workers. Traditionally, a hierarchy of
controls has been used as a means of determining how to implement feasible and effective
control solutions. The hierarchy falls into three general categories, which in the order of
importance are as follows: (1) engineering controls, followed by (2) administrative and work
practice controls and, supplemented by (3) personal protective equipment (PPE). (Table 2)
describe categories of hierarchy of controls. These can be used together in combination or
individually while other (higher level) controls in the hierarchy are being implemented.

78
Following this hierarchy normally leads to the implementation of inherently safer systems,
where the risk of illness or injury has been substantially reduced.[28]
Table. II. Categories of the hierarchy of controls.
1-Engineer measures
a-Isolation measures
Is by protecting people from hazard using designing, building
refurbishment and organizing of health care facilities example placement
of registration counters, outpatients waiting area and other health care
facilities sections. Provision of running water and wash basin should be
there in strategic locations.[5,29]
b-Ventilation measures
Is by ensuring adequate natural cross ventilation by keeping windows in
strategic locations and provision of adequate mechanical ventilation.
Ventilation recognized as an important factor of air dilution so to remove
infectious droplets from the air.[5,29]
2-Administrative measures
To change the way people work by providing an infrastructure of
policies, procedures and patient care practices intended to prevent
exposure to and/or transmission of microorganisms to a susceptible host
during the provision of health care. The role of healthcare facility
administration includes risk assessment, identify point for the
implementation of IPC activities, ensure proper implementation of
administrative measures, utilizing existing infrastructure and consider a
renovation, allocate budget to the maintenance of IPC measures,
supervise and monitor IPC activates and address training of HCWs,
patients and visitors.[29]
3-PPE measures
Refers to the availability and appropriate use of barriers that a
susceptible host may wear to provide a physical barrier between him/her
and an infectious agent/infected source. These barriers include gloves,
gowns, masks, facial protection, eye protection (including face shields,
or masks with visor attachments) and respirators. The health care
organization plays a critical role in ensuring the availability of
appropriate PPE for use by patients, HCWs, visitors, etc.[29]
Using the multimodal strategies
Multimodal strategies consist of several elements implemented in an integrated way with the
aim of improving an outcome and changing behavior. The WHO multimodal improvement
strategy includes the areas of system change (build it), training and education (teach it),
monitoring and feedback (check it), reminders and communications (sell it), as well as
cultural change (live it) supporting IPC in a patient safety perspective.[30]
Implementing IPC
control activities at the facility and national level using multimodal strategies is effective to
improve infection prevention and control practices and reduce HAIs and combat AMR.[31]
Lee el. at.,[32]
described evidence that IPCP, including a WHO multimodal strategy with four
or more elements, were associated with decreased respiratory infections and Multi-drug
resistant organism infections and with improved adherence to hand washing practices in long-

79
term care facilities. The WHO multimodal strategy has been applied and proven effective in
several studies of IPC practice as hand hygiene practices.[32]
Auditing and monitor workload, staffing and bed occupancy
Addressing bed occupancy and staffing factors will significantly reduce the cross-
transmission risk and ultimately reduce HAIs and the spread of AMR in health care facility.
Bed occupancy should not exceed the standard capacity of the facility, and health care
staffing should be at acceptable levels in relation to patient workload. Zing et al.,[33]
evaluated several studies that showed transmission of infection with MRSA was associated
with bed occupancy and with low staffing and nurse-to-patient ratios. Higher numbers of
permanent staff HCWs and improved nurse-to-patient ratios reduced HAIs. Low staffing
levels and high workload are associated with inadequate adherence to hand hygiene protocols
and increase MRSA infections. Long work hours were associated with increased rates
of HAIs.[33]
Supervising and monitoring of infection prevention and control program
the supportive supervision is an act of observing the conduct of activity to make sure that is
implemented as per plan and it consists of on-site visits, observing tasks being performed,
imparting hands-on training, helping to organize tasks, enhance the motivation of staff and
monitoring the activities and results.[30,31,34]
The Laboratory Role in Infection Prevention and Control
Microbiology laboratories (MLs) are an essential element of the infection prevention program
at every health care facility. Effective prevention saves not only lives, but money and these
savings are rarely credited to the MLs. Some of the major roles played by the MLs in IPC
include contributions to (i) Recovering and identifying the causative organism (ii)
Antimicrobial susceptibility testing for many of these organisms[3,35]
, (iii) surveillance (iv)
outbreak detection and management (v) antimicrobial stewardship (vi) Participation in the
ICC, and (vii) Education of HAIs prevention personnel.[3,35,36,37]
Recovering and identifying the causative organisms
Thus, the ability of the MLs to isolate and accurately identify microorganisms is as crucial to
infection control as it is to the individual patient. Due to technological developments,
the MLs have continued to increase the efficiency with which nosocomial organisms can
be recognized and recovered. There are three main aspects to this. First, new instruments and

80
devices have become widely available. Second, newer nonculture tests have permitted the
identification of agents of nosocomial infection such as immunologic and nucleic acid
testing. Third, these newer tests and instruments not only permit the identification
of additional agents, but also the more rapid diagnosis of both new and old pathogens.[35]
MLs should be able to examine blood, cerebrospinal fluid, urine, stool, wound exudate or
swab, respiratory secretions and perform basic serological tests (HIV, HBV, HCV,
influenza). Different methods used in the diagnosis of infections such as classical methods
which include (i) Direct smear (ii) Culture (iii) Antigen detection (iv) Serological tests and
molecular methods which consist of (i) Hybridization (ii) Amplification (iii) Real-time
amplification.[3]
Antimicrobial susceptibility testing
Antimicrobial susceptibility testing (AST) is an inexpensive, easy to use and readily available
means that is often used to characterize microorganisms. The infection perventionist
frequently reviews daily and cumulative AST reports (antibiograms) for emerging patterns of
resistance.[38]
Every IPCP must implement control measures to prevent the spread of
multidrug-resistant organisms (MDROs). However, the success of any program to control
MDROs depends upon the ability of the MLs to detect these organisms. Laboratory directors
must keep current with the literature regarding manual, semi automated and automated
systems' ability to detect emerging resistances and they must implement if necessary,
additional methods to detect or confirm particular resistance patterns. Increasingly, such
confirmatory testing will be performed using molecular methods. New AMR continues to
emerge and existing resistances are increasing in frequency. The most important resistances
emerging in HAls pathogens include extended spectrum β-lactamases among
Enterobacteriaceae. glycopeptide resistance among enterococci, MRSA, and MDROs among
nonfermenters such as Pseudomonas aeruginosa, Acinetobacter, and Stenotrophomonas
maltophilia.[39]
AST has been used successfully as effective tool in the investigation of
several outbreaks.[38]
Participation in HAIs surveillance
Surveillance is the systematic collection, analysis, and interpretation of data on the frequency
of disease. It is essential to the planning, implementation, and evaluation of public health
practices and the timely dissemination of the data for public health action.[40,41]

81
Objective of surveillances
- Establish endemic baseline rate
- Reducing infection rates in the hospitals
- Identifying and containing the outbreaks
- Evaluating and monitoring infection control measures
- Monitoring AST.[40]
Types of surveillance to monitor HAIs
- Passive surveillance of HAIs refer to the identification of HAIs by patient care providers,
who may not be formally trained in surveillance and may not consistently use standardized
surveillance case definitions to identify HAIs. Examples of Passive surveillance consist of
laboratory-based surveillance and ward-based surveillance.[40,42]
- Active surveillance is the identification of HAIs by trained personnel who proactively look
for HAIs using multiple data sources. Active surveillance is conducted by trained staff using
standardized case definitions and is more accurate than passive surveillance.[40,42]
- Targeted surveillance aimed at high-risk areas (e.g. Intensive Care Unit and Neonatal
Units), type of infections (e.g. bloodstream and surgical site infections), or procedure directed
(e.g., infections associated with central venous or urinary catheters) are the most cost-
effective and manageable, and should be used in health care facilities.[41,43]
- In MLs, use strategies of traditional systems, passive and active surveillances remain the
most common method for case finding in HAIs surveillance. Therefore, the most important
role of the MLs is to promptly and accurately detect nosocomial pathogens and
their AMR patterns. Virtual surveillance is active surveillance systems augmented by the
inclusion of new computing technologies and the use of mathematical models. Virtual
surveillance should be the goal of early detection of unusual patterns of microbial pathogens
and HAIs.[44,45]
Major surveillance challenges facing the MLs include the continued
emergence of novel infectious agents (e.g., the H1N1 influenza A virus)[45]
, novel
antimicrobial-resistant pathogens (e.g., vancomycin-intermediate/resistant Staphylococcus
aureus [VISA/VRSA], carbapenem-resistant Enterobacteriaceae [CRE]), Vancomycin-
resistant enterococci (VRE), multi-drug resistant Pseudomonas aeruginosa, multi-drug
resistant Acinetobacter baumannii, multi-drug resistant Mycobacterium tuberculosis and
Clostridium difficile.[3,45]

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Outbreak detection and management
The outbreak may be defined as the occurrence of disease at a rate greater than that expected
within a specific geographical area and over a defined period of time.[41,43,46]
Types of outbreaks: Common source outbreak is a type of epidemic caused by exposure of a
group of people to a common risk factor, such as an infectious agent or a toxin or a chemical,
etc. This can take two forms: (i) Point source outbreak is brief and simultaneous exposure
and all exposed will develop the disease within one incubation period (ii) Continuous/
Intermittent common source refers to the source of an outbreak remains for a long time either
continuously or intermittently (iii) The propagated or progressive outbreak of this type occurs
from the transmission of an infectious agent from one susceptible an infected host to another.
It can be through direct person-to-person transmission or indirect transmission through a
vector, vehicle, etc.[47,48]
Outbreak investigation steps
When an outbreak is suspected, ten steps recommended are taken to investigate an outbreak.
The laboratory is integral in several of the steps. The steps that are followed in an outbreak
includes (i) Confirm the existence of the outbreak. (ii) Verify the diagnosis and determine the
aetiology of the disease. (iii) Develop a case definition, start case finding and collect
information on cases. (iv) Describe persons, places, and times and generate hypotheses. (v)
Test the hypotheses using an analytic study. (vi) Carry out necessary environmental or other
studies to supplement the epidemiological study. (vii) Draw conclusions to explain the causes
or the determinants of the outbreak based on clinical, laboratory, epidemiological and
environmental studies. (viii) Report and recommend appropriate control measures to
concerned authorities at the local, national and if appropriate international levels. (ix)
Communicate the findings to educate other public health professionals and the general public.
(x) Follow up the recommendations to ensure implementation of control measures.[41,47]
Outbreak identification
Early identification of an outbreak is important to protect patients as infection may be
transmitted to them by HCWs or through contaminated materials. A potential problem may
be initially identified by nurses, physicians, microbiologists, any other HCWs or through
a nosocomial infection surveillance program.[49]
MLs have important roles to play in any
potential outbreak situation, including early recognition of possible clusters and outbreaks,
rapid notification and collaboration with the ICT to enable the ICT to

83
take appropriate measures to stop it from spreading at the very beginning. Additionally case
finding and provision of molecular typing for determination of relatedness is requires
maintenance of an organism bank.[3,45]
The MLs, in association with the ICT, are the first to
detect an outbreak and determine whether an outbreak is real due to unusual clusters of
pathogens or resistance patterns or a potential pseudo-outbreak due to contamination of
specimens outside or within the laboratory. In addition, the laboratory can help generate
hypotheses and provide information on the epidemiology of the etiologic agent as to the
potential source of an outbreak, its reservoir and its mode of spread through phenotypic
methods and molecular typing of the suspected organisms and through testing the
environment and/or personnel as necessary. Traditionally, the epidemic strain has been
defined with phenotypic methods, which include genus, species, biotype, serotype, phage
type, bacteriocin production and AMR patterns. Sometimes, isolates share the same
phenotypic markers and when microbial pathogens are nontypeable by phenotypic methods
or have only a few types, the poor discriminatory power this has led to the use
of genotypic methods for typing. These molecular epidemiologic methods most often
involve genotyping of microbial plasmid or chromosomal DNA and go far beyond the current
limitations of phenotyping and provide more accurate data during outbreak investigations.
Moreover, outbreaks of viruses and free-living microorganisms can now be adequately
studied with current molecular epidemiologic methods. However, combining methods of
microorganism identification provide stronger evidence for the presumed relationship
between isolates. A major challenge to the MLs is in detecting outbreaks early enough to
allow effective intervention and impact morbidity and mortality.[38]
Effective and regular
communication between MLs personnel and infection preventionists is essential to this effort,
as many outbreaks are first noted at the MLs benches when technologists notice unusual
clusters of organisms or antimicrobial resistance patterns.[45,50]
Participation in antimicrobial stewardship
Antimicrobial stewardship can be defined as a bundle of interventions to promote
and ensure the optimal use of antimicrobial treatment that results in the best clinical outcome
for the treatment or prevention of infection, with minimal toxicity to the patient and minimal
impact on subsequent resistance.[51]
Dyar et al.,[52]
also defined antimicrobial stewardship as a
coherent set of actions designed to use antimicrobials responsibly.[52]
Determining antibiotic
susceptibility patterns for microorganisms causing HAIs is vital for individual patient care. It
can also help in planning antibiotic policy and designing the local antibiotic formulary.

84
The MLs should work closely with physicians and pharmacists
to determine appropriate antibiotics to be included in susceptibility testing panels, so good
communication between the laboratory, pharmacy, IPCP and a stewardship team are
essential. For guiding directed antimicrobial therapy, patient-specific culture and
susceptibility data are needed. These data should be available for every physician who
prescribes antibiotics.[45,51]
Morency-Potvin et al.,[51]
described essential antimicrobial
stewardship activities in the MLs which includes (i) Collaborate in educating local HCWs on
microbiology issues that impact treatment and microbial resistance (ii) Promptly report
unusual patterns of resistance, test supplementary agents and provide advice on therapy for
patients awaiting results (iii) Optimize communication of critical test result values and alert
systems (iv) Provide guidance for adequate collection of microbiology specimens (v)
Develop alert systems for specific MDROs. A major challenge to effective stewardship is an
inability to obtain antimicrobial susceptibility data from the MLs in a timely and
efficient manner, therefore using rapid diagnostic and AST technologies for targeted critical
specimen types is required. Importance of antimicrobial stewardship programs include but
are not limited to, reduction of C. difficile infection incidence, reduction of AMR, improving
antimicrobial dosing in renally impaired patients, improving the use of surgical antimicrobial
prophylaxis, improved infection cure rates, decreased mortality rates, more rapid
administration of effective antimicrobial therapy and appropriate de-escalation in critical
infections and hospital cost savings.[51]
Participation in infection control committee
It is paramount that the Laboratory scientists or clinical microbiologist participates on the
ICC and acts as a consultant to infection preventionists. MLs is the best department
to provide expertise services in the interpretation of culture results, advice about the utility
of microbiological approaches to an infection control problem and prepare specific reports to
the ICC such as (i) Blood culture contamination report (ii) Facility antibiogram with
contributing of pharmacy (iii) Legionella urinary antigen report (iv) Seasonal influenza and
respiratory virus surveillance report. Microbiologist should describe how changes in the
methods used for detection, identification and susceptibility testing
of nosocomial pathogens will impact the IPCP.[13,14,41,45,53]

85
Education of HAIs prevention personnel
Infection control education is a core component of IPCP since they were established and they
remain a constant feature in the modern healthcare context. HCWs should be equipped with
the requisite knowledge, skill and attitude for good IPC practices. A variety of educational
strategies are evaluated for their effectiveness as a measure of IPC. Some of the most
practiced methods are simulation-based training[33]
, and hands-on training quasi-experimental
settings where control and target groups are subjected to both didactic and practical sessions,
scenario-based simulation training, e-learning followed by a questionnaire and focused group
discussions and computer-assisted learning in IPC education. All the HCWs should be
adequately educated in the basic principles of IPC and should undergo continuous training to
acquire up-to-date knowledge and skills.[54]
The use of multimodal strategies was identified
in five interventional studies that successfully reduced HAIs by improving IPC knowledge
and increasing hand hygiene compliance.[34]
Laboratory specialists or microbiologist must not
only keep themselves educated in their contribution to the ICT, but also keep the IPC
personnel educated regarding the laboratory’s contribution to the team. Education of future
hospital epidemiologists and infection preventionists require training in infectious diseases
and structured clinical microbiology training due to the important role of microbiology
education as foundational knowledge in IPC practice.[39,41,55]
CONCLUSION
The IPC is very important approach in the health care facility as medicine becomes more
invasive and the proportion of ageing and immunocompromised patients in our population
continues to increase. Hospitals should come up with an in-house awareness programme
where staff members, patients and visitors can be educated on maintaining hygiene.
Moreover, MLs are becoming an integral part of HAI prevention programmes. The
emergence of new pathogens, and new resistances in old pathogens, makes microbiology
laboratory indispensable for successful prevention of HAI. MLs to be a part of the ICT, ICC
and antibiotic committee. Only very close communication, collaboration and cooperation
between microbiology laboratory and infection control personnel can fulfill the duties of
successful infection prevention and control in healthcare institutions.
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