PocketGuide: Infection Prevention

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PocketGuide for Family Planning Service Providers

Infection Prevention

Infection prevention (IP) in family planning and health care facilities has two primary objectives:

To prevent major postoperative infections when providing surgical contraceptive methods (e.g., IUDs, injectables, implants and voluntary sterilization)
To minimize the risk of transmitting serious infections such as hepatitis B¹ and AIDS not only to clients but also to service providers and staff, including cleaning and housekeeping personnel

The IP practices described in this chapter are intended for use in all types of medical and health care facilities—from large urban hospitals to small rural clinics. They are designed to minimize costs and the need for expensive and often fragile equipment while at the same time assuring a high degree of safety.

For additional information on IP as well as detailed instructions for preparing chemical solutions and specific IP guidelines for the surgical contraceptive methods currently provided, see Infection Prevention for Family Planning Service Programs (Tietjen et al 1996).

Infection Prevention Principles

In this chapter, the recommended IP practices are based on the following principles:

Consider every person (client or staff) infectious.
Wash hands—the most practical procedure for preventing cross-contamination (person to person).
Wear gloves before touching anything wet—broken skin, mucous membranes, blood or other body fluids (secretions or excretions)—or soiled instruments and other items.
Use physical barriers (protective goggles, face masks and aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated.
Use safe work practices, such as not recapping or bending needles, safely passing sharp instruments and properly disposing of medical waste.
Isolate patients only if secretions (airborne) or excretions (urine or feces) cannot be contained.²

Finally, process instruments and other items (decontaminate, clean, high-level disinfect or sterilize) using recommended IP practices.

Handwashing

Wash hands before and after examining any client (direct contact).
Wash hands after removing gloves because the gloves may have holes in them.
Wash hands after exposure to blood or any body fluids (secretions and excretions), even if gloves were worn.

Experience has shown that the most effective way to increase handwashing is to have physicians or other respected individuals (role models) consistently wash their hands and encourage others to do the same.

To encourage handwashing, program managers should make every effort to provide soap and a continuous supply of clean water, either from the tap or a bucket, and single-use towels. (Do not use shared towels to dry hands.)

Surgical Handscrub

During surgical procedures such as minilaparotomy or vasectomy, sterile or high-level disinfected gloves must be worn. A 3- to 5-minute handscrub with a solution containing chlorhexidine or an iodophor is recommended. (Chlorhexidine has been shown to be less irritating than iodophors.) Alternatively, surgical staff can wash hands with plain soap, then apply alcohol solution containing an emollient and rub until dry. (See below for directions on how to make an alcohol solution for surgical scrub.)

Applying an antiseptic prior to putting on gloves minimizes the number of microorganisms on hands under the gloves. This is important because gloves may have invisible holes or tears, or may be nicked during surgery.

Alcohol Solution for Surgical Scrub

A nonirritating alcohol solution for surgical scrub can be made by adding either glycerine, propylene glycol or Sorbitol^Ž to the alcohol (2 ml in 100 ml 60–90% alcohol solution). Use 3 to 5 ml for each application and continue rubbing the solution over the hands for about 2 minutes, using a total of 6 to 10 ml per scrub.

Note: Skin damage caused by allergic reactions provides an ideal place for microorganisms to multiply and should be avoided. Personnel with allergies to antiseptics or detergents may use plain soap followed by an alcohol rub.

Supplies

Soap (plain) or antiseptic, which is preferred, as provided by the facility
Running water
Stick or brush for cleaning the fingernails
Soft brush or sponge for cleaning the skin
Towels (sterile towels should be provided in the operating room)

Preparation

The surgeon, scrubnurse or technician should wear a short sleeved shirt or scrub suit to perform this procedure because it involves scrubbing to the elbows.

Instructions

STEP 1:	Remove all jewelry.
STEP 2:	Adjust water to a comfortable temperature.
STEP 3:	Holding hands above the level of the elbows, wet hands thoroughly. Apply soap and clean under each fingernail using a brush.
STEP 4:	Beginning at the fingertips, lather and wash with a soft brush or sponge, using a circular motion. Wash between all fingers. Move from fingertips to the elbow of one arm and repeat for the second arm.
STEP 5:	Wash using a soft brush or sponge for 3 to 5 minutes (when using alcohol, pour or rub for 2 minutes).
STEP 6:	Rinse each arm separately, fingertips first, holding hands above the level of elbows.
STEP 7:	Using a separate towel for each hand, wipe from the fingertips to the elbow, and then discard the towel.
STEP 8:	Before putting on sterile gloves (and gown), hold hands above the level of the waist and do not touch anything.
STEP 9:	If scrubbed hands touch any “dirty” (nonsterile or non-high-level disinfected) object during the procedure, steps 3 through 8 must be repeated.

Skin Preparation Prior to Surgical Procedures

Although skin cannot be sterilized, skin preparation with antiseptic solutions minimizes the number of microorganisms that may contaminate the surgical wound and cause infection. Antiseptics should be used for skin preparation prior to injections, surgical procedures (e.g., minilaparotomy) and for vaginal preparation prior to IUD insertion.

Instructions for Skin and Mucous Membrane Preparation

STEP 1:	Do not shave hair at the operative site. Shaving increases the risk of infection as the tiny nicks in the skin provide an ideal setting for microorganisms to grow and multiply. If the hair must be cut, trim the hair close to the skin surface immediately before surgery.
STEP 2:	Ask the client about allergic reactions (e.g., to iodine preparations) before selecting an antiseptic solution.
STEP 3:	If visibly soiled, thoroughly clean the client's skin or external genital area with soap and water before applying an antiseptic.
STEP 4:	Apply antiseptic. Select antiseptic from the following recommended products: Alcohols (60–90% isopropyl, ethyl alcohol or “methylated spirit”) (do not use on mucous membranes such as the vagina) Chlorhexidine gluconate 4% (e.g., Hibitane^Ž, Hibiclens^Ž) Chlorhexidine gluconate and cetrimide, various concentrations (e.g., Savlon^Ž) Iodine preparation (1–3%); aqueous iodine and alcohol (tincture of iodine) Iodophors, various concentrations (e.g., Betadine^Ž) Parachlorometaxylenol (PCMX or chloroxylenol), various concentrations (e.g., Dettol^Ž)
STEP 5:	Using dry, high-level disinfected forceps and cotton soaked in antiseptic, thoroughly clean the skin by gently scrubbing. Work from the operative site outward for several inches. (A circular motion from the center out helps to prevent recontamination of the operative site with local skin bacteria.)

For cervical and vaginal preps, prior to inserting a uterine elevator for minilaparotomy or IUD insertion or removal, select an aqueous (water-based) antiseptic, such as an iodophor or chlorhexidine gluconate (e.g., Hibiclens or Savlon). Do not use alcohols or alcohol-containing preparations (e.g., tincture of iodine). Alcohols burn; they also dry and irritate mucous membranes, which in turn promotes the growth of microorganisms.

Follow STEPS 1–3 above, then:

STEP 4:

After inserting the speculum, apply antiseptic solution liberally first to the cervix (2 or 3 times) and then the vagina. (It is not necessary to prep the external genital area if it appears clean. If heavily soiled, it is better to have the client wash her genital area thoroughly with soap and water before starting the procedure.)

Instructions for Skin Preparation for Injections

Skin preparation is done before injections (e.g., injectable contraceptives such as DMPA) to remove as many microorganisms as possible from the client's skin in order to prevent superficial infection at the injection site or possibly an abscess.

Steps for Skin Preparation Prior to Injection

STEP 1:	Before cleaning the skin with an antiseptic, be sure to remove all visible soil from the proposed injection site.
STEP 2:	With antiseptic applied to a fresh cotton swab, wipe the injection site thoroughly using a circular, overlapping motion starting at the center.

Gloves

Wear gloves:

When performing a procedure in the clinic or operating room
When handling soiled instruments, gloves and other items
When disposing of contaminated waste items (cotton, gauze or dressings)

A separate pair of gloves must be used for each client to avoid cross-contamination.

Using disposable gloves is preferable, but where resources are limited, surgical gloves can be reused if they are:

decontaminated by soaking in 0.5% chlorine solution for 10 minutes,
washed and rinsed, and
sterilized (by autoclaving) or high-level disinfected (by steaming or boiling).

Who Gets Needlestick Injuries

If you handle needles in any way, accidental needlesticks will occur.

Surgeons are most often stuck by needles in the operating room—by accidentally sticking themselves during suturing.
Nurses are most often stuck by needles in the hospital—by accidentally sticking themselves while handling hypodermic needles and syringes or being accidentally stuck by surgeons.
Cleaning staff are most often stuck by needles when processing soiled instruments.
Housekeeping staff are most often stuck by needles when disposing of waste material.

How to Handle Hypodermic Needles, Scissors and Other Sharp Items

Operating Room

Use a pan (safe zone) to carry and pass sharp items (e.g., pass suture needles on a needleholder).
Do not leave sharps in places other than safe zones.
Tell other workers before passing sharps.

Safety Tips When Using Hypodermic Needles and Syringes

Use each needle and syringe only once.
Do not disassemble needle and syringe after use.
Do not recap, bend or break needles prior to disposal.³
Decontaminate needle and syringe prior to disposal.
Dispose of needle and syringe in a puncture-proof container.
Make hypodermic needles unusable by burning them.

¹ Throughout this manual, when hepatitis B (HBV) is mentioned, hepatitis C (HCV) and Delta hepatitis (HDV) also are referred to because their occurrence is worldwide and their modes of transmission/prevention are similar.
²Examples include patients who have infectious diseases (e.g., tuberculosis) that can be transmitted by airborne secretions or who have urinary or fecal incontinence. When possible, these patients should be isolated to limit the chance of spreading the infection.

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