Infection Control

I. TERMINOLOGY AND BASIC CONCEPTS

A. MEDICAL AND SURGICAL ASEPSIS
Antisepsis is a practice that retards the growth of pathogenic bacte-
ria. Medical asepsis refers to the destruction of pathogenic microor-
ganisms (bacteria) through the process of disinfection. Examples of
disinfectants are hydrogen peroxide, chlorine, iodine, boric acid, and
formaldehyde. Surgical asepsis (sterilization) refers to the removal of
all microorganisms and their spores (reproductive cells) and is prac-
ticed in the surgical suite. Health care practitioners must practice med-
ical asepsis at all times.

B. HANDWASHING
As early as 1843, Dr. Oliver Wendell Holmes advocated handwashing
to prevent childbed fever. Holmes’s ideas were greeted with disdain by
many physicians of his time. Today we know that the most important
precaution in the practice of aseptic technique is proper handwashing.
The radiographer’s hands should be thoroughly washed with soap
and warm, running water for at least 10 seconds after each patient
examination. If the faucet cannot be operated with the knee, it should
be opened and closed using paper towels (to avoid contamination of
or by the faucet). The radiographer’s uniform should not touch the
sink. The hands and forearms should always be kept lower than the
elbows; care should be taken to wash all surfaces and between fingers.
Hand lotions should be used to prevent hands from chapping; broken
skin permits the entry of microorganisms. Disinfectants, antiseptics,
and germicides are substances used to kill pathogenic bacteria; they
are frequently used in handwashing substances. Alcohol-based hand
sanitizers have been recommended as an alternative to handwashing
with soap and water.

C. PERSONAL CARE
Uniforms are recommended because clothing worn in patient ar-
eas should not be worn elsewhere. Because clothing becomes 33
34 PART I. PATIENT CARE AND EDUCATION

contaminated in the patient area, a clean uniform should be worn

daily. Microorganisms can find safe harbor in jewelry, especially in
rings with stones and other crevices; many facilities do not permit
health care workers to wear artificial nails, for they can harbor fungi
and microbes. It is recommended that the only jewelry a health care
practitioner wear is a wristwatch and unadorned wedding band. Re-
member that many microorganisms can remain infectious while await-
ing transmission to another host.
Sterile technique is employed during invasive procedures, such
as biopsies, and for the administration of contrast media via the in-
travenous (IV) and intrathecal routes (e.g., IV urography and myel-
ography). When radiography is required in the surgical suite, every
precaution must be made to maintain the surgical asepsis required in
surgical procedures. This requires proper dress, cleanliness of equip-
ment, and restricted access to certain areas. One example of a restricted
area is the “sterile corridor,” the area between the draped patient and
the instrument table. This area is occupied only by the surgeon and
the instrument nurse.

II. CYCLE OF INFECTION

A. PATHOGENS
Pathogens are causative agents—microorganisms capable of producing
disease. Pathogens termed opportunistic are usually harmless, but can
become harmful if introduced into a part of the body where they do
not normally reside, or when introduced into an immunocompromised
host. Bloodborne pathogens reside in blood and can be transmitted to
an individual exposed to that blood or body fluids of the exposed indi-
vidual. Common bloodborne pathogens include hepatitis C, hepatitis
B, and human immunodeficiency virus (HIV).
The control and prevention of infection must be a hospital-wide
Factors in Infection Transmission/Cycle effort; each department is required to have its own infection-control
of Infection protocol, designed according to the risks unique to the services pro-
vided. Because radiography often involves exposure to sickness and
1. An infectious agent disease, the radiographer must be aware of, and conscientiously prac-
2. Reservoir or environment for agent tice, infection control and effective preventive measures.
to live and multiply
3. A portal of exit from the reservoir B. CONTACT: DIRECT AND INDIRECT
4. A means of transmission Infectious microorganisms can be transmitted from patients to other
5. A portal of entry into a susceptible patients or to health care workers, and from health care workers to
new host patients. They are transmitted by means of either direct or indirect con-
tact. Direct contact involves touch. The courteous act of handshaking
is a simple way of transmitting infection from one individual to another.
Diseases transmitted by direct contact include skin infections such as
boils, and sexually transmitted diseases such as syphilis and acquired
immunodeficiency syndrome (AIDS). Direct contact with droplets of
nasal or oral secretions from a sneeze or cough is referred to as droplet
contact.
Indirect contact involves transmission of microorganisms via air-
borne contamination, fomites, and vectors. Pathogenic microorganisms
expelled from the respiratory tract through the mouth or nose can be
carried as evaporated droplets through the air or on dust and settle
 CHAPTER 3. INFECTION CONTROL 35

on clothing, utensils, or food. Patients with respiratory tract infections

or disease transported to the radiology department, therefore, should Direct contact
wear a mask to prevent such transmission during a cough or sneeze; it
is not necessary for the health care worker to wear a mask (as long as • touch
the patient does). Many microorganisms can remain infectious while • droplet
awaiting transmission to another host. A contaminated inanimate ob- Indirect contact
ject such as a food utensil, doorknob, or IV pole is referred to as a
fomite. A vector is an insect or animal carrier of infectious organisms, • airborne
such as a rabid animal, a mosquito that carries malaria, or a tick that • fomites
carries Lyme disease. They can transmit disease through either direct • vectors
or indirect contact.

C. NOSOCOMIAL
Nosocomial infections are infections acquired by patients while they
are in the hospital—these infections are unrelated to the condition for
which the patients were hospitalized. The Centers for Disease Control
and Prevention estimates that from 5% to 15% of all hospital patients
acquire some type of nosocomial infection. Hospital personnel can
also become infected. It is somewhat surprising, yet understandable,
that many infections can be acquired in the hospital; surprising be-
cause hospitals are places where people go to regain their health, yet
understandable because individuals weakened by illness or disease
are more susceptible to infection than are healthy individuals. Infec-
tions acquired in hospitals, especially by patients whose resistance to
infection has been diminished by their illness, are termed nosocomial.
The most common nosocomial infection is the urinary tract infection,
often related to the use of urinary catheters that can allow passage of
pathogens into the patient’s body. Other types of nosocomial infec-
tions include sepsis, wound infection, and respiratory tract infection.
Health care practitioners must exercise strict infection-control pre-
cautions so that their equipment and/or technique will not be the
source of nosocomial infection. Contaminated waste products, soiled
linen, and improperly sterilized equipment are all means by which mi-
croorganisms can travel. Not every patient will come in contact with
these items; however, the health care professional is in constant con-
tact with patients and is therefore a constant threat to spread infec-
tion. Microorganisms are most commonly spread by way of the hands;
spread of infection can be effectively reduced by proper disposal of
contaminated objects and proper handwashing before and after each
patient. Disinfectants, antiseptics, and germicides are used in many
handwashing liquids to kill microorganisms.

SUMMARY

Antiseptics retard the growth of bacteria.

Medical asepsis refers to the destruction of bacteria through
the use of disinfectants/antiseptics.
Surgical asepsis refers to the destruction of all microorgan-
isms and their spores through sterilization.
The practice of medical asepsis is required at all times,
whereas surgical asepsis is required for invasive procedures.
36 PART I. PATIENT CARE AND EDUCATION

The single most important component of medical asepsis is

proper and timely handwashing.
A clean uniform must be worn daily; uniforms become con-
taminated and should not be worn elsewhere; pathogenic
microorganisms thrive in jewelry crevices and cracked nail
polish.
Infectious microorganisms are transmitted by either direct or
indirect contact. Direct contact involves touch. Indirect con-
tact includes airborne contamination, fomites, and vectors.
Infections acquired in hospitals are called nosocomial infec-
tions; the most common nosocomial infection is urinary tract
Guidelines for Standard Precautions infection.
Disinfectants (germicides) are used in handwashing liquids
The radiographer is now legally, as to kill microorganisms.
well as ethically, responsible for strict
adherence to standard precaution
principles identified in the following III. STANDARD PRECAUTIONS
guidelines:
• Shielding for the face and eyes must The Centers for Disease Control and Prevention (CDC) and the Hospi-
be in place whenever the possibility tal Infection Control Practices Advisory Committee (HICPAC) have re-
of blood or body fluid splashes may vised and simplified infection control guidelines for hospitals and other
occur near the face. health care facilities. The various types of isolation techniques, disease-
• Plastic aprons must be worn when- specific precautions, and varied terminology have been reviewed, re-
ever the possibility of blood or body vised, and updated. All these considerations are now incorporated into
fluid splashes may occur on the standard precautions and transmission-based precautions.
clothing. Exposure to infectious microorganisms is a daily concern for
• Gloves must be worn whenever health care professionals, especially with the rapid spread of HIV,
touching blood or body fluids is AIDS, and the hepatitis B virus (HBV ) infection. HIV-infected individ-
possible, and whenever handling uals may be symptomless and go undiagnosed for 10 years or more,
equipment or touching surfaces yet they are carriers of the infection and have the potential to spread
contaminated with blood or body the disease. Epidemiologic studies indicate that HIV infection can be
fluids is possible. transmitted only by intimate contact with blood or body fluids of an in-
• Gloves must be changed and the fected individual. This can occur through the sharing of contaminated
hands washed after every patient needles, through sexual contact, from mother to baby at childbirth,
contact. and from transfusion of contaminated blood. HIV cannot be transmit-
• Blood and body fluid spills should ted by inanimate objects such as water fountains, telephone surfaces,
be carefully cleaned and disinfected or toilet seats. Hepatitis B is another bloodborne infection; it affects
using a solution of 1 part bleach to the liver. It is thought that more than 1 million people in the United
10 parts water. States have chronic hepatitis B and, as such, can transmit the disease
• Used needles must not be separated to others.
from the syringe and must be placed Because no symptoms may be evident in patients infected with
in designed puncture-proof contain- particular diseases, such as HIV, AIDS, and HBV, all patients must be
ers. treated as potential sources of infection from blood and other body
• Prescribed procedures must be fol- fluids. The practices associated with this concept are called standard
lowed and sufficient care and at- precautions. This rationale treats all body fluids and substances as in-
tention given to risky tasks to avoid fectious and serves to prevent the spread of microorganisms to other
needle sticks and other skin pen- patients by the radiographer, as well as to protect the radiographer
etrations from cutting instruments from contamination. Body fluids and substances that may be consid-
(“sharps”). ered infectious include blood, breast milk, vaginal secretions, amniotic
• Emergency cardiopulmonary resus- fluid, semen, peritoneal fluid, synovial fluid, cerebrospinal fluid, feces,
citation (CPR) equipment must in- urine, secretions from the nasal and oral cavities, and secretions from
clude resuscitation bags and mouth- the lacrimal and sweat glands.
pieces. It is essential, then, that the radiographer makes the practice of
blood and body fluid precautions standard; that is, they must be
 CHAPTER 3. INFECTION CONTROL 37

practiced on all patients without exception. This involves the use

of barriers, such as gloves, to provide a separation between a pa-
tient’s blood and body fluids and the radiographer or other health
care worker. Special precautions must also be taken with the disposal
of biomedical waste, such as laboratory and pathology waste, all sharp
objects, and liquid waste from suction, bladder catheters, chest tubes,
and IV tubes, as well as drainage containers.
Biomedical waste is generally packaged in easily identifiable im-
permeable bags and removed from the premises by an approved
biomedical waste hauler.

IV. TRANSMISSION-BASED PRECAUTIONS

Adherence to standard blood, body fluids, and substances precautions
in the care of all patients will minimize the risk of transmission of HIV
and other blood and body substance-borne pathogens from the patient
to the radiographer and from the radiographer to patient. The use of
standard precautions also minimizes the need for category-specific iso-
lation. These have been replaced by transmission-based precautions:
airborne, droplet, and contact (Table 3–1). Under these guidelines,
some conditions/diseases can fall into more than one category.

A. AIRBORNE
Medical asepsis and blood and body fluids precautions are used when
performing radiographic examinations on all patients, but additional
precautions may be required when a patient is suspected or known to
have a particular communicable disease. For example, airborne pre-
caution is employed with patients suspected or known to be infected
with the tubercle bacillus (TB), chickenpox (varicella), and measles
(rubeola). Airborne precaution requires the patient to wear a mask to
avoid the spread of acid-fast bacilli (in bronchial secretions) or other
pathogens during coughing. If the patient is unable or unwilling to
wear a mask, the radiographer must wear one. An N95 Particulate
Respirator mask, which requires fit-testing, is the mask to be worn

TABLE 3–1. TRANSMISSION-BASED PRECAUTIONS

EXAMPLES PROTECTION
⎫
Airborne⎪ ⎪ Patient: wears mask, private, negative-pressure room
⎬
TB Radiographer: wears gloves; gown for blatant
Varicella ⎪
⎪ contamination
⎭
Rubeola
Droplet ⎫
Rubella ⎬ Patient: wears mask, private room
Mumps Radiographer: gown and gloves as indicated
⎭
Influenza
Contact ⎫
MRSA∗ ⎬ Patient: private room, wears mask if required by your
C difficile∗ facility
⎭
Some wounds Radiographer: gloves and gown, mask for MRSA if
required by facility
∗C difficile: Clostridium difficile; MRSA: methicillin-resistant Staphylococcus aureus.
38 PART I. PATIENT CARE AND EDUCATION

by health care workers. The radiographer should wear gloves, but

a gown is required only if flagrant contamination is likely. Patients
infected with airborne diseases require a private, specially ventilated
(negative pressure) room (Table 3–1).

B. DROPLET
A private room is indicated for all patients on droplet precaution; that
is, diseases transmitted via large droplets expelled from the patient
while speaking, sneezing, or coughing. The pathogenic droplets can
infect others when they come in contact with mouth or nasal mucosa
or conjunctiva. Rubella (“German measles”), mumps, and influenza
are among the diseases spread by droplet contact; a private room is
required for the patient, and health care practitioners must wear a
regular (string) mask to enter a droplet-precautions isolation room.

C. CONTACT
Any disease spread by direct or close contact, such as MRSA (methicillin-
resistant Staphylococcus aureus), Clostridium difficile (C difficile), and
some wounds, requires contact precautions. Contact precaution proce-
dures require a private patient room, and the use of gloves and gown
for anyone coming in direct contact with the infected individual or
the infected person’s environment. Some facilities require health care
workers to wear a mask when caring for a patient with MRSA.
Patients in contact isolation occasionally have to be transported
to the radiology department for examination. When this is the case, the
department should be notified first in order to prepare properly. The
patient should wear a mask and gown. The wheelchair or stretcher
should first be covered with a clean sheet, followed by a second
sheet or thin blanket. After transferring the patient to the wheelchair
or stretcher, the inner sheet is wrapped around the patient, and the
outer sheet over it (thus, the inner sheet is the contaminated one). The
radiographic room should be available and ready for the patient to
be taken in directly. The x-ray table should be covered with a clean
sheet before the patient is transferred to it. One radiographer (wearing
gloves) must be responsible for patient positioning and the other for
equipment controls and operation (to avoid contamination of equip-
ment and possible transmission of disease to others via indirect contact
or fomites).
After the examination is completed, the patient is transferred to
the wheelchair or stretcher and wrapped in the same way. Any con-
taminated linens should be placed in a plastic bag and contaminated
disposables such as tissues are placed in a separate bag; both are re-
turned with the patient to his private room.
The radiographic table and other equipment should be cleaned
with a disinfectant and hands should be washed carefully when the
task is completed.
Mobile radiography performed on patients on contact isolation
generally requires special precautions and the teamwork of two radio-
graphers. The first (or “dirty”) radiographer dons gown, gloves (gloves
must cover gown cuffs), and mask, usually available just outside the pa-
tient’s room. The necessary cassette(s) must be placed in a plastic bag
or pillowcase to protect them from contamination. This radiographer
must remember to bring an extra pair of gloves into the patient room.
 CHAPTER 3. INFECTION CONTROL 39

The mobile x-ray unit is brought into the room, and all possible adjust-
ments must be made before the radiographer touches anything else.
The equipment and cassette are positioned, and the patient is
adjusted properly. At this point, the mobile x-ray unit must not be
touched until the radiographer disposes of the gloves he or she has
on and replaces them with the clean extra pair.
The exposure is then made; the covered cassette is removed from
behind/under the patient and brought to the door. The “dirty” radio-
grapher slides the pillowcase or plastic cover away from the cassette
and the second member of the team (the “clean” radiographer) grasps
the uncovered cassette. Just inside the patient room door, the contami-
nated gloves should be removed properly and the hands washed thor-
oughly. The mask and gown ties are then untied with clean hands; the
gown is removed by placing a clean hand under the cuff and pulling
the arm down from underneath. The other sleeve is also removed by
touching only the inside of the gown. The gown is slipped off and
folded forward with the contaminated surfaces touching.
The discarded garments must be placed in the container provided.
The radiographer should then carefully rewash his or her hands, dry
them with paper towels, and take care not to touch the faucets. After
leaving the room, the mobile unit must be thoroughly cleaned with a
disinfectant and the hands carefully washed once again.
It should be noted that these patients may feel ostracized and
relegated to a kind of solitary confinement. The radiographer must
remember that these patients have the same needs as other patients
(indeed, perhaps greater needs) and be certain to treat them with
dignity and care.
Protective, or reverse, isolation is used to keep the susceptible
patient from becoming infected. Burn patients who have lost their
means of protection, their skin, have increased susceptibility to bacte-
rial invasion. Patients whose immune systems are compromised (e.g.,
transplant recipients, leukemia) are unable to combat infection and are
more susceptible to infection. These patients are treated with strict iso-
lation technique, taking care to protect the patient from contamination.

SUMMARY

Because no symptoms may be evident in patients afflicted

with certain diseases such as HIV, AIDS, and hepatitis B, all
patients must be treated as potential sources of infection from
blood and other body fluids; this is the standard precautions
concept.
The practice of standard precautions helps prevent transmis-
sion of infection to the health care professional and to other
patients.
The health care professional is legally and ethically responsi-
ble for adhering to standard precautions principles; they must
be practiced on all patients at all times without exception.
Biomedical waste (body substances and their containers)
must be disposed of in carefully controlled circumstances.
Transmission-based precautions include airborne, droplet,
and contact.
40 PART I. PATIENT CARE AND EDUCATION

Airborne precaution requires that the patient wear a mask

and be admitted to a private, specially ventilated room.
Droplet precaution and a private room are required for
measles, mumps, and influenza; the radiographer requires
a mask (if the patient is not wearing one) and may also need
to wear gown and gloves.
Contact precaution (C difficile, MRSA, some wounds) re-
quires that the radiographer use mask, gown, and gloves
when in direct contact with the patient.
Mobile radiography on a patient with contact precaution re-
quires the teamwork of two radiographers.
Protective, or reverse, isolation is used to keep the susceptible
patient from being infected.