Infection Control in Small Animal Clinical Practice

Infection Control in Small Animal Clinical Practice
	CABI is a trading name of CAB International
	Contents
	Contributors
	Acknowledgements
	Dedication
	Section 1: Introduction toInfection Prevention and Control
	1 Historical Perspective
		1.1 Introduction
		1.2 Germ Theory Meets Veterinary Practice
			1.2.1 Lister and ‘something in the air’
			1.2.2 ‘The operation, at first sight, appears to be a terrible business’
		1.3 Infection Control and the Small Animal Clinic
			1.3.1 ‘The greatest enemy of the surgeon are micro-organisms’
		1.4 Antimicrobials
		Acknowledgements
		References
	2 Epidemiology of Nosocomial Infections
		2.1 Introduction
		2.2 Sources of Infection
		2.3 Routes of Infection
			2.3.1 Direct routes of infection
				Direct contact transmission
				Airborne aerosols
				Oro-faecal transmission
				Urine, blood and other bodily fluids
			2.3.2 Indirect routes of infection
		2.4 Common-Source Infections
		2.5 Biofilms
		2.6 Patient Risk Factors for Nosocomial Infections
		2.7 Risks Associated with Raw Food Feeding
		2.8 Infectious Organisms in Veterinary Care
			2.8.1 Bacteria associated with HAIs
			2.8.2 Fungi associated with HAIs
			2.8.3 Protozoal HAIs
			2.8.4 Viral HAIs
		2.9 Levels of Disinfection
		References
	Section 2: Principles of InfectionPrevention and Control
	3 Patient Screening
		3.1 Introduction
		3.2 The Benefits of Patient Screening
		3.3 Screening as a Tool for Outbreak Investigation
		3.4 Routine Patient Screening
			3.4.1 Methicillin-resistant staphylococci
			3.4.2 ESBL-producing Enterobacterales and CRE
		3.5 Practicalities of Screening for MDR Carriage
		3.6 Conclusion
		References
	4 Hand Hygiene
		4.1 Introduction
		4.2 Hand Hygiene: When and How
		4.3 Impediments to Hand Hygiene: Fomites
			4.3.1 Jewellery
			4.3.2 Nail polish and nail length
		4.4 Maintaining Skin Health
			4.4.1 Using hot water
			4.4.2 Low relative humidity (especially during winter or in air-conditioned buildings)
			4.4.3 Failure to use supplementary hand lotion or cream
			4.4.4 Paper towel quality
			4.4.5 Allergies to latex gloves
			4.4.6 Irritant contact dermatitis
		4.5 Hand Hygiene Products
		4.6 Use of Gloves as Personal Protective Equipment
		4.7 Hand Hygiene Auditing and Compliance
			4.7.1 Options for monitoring hand hygiene compliance
				Direct observation
				Self-reporting
				Measuring product consumption
			4.7.2 Maximizing hand hygiene compliance
				How can we improve hand hygiene compliance?
		4.8 Conclusion
		References
	5 Surgical Hand Preparation
		5.1 Aseptic Hand Preparation: Where Did It All Begin?
		5.2 Objectives of Surgical Hand Preparation
		5.3 Hand Hygiene for Healthcare Workers
		5.4 Is Hand Preparation for Surgery Necessary?
		5.5 Surgical Hand Preparation Products
			5.5.1 Aqueous solutions containing a medicated soap
				Chlorhexidine gluconate
				Povidone-iodine
				Triclosan
			5.5.2 Alcohol-based products
				Alcohol-based hand rubs
				Alcohol-based rubs containing additional non-volatile active ingredients
			5.5.3 Which product to choose for surgical hand preparation?
				Product comparisons
				Effects on the skin of the user
				Economics
				Conclusion
		5.6 Jewellery, Nail Polish and Artificial Nails
		5.7 Equipment: Scrub Brushes and Nail Picks
		5.8 Scrubbing with Products that Require Water
		5.9 Drying Hands
		5.10 Methods for Surgical Hand Preparation
			5.10.1 Antimicrobial soap
			5.10.2 Alcohol-based hand rub
		5.11 Gloving
			5.11.1 History of gloves in surgery
			5.11.2 Types of glove materials
			5.11.3 Glove performance
				Punctures/damage to gloves
				Length of wear
				Double gloving
			5.11.4 Options to reduce glove damage
				Undergloves
				Glove-in-glove
				Heavy-duty gloves
				Knitted cotton gloves
				Knit fabric glove liners
				Glove hole detection systems
			5.11.5 Other glove options
				Sensitive gloves
				Gloves containing additional coatings
			5.11.6 Methods of donning sterile gloves
				Open gloving
				Closed gloving
				Assisted gloving
			5.11.7 Changing gloves
				Technique for changing gloves
		5.12 Conclusion
		References
	6 Personal Protective Equipment
		6.1 Introduction
		6.2 Apparel and Personal Protective Equipment
			6.2.1 Apparel policies
				Scrubs and uniforms
			6.2.2 PPE
				Donning and doffing
				Appropriate use of aprons
				Appropriate use of gowns
				Appropriate use of coveralls
				Appropriate use of gloves
				Appropriate use of face protection: masks, goggles and face shields
				Hair and hair coverings
				Appropriate use of footwear
		6.3 Stethoscopes and Infection Risk
		6.4 Policy Implementation and Adherence
			6.4.1 Interventions to improve PPE implementation
		6.5 Conclusion
		References
	7 Environmental Cleaning and Disinfection
		7.1 Infection Control, Prevention and Biosecurity
		7.2 Healthcare-Associated Infections
		7.3 Infection Prevention Status Quo
		7.4 Environment
		7.5 Environment and Pathogens
		7.6 Cleaning, Disinfection and Sterilization
			7.6.1 Completeness of prior cleaning
			7.6.2 Type and level of microbial contamination
			7.6.3 Concentration and contact time of the disinfectant
			7.6.4 Presence of biofilm
			7.6.5 Product temperature and pH
		7.7 Toxic and Environmental Effects
		7.8 Surface Disinfection
		7.9 Application of Disinfectants: Wiping or Mopping?
		7.10 Challenges
		7.11 The Ideal Disinfectant
		7.12 Proper Use of Disinfectants According to Risk Level
		7.13 Transmission-Based Precautions
		7.14 New Technologies
			7.14.1 Chemical-free cleaning
			7.14.2 Self-sanitizing surfaces
		7.15 Conclusion
		References
	Section 3: Infection Control of the Surgical Patient
	8 Infection Prevention and Control in Theatre
		8.1 Introduction
		8.2 Patient Preparation
			8.2.1 Terminology
			8.2.2 General considerations
			8.2.3 Pre-operative bathing
			8.2.4 Hair removal
		8.3 Antiseptics and Surgical Skin Preparation
			8.3.1 Iodine/iodophors
			8.3.2 Chlorhexidine
			8.3.3 Alcohol
			8.3.4 Choice of antiseptic and antiseptic formulation
			8.3.5 Potential side effects of antiseptics
			8.3.6 Chlorhexidine ‘resistance’
			8.3.7  Which is better, a circular or a back-and-forth skin preparation technique?
			8.3.8 How many applications of antiseptic are required?
			8.3.9 Quality control and monitoring of surgical preparation protocols
		8.4 Theatre Ventilation
		8.5 Operating Room Traffic and Personnel
		8.6 Peri-operative Hypothermia and Forced-Air Warming Devices
		8.7 Mobile Phones, Tablets and Computers as a Source of Contamination in Operating Rooms
		References
	9 Monitoring and Prevention of Surgical-­Site Infections
		9.1 Introduction
		9.2 What Are SSIs? Definition and Classification
			9.2.1 Procedural definitions
				Surgical procedure
				Duration of the anaesthetic procedure
				Duration of the surgical procedure
			9.2.2 Wound definitions
			9.2.3 Infection definitions
		9.3 Epidemiology of SSIs
			9.3.1 The basic SSI risk index
			9.3.2 Infection rates and risk factors
		9.4 How to Recognize SSIs
			9.4.1 Physical examination
			9.4.2 Wound evaluation
			9.4.3 Markers of SSIs
			9.4.4 Imaging
				Ultrasound
				Radiography and computed tomography
				Scintigraphy
				Magnetic resonance imaging
		9.5 Prevention of SSIs
			9.5.1 Understanding the occurrence of SSIs
			9.5.2 SSI preventative measures
				Time
				Surgical experience, technique and operating room etiquette
				Optimizing surgical cleanliness
				Lack of compliance as a contributor to SSIs
				Postponing elective surgeries in case of remote infection or systemic disease
				SSI surveillance
				Surveillance period for SSIs
				SSI monitoring activities
		9.6 Conclusion
		Acknowledgements
		References
	10 Treatment of Surgical-­Site Infections
		10.1 Introduction
		10.2 Patient Assessment
			10.2.1 Patient history
			10.2.2 Physical assessment
			10.2.3 Wound evaluation
			10.2.4 Necrotizing fasciitis
			10.2.5 Summary
		10.3 Treatment of SSIs
			10.3.1 Generous multi-modal analgesia, adequate nutrition and excellent nursing
			10.3.2 Addressing and reducing contamination
				Debridement
				Wound lavage
			10.3.3 Removing implants
			10.3.4 Obtaining samples for bacteriological analysis
			10.3.5 Open-wound management
			10.3.6 Antimicrobial therapy
				MRSA
				MRSP
				Management of patients with MDR SSIs
			10.3.7 Wound closure
				Second intention healing
				Secondary closure
		10.4 Conclusion
		Acknowledgements
		References
	11 Open Wound Management
		11.1 Introduction
		11.2 Wound Healing: An Overview
			11.2.1 The ideal wound environment
		11.3 Supporting Development of a Healthy Granulation Bed
			11.3.1 Negative-pressure wound therapy
			11.3.2 Adherent dressings and hydrogels
		11.4 Supporting Wound Contraction and Epithelialization
			11.4.1 Evidence for dressing types
			11.4.2 Advanced wound dressings
				Hydrogel dressings
				Hydrocolloid dressings
				Capillary-acting dressings
				Vapour-permeable films and membranes
				Foam dressings
				Soft polymer dressings
				Odour-absorbent dressings
				Alginate dressing
				Miscellaneous
		11.5 Assessment of the Dressing
		11.6 The Chronic Wound
		11.7 Conclusion
		Acknowledgement
		References
	Section 4: Infection Control of the Hospitalized Patient
	12 Infection Prevention for Invasive Procedures
		12.1 Introduction
			12.1.1 Procedure site preparation
		12.2 Intravenous Catheters
			12.2.1 General considerations
			12.2.2 IV catheter placement
			12.2.3 Monitoring
				Flushing IV catheters
				Replacing IV catheters
			12.2.4 Evaluating for phlebitis
			12.2.5 Treatment of phlebitis
		12.3 Central Lines
			12.3.1 Central line placement
			12.3.2 Monitoring
			12.3.3 Evaluating for central line-associated phlebitis
			12.3.4 Treatment of central line-associated phlebitis
		12.4 Oesophageal, Gastric and Jejunal Feeding Tubes
			12.4.1 Feeding tube placement
			12.4.2 Monitoring
			12.4.3 Evaluating for feeding tube-associated infection
			12.4.4 Treatment of feeding tube-associated infection
		12.5 Urinary Catheters
			12.5.1 Indications for urinary catheterization
			12.5.2 Urinary catheter placement
			12.5.3 Management of indwelling urinary catheters
			12.5.4 Evaluating for urinary catheter-associated infection
		12.6 Thoracostomy Tubes
			12.6.1 Indications for thoracostomy tubes
			12.6.2 Thoracostomy tube placement
			12.6.3 Management of thoracostomy tubes
				Care of thoracostomy tubes
				Evacuation of the thoracic cavity using a thoracostomy tube
			12.6.4 Evaluating for thoracostomy tube-associated infection
			12.6.5 Thoracostomy tube removal
		12.7 Tracheostomy Tubes
			12.7.1 Indications for a TTT: routine versus emergent
			12.7.2 Management of TTTs
			12.7.3 Tracheostomy tube (TT) maintenance supply station
			12.7.4 Routine maintenance
				After suctioning
			12.7.5 Evaluation for pneumonia
		12.8 Conclusion
		References
	13 Management of the Infectious Patient
		13.1 Introduction
		13.2 Principles of Isolation
		13.3 Identifying Infectious Patients
		13.4 Zoonotic Diseases
		13.5 Infectious Diseases
		13.6 Admission and Hospitalization
		13.7 Selecting Biosecurity Tiers
			13.7.1 Risk assessments
				Infants and young children
				Pregnant team members
				Immunocompromised people
			13.7.2 PPE
				Gloves
				Face mask
				Clothing
		13.8 Clinics with Isolation Facilities
			13.8.1 Purpose-built ward area
			13.8.2 Clear signage and documentation
			13.8.3 Separate medical equipment and consumables
			13.8.4 Separate husbandry items
			13.8.5 PPE
			13.8.6 Dedicated cleaning supplies and cleaning protocols
			13.8.7 Hand hygiene
			13.8.8 Separate ventilation and drainage
			13.8.9 Waste-disposal protocol
			13.8.10 Direct access to outside
			13.8.11 Nursing care
		13.9 Clinics Without Isolation Facilities
		13.10 Other Considerations
			13.10.1 Adverse effects of isolation
			13.10.2 Maximizing observations in isolated patients
			13.10.3 Owner visits to isolated or barrier-nursed patients
			13.10.4 Personal items
			13.10.5 Audits
		13.11 Conclusion
		References
	14 Investigation and Management of Outbreaks
		14.1 Introduction
		14.2 Outbreak Investigation
			14.2.1 What and how much: defining the problem
			14.2.2 Who, where and when: orienting the problem
				The who: defining a case and a non-case
				The where and when: defining the pattern of disease in space and time
			14.2.3 Why and how: identifying key determinants
		14.3 Outbreak Management
			14.3.1 Access
			14.3.2 People
			14.3.3 Animals
			14.3.4 Environment
			14.3.5 Movement
		14.4 Outbreak Communication
			14.4.1 Real-time communication
			14.4.2 Investigation summary report
		14.5 Conclusion
		References
	Section 5: Antibiotic Use
	15 Management of the Immunosuppressed Patient
		15.1 Introduction
		15.2 Immunosuppression Following Cancer Chemotherapy
			15.2.1 Febrile neutropenia
				Definition and frequency
				Origin of infection
				Treatment
			15.2.2 Asymptomatic neutropenia
				Evidence for antimicrobial prophylaxis
				Evidence against antimicrobial prophylaxis
				Appropriate cut-offs for initiating antimicrobial prophylaxis
				Appropriate antimicrobials for prophylactic use
				Alternative strategies for reducing infection
		15.3 Other Immunosuppressive Medications
		15.4 Naturally Occurring Immunosuppression
		15.5 Conclusion
		References
	16 Antibiotic Mechanism of Action and Resistance
		16.1 Introduction
		16.2 Mechanism of Action
			16.2.1 Antibiotics that target the structural protective barriers of bacteria
				Antibiotics that target cell-wall synthesis
				Antibiotics that target cell-membrane synthesis
				Loss of outer-membrane permeability
			16.2.2 Antibiotics that inhibit protein synthesis
				Inhibition of the 30S ribosomal subunit
				Inhibition of the 50S ribosomal subunit
			16.2.3 Antibiotics that affect nucleic acid synthesis
			16.2.4 Antibiotics targeting biochemical pathways
		16.3 Mechanisms of Resistance
			16.3.1 Modification of the antibiotic
				Chemical alteration of the antibiotic
				Inactivation of the antibiotic
			16.3.2 Reduction of intracellular antimicrobial concentrations
				Prevention of antibiotic penetration into the cell
				Increased antibiotic efflux out of the cell
			16.3.3 Modification of the antibiotic target site
		16.4 Transfer of Antimicrobial Resistance
		16.5 Conclusions
		References
	17 Responsible Antimicrobial Usage in Small Animal Practice
		17.1 Introduction
		17.2 Responsible Antimicrobial Usage
		17.3 Antimicrobial Stewardship
		17.4 Antimicrobial Usage in Small Animal Practice
			17.4.1 Changes in antimicrobial usage over the last decade
		17.5 Factors that Influence Antimicrobial Prescribing
			17.5.1 Clinical and patient-level elements
			17.5.2 Non-clinical, higher-level elements
		17.6 In-Practice Measures to Reduce and Improve Antimicrobial Usage
			17.6.1 More accurate diagnosis: greater use of easily available diagnostic tests
			17.6.2 Use professional guidelines and create a practice prescribing policy
			17.6.3 Access and availability of antimicrobial products in practice, and measures to reduce usage of HPCIAs
			17.6.4 Not using antimicrobials when they are not required
			17.6.5 Clinical governance: oversight, audit, benchmarking and prescription review with feedback to veterinarians
				Oversight
				Audit and benchmarking
		17.7 Conclusion
		References
	18 Antimicrobial Use and Resistance Surveillance in Companion Animals
		18.1 Introduction
		18.2 Antimicrobial Prescription
		18.3 Antimicrobial Use and Prescription Surveillance
			18.3.1 Quantifying antimicrobial prescription
				Antimicrobial sales by weight
				Survey-based approaches
				EHRs
				Other surveillance methods
			18.3.2 Characterizing antimicrobial prescription
				Qualitative approaches
				Survey-based approaches
				EHRs
		18.4 Approaches to Antimicrobial Resistance Diagnosis
			18.4.1 AMR surveillance
		18.5 Antimicrobial Stewardship
		18.6 Conclusion
		References
	19 Antibiotic Use in Surgical Patients
		19.1 Introduction
		19.2 Prophylactic Antibiotic Use in Surgical Patients
			19.2.1 Bacterial contamination of the surgical site and infection risk
			19.2.2 Principles of surgical antimicrobial prophylaxis
			19.2.3 Wound classification to guide antibiotic use in surgical patients
				Clean surgical procedures
				Clean-contaminated surgical procedures
				Contaminated surgical procedures
				Dirty surgical procedures
			19.2.4 Antibiotic regimens for prophylactic purposes
				Agent selection
				Route of antibiotic administration
				Timing of antibiotic administration
				Redosing intervals
				Duration of antibiotic administration
		19.3 Therapeutic Antibiotic Use in Surgical Patients
			19.3.1 Diagnosis of bacterial disease
			19.3.2 Antibiotic regimens for therapeutic purposes
				Agent selection
				Route of antibiotic administration
				Dosing and duration of antibiotic administration
		19.4 Inappropriate Antibiotic Use in Surgical Patients
		19.5 Conclusion
		References
	20 Antimicrobial Use in Medical (Including Chemotherapy) Patients
		20.1 Introduction
		20.2 Treatment of Sepsis
		20.3 To Use or Not To Use?
			20.3.1 Gastrointestinal disease
			20.3.2 Respiratory tract disease
			20.3.3 Urinary tract disease
		20.4 The Non-Prescription Form
		20.5 Conditions of Use
		20.6 Will It Get to Where It Is Needed?
		20.7 Broad Versus Narrow Spectrum
		20.8 Could Antibiotics Make Things Worse?
		20.9 Shorter is Better
		20.10 Conclusion
		References
	Index