HYGIENEAND
HEALTHCAREASSOCIATED
INFECTIONS
II
STANDARDPRECAUTIONS
MUDr. Bohdana Rezková, Ph.D.
STANDARD
PRECAUTIONS
WHO
1. Hand hygiene
2. Personal protective equipment (PPE)
3. Respiratory hygiene and cough etiquette
4. Prevention of needle stick and injuries from other sharp
instruments
5. Environmental cleaning
6. Linen - safe handling, transport, and processing of used linen
7. Safe waste disposal
8. Safe patient care equipment
PERSONAL
PROTECTIVE
EQUIPMENT
(PPE)
I
in DentalSettings
GLOVES
Wear gloves whenever there is potential for contact with blood,
body fluids, mucous membranes, non-intact skin or contaminated
equipment.
 a. Do not wear the same pair of gloves for the care of more than
one patient.
 b. Do not wash gloves. Gloves cannot be reused.
 c. Perform hand hygiene immediately after removing gloves.
PERSONAL
PROTECTIVE
EQUIPMENT
(PPE)
II
in DentalSettings
 Wear PROTECTIVE CLOTHING that covers skin and personal
clothing during procedures or activities where contact with blood,
saliva is anticipated.
 Wear MOUTH, NOSE, AND EYE PROTECTION during
procedures that are likely to generate splashes or spattering of
blood or other body fluids.
 Remove PPE before leaving the work area.
RESPIRATORY
HYGIENE /
COUGH
ETIQUETTE
I
in DentalSettings
Post this information in entrance for patients:
 Cover your mouth / nose when coughing or sneezing.
 Use and dispose of tissues.
 Perform hand hygiene after hands have been in contact with
respiratory secretions.
RESPIRATORY
HYGIENE /
COUGH
ETIQUETTE
II
in DentalSettings
 Provide resources for performing hand hygiene in or near
waiting areas.
 Offer masks to coughing patients and other symptomatic
persons when they enter the dental setting.
 Provide space and encourage persons with symptoms of
respiratory infections to sit as far away from others as possible.
PREVENTION
OF NEEDLE
STICKAND
INJURIES FROM
OTHERSHARP
INSTRUMENTS
I
 Protection especially from bloodborn pathogens transmission .
 Most exposures in dentistry are preventable.
 Each sharp item that is contaminated with patient blood and
saliva is potentially infective!!!
 Basic methods to reduce exposures to pathogens from sharp
instruments and needles are engineering and work-practice
controls.
PREVENTION
OF NEEDLE
STICKAND
INJURIES FROM
OTHERSHARP
INSTRUMENTS
II
 Engineering controls should be used as the primary method
((e.g., self-sheathing anesthetic needles, safety scalpels, and
needleless IV ports).
 Work-practice controls are behavior-based and should be used
when engineering controls are not available.
 Placing used disposable syringes and needles, scalpel blades, and
other sharp items in appropriate puncture-resistant containers
located as close as possible to the area where the items are used.
Sterilization
and
Disinfection
I
 Reused instruments must be treated according to the
manufacturer's instructions and state legislatives.
 Reprocessing procedures must be stated in written form and all
concerned person have to be trained for it.
 Using single-use items if appropriate is preffered.
 Single-use items are for one patient only and must be disposed of
appropriately.
Sterilization
and
Disinfection
II
 Patient-care items (e.g., dental instruments, devices, and
equipment) are categorized depending on the potential risk for
infection associated with their intended use:
A. Critical items - surgical instruments, periodontal scalers
(penetrate soft tissue or bone) should always be
sterilized.
B. Semicritical items (e.g., mouth mirrors, amalgam condensers,
reusable dental impression trays) come in contact with mucous
membranes or non-intact skin should be also sterilized
(dental handpieces and associated attachments), or if
inpossible, at a minimum, be processed using high-level
disinfection.
C. Noncritical items (e.g., radiograph head / cone, blood pressure
cuff, facebow), contact intact skin cleaning, or if visibly
soiled, cleaning followed by disinfection with registered
hospital disinfectant is adequate.
SELECTION
OF
DISIFECTANT
Destroying
activity
1. Bactericidal
2. Virucidal (full spectrum – also for non-enveloped
viruses (VHA), partial spectrum – only for enveloped
virusis (HIV,VHB)
3. Sporicidal - C
4. Tuberculocidal -T
5. Fungicidal -V
DISIFECTION
SOLUTIONS
Chemical
composition
I
 Aldehydes are widely used as potent sterilants and high-level
disinfectants with broad spectrum, covering bactericidal,
sporicidal, fungicidal and virucidal activity.
 Hydrogen peroxide used for sterilisation and high-level disinfection
in healthcare settings.
 Peracetic acid – broad spectrum, solutions are sporicidal,
bactericidal, virucidal and fungicidal at low concentrations;
 Chlorine-releasing agents - broad spectrum, high concentrations of
sodium hypochlorite display significant levels of sporicidal and
virucidal activity.
 Iodine – broad spectrum, bactericidal, fungicidal, tuberculocidal,
virucidal and sporicidal properties (also as antiseptic).
DISIFECTION
SOLUTIONS
Chemical
composition
II
 Phenols - disinfectants are effective bactericides, fungicides,
tuberculocides and virucides, but are ineffective against sporeforming
bacteria such as Clostridium difficile.
 Quaternary ammonium compounds - possess bactericidal,
fungicidal and virucidal properties; however, they only display
mycobacteriostatic and sporostatic activity.
DISIFECTION
products
Utility
 Hands
 Skin (antiseptics)
 Surfaces
 Equipments
Always follow manufacturer instructions for
use registered disinfectants (e.g., amount,
dilution, contact time, safe use, disposal).
STERILIZATION
Instrument reprocessing requires multiple steps (using specialized
equipment):
1. Pre-sterilization preparation (decontamination, cleaning,
disinfection, drying, packaging)
2. Sterilization
3. Storage appropriate (in covered or closed cabinets).
+ Controll tools for all these procedures.
STERILIZATION
Pre-sterilization
preparation
1. Decontamination of all instruments contaminated by human
liquids before handlig and mechanical cleaning as a protection
of staff (with virucidal disinfection).
2. Cleaning and disinfection – both in one step. Using washerdisinfector
and other device (ultrasonic cleaner) is recomanded.
3. Rincing with drinking water, drying and function check.
4. Packaging into disposable packages or placeing into container
systems. Packages should be labeled to show the sterilizer
used, the cycle or load number, the date of sterilization, and, if
applicable, the expiration date.
STERILIZATION
Physical
methods
I
A. HEAT STERILIZATION - for heat tolerant materials
Dry heat (metal, glass, powder,…)
• Parameters of sterilization (CZ):
o160 oC …… 60 min.
o170 oC …….30 min.
o180 oC …….20 min.
• Usually cheaper than autoclaving
Moist heat (steam) – autoclaves (metal, glass, plastic, …)
• Parametres of sterilization (CZ):
o121 oC - 205 kPa ….20 min.
o134oC - 304 kPa ….10 min.
B. RADIATION STERILIZATION – using gama X- rays
STERILIZATION
Chemical
methods
II
NON - HEAT STERILIZATION
- for heat - sensitive materials (plastic, device components, …)
1. Ethylene oxid (toxic gaz) - wide range of material compatibility.
2. Formaldehyde
STERILIZATION
Monitoring
Using a combination of biological, mechanical, and chemical
indicators:
1. Biological indicators (spore tests) - they assess the sterilization
process directly by killing known highly resistant
microorganisms (e.g., Geobacillus or Bacillus species).
2. Mechanical monitoring - checking the sterilizer gauges,
computer displays, or printouts; documenting the sterilization
pressure, temperature, and exposure time in sterilization
records.
3. Chemical monitoring - uses sensitive chemicals that change
color when exposed to high temperatures or combinations of
time and temperature (tapes, strips or tabs, and special
markings on packaging materials).
(Mechanical and chemical indicators do not guarantee sterilization;
however, they help detect procedural errors and equipment malfunctions.)
ENVIRONMENTAL
INFECTION
PREVENTION
ANDCONTROL
(CDC guidelines)
 Establish procedures for routine cleaning and disinfection of
environmental surfaces.
 Use surface barriers to protect clinical contact surfaces,
particularly those that are difficult to clean (e.g., switches on
dental chairs, computer equipment) and change surface barriers
between patients.
 Clean and disinfect clinical contact surfaces that are not barrierprotected
with an registered hospital disinfectant after each
patient.
 Use an virucidal disinfectant if visibly contaminated with blood.
 Select registered disinfectants or detergents / disinfectants with
label claims for use in health care settings.
DENTALUNIT
WATERLINE
!!!
 They consist of narrow-bore, plastic tubing, which are highly
susceptible to biofilm contamination.
 Oral Streptococcus species, human pathogens such as
Pseudomonas aeruginosa and Legionella species, and
nontuberculosis Mycobacterium species had all been isolated
from dental water systems.
 Cross contamination between patients has been reported in
numerous studies.
 Serological studies have also shown a higher prevalence of
antibodies to L. pneumophila in dentists and dental practice staff,
suggesting a potential health risk for these workers.
DENTALUNIT
WATER
QUALITY
 Use water that meets standards for drinking water for routine
dental treatment output water.
 Consult with the dental unit manufacturer for appropriate
methods and equipment to maintain the quality of dental water.
 Follow recommendations for monitoring water quality provided
by the manufacturer of the unit or waterline treatment product.
 Use sterile saline or sterile water as a coolant / irrigant when
performing surgical procedures.
CASE REPORT
 82-year-old woman was admitted to the intensive care unit with
fever and respiratory distress. Legionnaires’ disease was
diagnosed.The patient died in 2 days…. An investigation to find
the source of L. pneumophila infection was initiated.
 During the incubation period (2–10 d) she left her house only to
attend two appointments at a dental practice….
 Samples were taken from the tap and the high-speed turbine of
the dental unit waterlines, from the dental practice’s taps, and
from the patient’s home (taps and shower).
 All samples from her home were negative on culture, but those
from the dental practice were positive for L pneumophila (the
same serogroup 1, max. amount 6∙2×10⁴ CFU/L.)
Pneumonia associated with a dental unit waterline. Maria Luisa Ricci, Stefano Fontana, Federica Pinci, Emanuela
Fiumana, Maria Federica Pedna, Paolo Farolfi , Maria Antonietta Bucci Sabattini, Maria Scaturro
Lancet 2012; 379: 684
Legionella
pneumophila
 Gram-negative bacterium ubiquitous in natural water
environments and found also in manmade water systems;
 It can infect people by inhalation or microaspiration of aerosolised
water causing a severe pneumonia known as Legionnaires’
disease, or a flu-like disease, known as Pontiac fever.
 Potential health risk especially for immuno-compromised persons
(old persons, smokers, with cancer).
RECOMMENDATIONS
 Use of anti-stagnation and continuous-circulation water systems;
 Use of sterile water instead of the main water supply in the dental
unit waterline;
 Application of discontinuous or continuous disinfecting treatment;
daily flushing of all outlets and before each dental treatment;
 Use of filters upstream of the instruments;
 Annual monitoring of the waterline.