INFECTION PREVENTION AND CONTROL POLICY , HOSPITAL CANSELOR TUANKU MUHRIZ

Policies and Procedures on Infection Prevention and Control HCTM

3.4 : Pseudomonas aeruginosa
1. Pseudomonas aeruginosa is gram-negative bacteria usually implicated in with healthcare-associated

infection.
2. Pseudomonas aeruginosa may express multiple intrinsic resistance mechanisms or acquire resistance

conferred by the transfer of plasmids.
3. They can be found ubiquitously in soil, plants, and in the hospital environment.

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CHAPTER 4 : INFECTION CONTROL POLICY FOR MDROs

Introduction
▪ MULTIDRUG RESISTANT ORGANISM (MDROs) are bacteria that have developed resistance to
more than 2 different classes of antibiotics. Development of multi-drug resistance has been
associated with inappropriate and overuse of antibiotics
▪ They are major public health concerns due to them being associated to severe healthcare-
associated infections
▪ There are limited options even no treatment for many of the MDROs
▪ Examples of significant resistant organism include:
➢ Gram positive: MRSA and VRE
➢ Gram negative: ESBL-producing bacteria, CRE, Acinetobacter sp. MDROs, MDR
Pseudomonas aeruginosa

Gram Negative MDROs

A. Carbapenem-resistant Enterobacteriaceae (CRE) (To Refer CRE Guidelines)

B. ESBL producing bacteria
▪ ESBL Enterobacteriaceae (ESBL-E) confer resistance to second and third generation

cephalosporins group
▪ Gastro-intestinal tract is the main ESBL-E reservoirs
▪ ESBLs have since spread into community
▪ ESBL-E dissemination have led to overuse of carbapenems triggering the emergence of CREs

C. Acinetobacter species
▪ Acinetobacter spp. Is a gram-negative bacteria, usually pose no risk to healthy individuals

D. Pseudomonas aeruginosa
• Pseudomonas aeruginosa is a gram-negative bacteria that usually implicate HCAI

E. Transmission of GN-MDROs
▪ GN-MDROs are transmitted via direct contacts, carried by patients, healthcare staff or visitors,

either harmlessly or if they are infected with it. It can spread between patients through direct
contact with each other, particularly with wounds and stool, or by touching items or surfaces
that person with MDROs may have touched such as bed rails, toilets or equipments
▪ GN-MDROs causes infections when they enter the body, often via medical devices like
ventilators, intravenous catheters, urinary catheters or wounds.

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▪ Patients who had been administered with multiple antibiotics can be also be at risk of picking
up MDROs

Gram Positive MDROs
A. MRSA
▪ Staphylococcus aureus that is resistant to the synthetic penicillin (methicillin, oxacillin, nafcillin)
is referred to MRSA
▪ They colonise the skin, anterior nares, skin folds, hairline, axillae, perineum and umbilicus
▪ They may also colonise chronic wounds

B. VRE
▪ Vancomycin-resistant enterococci (VRE) are a common and difficult-to-treat cause of hospital-

acquired infection
▪ Concerns about MRSA and VRE are related to their high potential risk of transmission and

limited number of antibiotics available to treat these organism
▪ Simply starting vancomycin to empirically “cover for” MRSA is a risk factor for VRE which has

considerable high mortality risk

C. Transmission of GP-MDROs
▪ MRSA is transmitted via direct contact between person-to person, commonly through the hands

of health care workers
▪ Nasal carriage of MRSA is also common

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INFECTION CONTROL AND PREVENTION OF MDROs

Objectives:
▪ To prevent and control the spread of Multidrug-resistant Organisms
▪ To minimise the risk of cross-infection to other patients, staff and visitors

Screening
▪ Screening patients for MDRO is an important measure in the control of the spread of these
resistant organisms
▪ Who to screen?
➢ Patients are screened for MRSA, VRE, CRE and ESBL according to high risk areas.
(see figure 1 and 2)
➢ Screen positive patient on discharge
➢ Screen all patients in the event of outbreak
➢ Screen patients that may have come in contact with positive MDRO patient
➢ Previously infected or colonised patient
▪ When to screen?
➢ Screen newly admitted patients who were recently infected or colonised with MDROs
( up to 6 months for GNR, 1 year for GP MDROs)
➢ Screen positive gram-positive MDRO patient at discharge
▪ Screening specimens
➢ MRSA: nasal swab (one for both nostrils) and perineum. Other areas include axillae,
groins and wounds
➢ VRE: faeces and rectal swab
➢ CRE: faeces and rectal swab. Additionally, can screen from urinary, discharging
wounds or tracheal aspirate samples
➢ ESBL: faeces or rectal swab (Do not screen for ESBL unless clinically indicated)

SPECIAL NOTES ON HCW SCREENING: routine screening for HCW is not recommended.
Screening for HCW is only indicated when an outbreak situation is uncontrolled.

Communication Alert
▪ Patients found to be positive upon screening or having proven clinical infection of MDROS need
to be alerted to other staff
▪ Booking staff will stamp “Contact Precaution Alert” on the patient’s registration note
▪ Notifications need to be made to the Hospital Infection Control Unit
▪ Coloured sticker or star will be put in patients’ clinical notes
▪ Tagging of patient alert status will also appear electronically in patients’ information system
▪ Type of precaution signage will be put at the door of patients’ isolation room or at the front of
cohorting area

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Figure 1: Risk categories for acquiring MDROs

Placement
▪ Patients with confirmed positive MDRO are cared for in a single room, with access to a
dedicated bathroom with toilet
▪ If a dedicated toilet for the isolation patient is not possible, a commode at the bedside must be
used
▪ In the event of an outbreak and insufficient isolation rooms, affected patients need to be
cohorted at a designated area away from other inpatients.
▪ Signage at the doorway of the room indicating type of PPE (transmission-based precautions)
must be displayed
▪ Signage at the doorway indicating alert organism
▪ When isolation facilities are limited, the following isolation room prioritisation for patients with
an MDRO is recommended:
* Carbapenem-resistant Enterobacteriaceae (CRE)
* Vancomycin-Resistant Enterococcus (VRE)
* multi-resistant gram-negative species (GN-MDRO) e.g. Acinetobacter baumanii and
Pseudomonas aeruginosa
* ESBL-Other than E.coli (e.g., Extended spectrum beta-lactamase Kleb. pneumo, Kleb. oxytoca,
Enterobacteriaceae)

Movement of Colonised/Infected Patient

A. Within hospital
▪ The receiving area should be informed regarding MDR status of the patient, and be advised
on need for contact or standard precautions
▪ Dress the patient in a fresh gown
▪ Ensure all dressings are occlusive and that all drips, drains and other devices are secure

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▪ Encourage the patient to perform hand hygiene before leaving the room
▪ The patient must not use patient areas such as family rooms or communal lounge areas

B. Specialised area – Procedure rooms, Specialist clinics, Radiology
▪ As above and if possible keep at the end of working session

C. Another hospital
▪ Before transfer, liaise with the receiving health care facility regarding the MDRO status of
the patient
▪ MDRO status should be indicated on any transfer documentation

D. Discharge
▪ Liase with GP/ community health care staff regarding patient MDR status via documentation

in referral letter
▪ Home care advice to family members
▪ Tag patient for future references

E. Transportation
▪ Lesions should be covered with impermeable dressing
▪ Drains and devices are secure
▪ Staff should wear appropriate PPE
▪ Wheelchairs used for transporting the MDRO patients must be covered with a clean sheet
or disinfected after use by the ward assistant or nurse with cleaner and disinfectant wipe
currently approved for use

Prevention on Colonisation and Infection

A multifaceted strategy composed of standard precautions, antibiotic stewardship practice, environmental
cleaning and source control were found to be the most effective interventions to prevent the acquisition of
GN-MDROs.

A. Contact Precautions

1. Hand hygiene
▪ Perform 5-moments-hand-hygiene at ALL times when caring for MDRO patients
▪ Either alcohol rubs or water with soap can be used for hand hygiene

2. Gloves
▪ Gloves should be used when caring for MDRO patients
▪ Regardless of gloving, 5 moments hand hygiene MUST be practised

3. PPE

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▪ Choice of PPE is according to the organism being attended

▪ If the patient has a respiratory infection/and or is coughing, droplet precautions in addition
to contact and standard precautions are required, and the patient will be required to wear a
surgical mask if being transported or transferred

B. Ward practices
1. General practices

▪ Avoid re-use of a previously opened ampoule water of sodium chloride solution for injections
▪ Avoid the use of stock solutions for preparations of IV fluids
▪ Use sterile fluid for nebulisers and humidifiers
▪ All shared communal facilities such as lavatories, bathrooms etc should be cleaned at least

three times daily and kept dry
▪ Terminal cleaning shall be performed upon patient discharge
▪ The taps and sinks should be designed to minimise splashing from the sink area

2. Visitors policy
▪ Visitors may need to wear PPE depending on type of MDRO
▪ Visitors must be instructed to perform hand hygiene before and after visiting
▪ Visitors are not to visit other areas or other patients after visiting MDRO patient
▪ It is recommended that children are not allowed to visit MDRO patients

C. Antimicrobial Stewardship Program (ASP)
▪ ASP as a core component were strongly associated with a decrease of ESBL acquisition
▪ Antibiotic usage should follow the HCTM antibiogram or local antibiotic guidelines with
special reference to antibiogram pattern
▪ Avoid excessive use of broad-spectrum antimicrobials as a first line treatment
▪ Injudicious use of broad spectrum antimicrobials will promote emergence if MDROs
▪ Surgical antimicrobial prophylaxis should be as narrowest spectrum as possible, given at
appropriate time and restricted to one dose pre-operatively, unless clinically indicated (**
refer on AMS chapter)

D. Disinfection and Environmental Cleaning
▪ Acinetobacter baumannii has been noted for its apparent ability to survive in the
environment for a prolonged period, even in dry conditions on particles and dust thus
contributing to development and persistence of outbreaks.
▪ In addition to standard practice and ASP, environmental cleaning reduces MDR-AB
acquisition.

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▪ Best practices in reprocessing medical equipment/devices must include a centralized area
for reprocessing (CSSD) or an area that complies with the requirements for reprocessing.

▪ Critical medical and surgical devices and instruments that enter normally sterile tissue, body
space or vascular system must be sterilized before use.

▪ Steam sterilization is the preferred method for sterilizing critical medical and surgical
devices.

▪ Needles must be single-use and must not be reprocessed.
▪ It is strongly recommended that catheters, drains and other medical equipment/devices with

small lumens (excluding endoscopy equipment) be designated single-use and not be
reprocessed and re-used, even if designated as reusable by the manufacturer.
▪ Reusable medical equipment/devices must be thoroughly cleaned prior to before
disinfection or sterilization. Gross soil should be removed immediately after use.
▪ All creams, gels, and liquids used must be stored in such a way to prevent contamination
and patient-to patient spread of gram-negative organism. Storage area temperature is
generally less than 24°C and Relative Humidity should not exceed 70%.
▪ All procedures, cleaning, disinfecting, disposing, re-packaging, storing and transportation
be checked and monitored by a trained and certified staff

Source Control or Decolonization Management.

MRSA

▪ Antibiotics are used for treatment of MRSA infections and eradication of skin and nasopharyngeal
colonisation

▪ Eradications are recommended for:
➢ Surgical procedures
➢ ICU admissions
➢ Inpatient outbreaks

• Decolonisation procedure: (see algorithm)
➢ Chlorhexidine gluconate 4% or 2% triclosan: Use daily for body wash during shower, and
twice weekly for hair wash. Repeat every day for 7 days
➢ Mupirocin 2% ointment: Apply small size ointment to both anterior nares using cotton buds
3 times daily for 7 days
➢ Use disinfectant dusting powder (hexachlorophene 0.33%) after bathing and drying. Apply
to axilla, groin and all skin folds
➢ Do not use topical antibiotics for localised wound infection

PROCEDURE FOR USING NASAL MUPIROCIN OINTMENT 2% (NASAL TREATMENT TDS X 5/7)

1. Clean both hands with water and antiseptic soap or alcohol hand rub.

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2. Place and apply nasal mupirocin ointment 2% into the nasal passages using a clean cotton bud. (1
clean cotton bud for each nasal cavity)

3. Squeeze and massage the nasal to even out the nasal mupirocin ointment 2% for 1 minute
4. Repeat the same procedure 3 times a day for 5 days.
5. Dispose of used equipment exposed to patient’s body fluids into a clinical waste bin.
PROCEDURE FOR USING CHLORHEXIDINE 4% (BATH OD X 5/7)
1. Wet the whole body with clean water
2. Use 4% chlorhexidine as soap and head shampoo.
3. Ensure all areas on body and head are covered. Focus on the thighs, armpits and other folds.
4. Avoid contact to eyes to avoid irritation
5. Leave on for 3 minutes, then rinse the whole body and head with clean water.
6. Wipe the whole body with a dry and clean towel. Dress patients with clean clothes as well.
7. Repeat the same procedure once a day for 5 days for patients and MRSA carriers.
8. Dispose of used equipment exposed to patient’s body fluids into a clinical waste bin.
9. Report to the Infection Control Unit if there are any side effects of use (skin irritation, coarse hair).

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MRSA TOPICAL DECOLONISATION ALGORITHM

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GUIDELINES ON MANAGEMENT OF CARBAPENEM-RESISTANT ENTEROBACTERIACEAE
(CRE) IN HOSPITAL CANSELOR TUANKU MUHRIZ.

Definitions
1. Carbapenem-resistant Enterobacteriaceae (CRE)

The terms refer to bacteria that are members of the family Enterobacteriaceae that have been found to
have resistance to carbapenem antibiotics by any mechanism.

2. Confirmed Carbapenem-resistant Enterobacteriaceae (CRE) case
A person with a laboratory confirmed CRE isolate (clinical sample or screening sample), who is either
colonized or infected with a CRE.

3. Suspect/Contact of Carbapenem-resistant Enterobacteriaceae (CRE) case
An individual who is exposed to a confirmed case (colonized or infected) with CRE during the infectivity
period or has had a contact in an area of high transmission risk.
➢ If undetermined, the period of likely acquisition is at least 2 days before the sample was taken.
➢ For example: A suspect can be defined as patient who shared a room or cubicle with the case
for ≥ 24 hours during the infectivity period of the case at least 2 days before the sample was
taken from the confirmed case.

4. High Transmission Risk Area
An area or a ward is considered high risk transmission area whenalocal transmission has occurred, and
the following criteria is used:
➢ At least 2 or more confirmed cases of CRE of which at least one case is locally acquired AND
➢ There is epidemiological link eg: proximity of cases / sharing of staffs / equipment or from a
possible environmental source (e.g. bathroom or toilet facility)

5. Infectivity Period
The time when the laboratory confirmed CRE case could potentially transmit to another patient.
The period should be the date of likely acquisition to the time the case is placed into contact precaution
(either isolation) OR discharged or transferred.
If unclear, the period of likely acquisition is at least 2 days before the sample was taken.

6. Carbapenem-resistant Enterobacteriaceae (CRE) Carrier
Majority of people who acquired CRE are colonized rather than infected. The primary site of colonization
is lower gastrointestinal tract. Duration of colonization can be prolonged (> 6 months). CRE can survive
on environmental surface and equipment.

CRE Screening

A. Choice of Screening Specimen
▪ Infection control laboratory request forms are to be marked CRE screening.
▪ Rectal swab (with evidence of faecal matter on the swab)** or fecal specimen (when rectal
swab is contraindicated e.g Neutropenic patient) is mandatory.
▪ A peri-anal swab is not acceptable because of low sensitivity and specificity.
▪ In addition, the following samples can be considered, but not routinely undertaken:
o wound swab
o urine sample
o tracheal aspirate
o stomal specimen

In order to avoid unnecessary screening samples, please discuss with microbiologist or infection control unit
regarding appropriate samples.

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B. Procedure for collecting rectal swab
▪ Clean the gluteal area with clean water.
▪ Wet the sterile cotton swab with sterile water.
▪ Insert wet sterile cotton swab 2-3 cm deep from anal canal and gently rotate 360 degrees 2-3
times.
▪ Ensure the swab has faecal material.
▪ Place swab into transport media.

C. Who to screen ?
▪ ROUTINE screening will be conducted on this group of patients:
i. Contact(s) of a CRE case.
ii. Patient transferred from another hospital with CRE cluster or outbreak.
iii. Critical Area (when needed)
iv. A contact of confirmed CRE case who has not screened before in the initial period (e.g.
due to early discharge).

**Note: These group of patients should be isolated.

▪ In OUTBREAK situation, additional screening strategies for HIGH-RISK PATIENTS should be
considered:
i. Prolonged hospital stays (more than 2 weeks).
ii. Multiple use of antibiotic agents (the last 3 months) including extended-spectrum
penicillin, cephalosporins, fluoroquinolones and carbapenems.
iii. Indwelling medical device, such as a central venous catheter, haemodialysis catheter,
urinary catheter, biliary catheter or wound drain.
iv. Mechanical ventilation.
v. Admission to the intensive care unit.
vi. Organ or stem-cell transplant.
vii. Severe illness.
viii. Haematology patients.

D. Screening Strategy
▪ Sequential screening is implemented for contact who are negative on the first screen i.e. If 1st
rectal swab (Day 1) reported as CRE negative, to repeat 2nd rectal swab (Day 7). Refer Diagram
1. This is because most patient tend to develop faecal positivity at around day 8 of exposure.

▪ A suspect / contact is considered negative when:
➢ ≥1 screening specimen/s reported negative taken >7 days after the last contact with the CRE
case.

▪ If patient is discharged before 1st or 2nd rectal swab is taken, to tag patient as ‘suspect’ for CRE
➢ Take rectal swab for CRE screening if this patient is readmitted within 1 year.
o If positive, to follow CONFIRMED CASE PROTOCOL
o If negative, to off tag as suspect

➢ If this patient is readmitted after 1 year, repeat rectal swab is not needed.

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E. Methods of surveillance (To refer on MOH Guidelines on Management of CRE in Healthcare setting)

Diagram 1: Determination of contact to be screened based on the period of
infectivity of CRE case

CONTACT OF A CONFIRMED CRE CASE

Definition:
1. Individual who had contact ≥24 hours with the confirmed CRE case
2. Individual who had been in contact ≥24 hours AND at least 2

days before sampling date till index case is isolated /
cohorted

Contact precaution initiated

Sample taken CRE positive

1st March 2nd March 3rd March 4th March 5th March

Period of infectivity/ contact to be screened

Note:
• Contacts needed to be screened are those who have

had exposure of ≥24 hours starting from 1st March till 5th
March
• Screening sample need to be taken on Day 1= 5th March
and if negative, Day 7= 11th March

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Management of Confirmed CRE Case

Flow Chart 1: Management of Confirmed CRE Case

▪ Reporting by ICLN into the system eNsiden
▪ Reporting of CRE result from Laboratory
▪ Infection control Nurse (ICN) to complete the MDRO/MRSA

surveillance database.

CONFIRMED CRE CASE

Identify Contacts Confirmed CRE • Notification:
according to (infection / colonization) Fill up MDRO –

Contact Definition ** No further screening samples MRSAB Surveillance
(only for CRE (rectal swab/urine sample) need to be
sent for a confirmed CRE case form
cases tested from • Infection Control
clinical sample)
Precautions
Refer to Flow • Tag patient for minimum
Chart 2
of 1 year

If patient is readmitted If patient is readmitted
within 1 year after > 1 year

To cohort / isolate the Repeat rectal swab for CRE
patient *can consider other
No screening screening samples according
samples need to be to clinician judgement /site of
taken active infection
Refer to Infection Control
Precautions table

Positive Negative

Continue Off CRE tag
CRE tag

** However further screening sample can be considered after discussion
with ID Physician / Microbiologist, on case to case basis

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Diagram 2: Implementation of Infection Control Precautions for Confirmed MDROs Case

Patient placement (in order of preference):
• Single room with attached bathroom
• Single room without attached bathroom
• Cohort in dedicated cubicle / area
• General ward with dedicated toilet facilities / commode and

isolation tray / trolley beside the bed are strongly
recommended

Clear signage should be visible to alert healthcare workers and
visitors of requirement of transmission precautions before entering
the room / cubicle

When patient is placed in isolation room:
• Gloves and isolation gown must be worn before entering the

room
• Gloves need to be removed first before isolation gowns
• Hand hygiene should be performed after removing each PPE
For patients who are nursed in a dedicated cubicle / area or
general ward:
• Wear gloves and isolation gown / plastic apron only when there

is bodily contact (i.e., HCW clothing will have direct contact
with the patient) or potentially contaminated environmental
surfaces or equipment in close proximity to the patient
• Gloves need to be removed first before isolation gowns / plastic
apron
• Hand hygiene should be performed after removing each PPE
Note: Surgical mask and eye protection should be worn for
procedures / activities likely to generate splashes/ sprays of blood,
body fluids, secretion and excretions.

Hand hygiene is to be practiced according to WHO 5 moments of
hand hygiene

• Clean and disinfect the environmental surfaces which are
frequently touched including toilet with hospital-approved
disinfectants daily

• Terminal cleaning shall be performed upon patient discharge /
transfer

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Patient care equipment and linen:
• Dedicated equipment of non-critical patient care equipment (i.e.,

stethoscope, blood pressure set, thermometer or bedside
commode)
• If unavoidable, adequately clean and disinfect them before use
on another patient
• Contaminated linen should be handled as little as possible to
prevent gross microbial contamination of the air. Washing /
disinfecting linen should be handled according to hospital
protocol

Place tag on medical record/ BHT/ follow-up cards so that contact
precautions are instituted during revisits/ readmissions

Dedicated nursing staffs (recommended)

Minimize patient movement (refer Section 3 Patient movement)

Notify the receiving facilities if patients are to be transferred to other
facilities

Decolonization strategy is not recommended

Daily Chlorhexidine 2% bath to all affected patients

Disposable utensils if possible

Limit visitors

Non-essential staffs, example medical students, trainee nurses
should be restricted/ supervised in patient’s care

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Management of CRE Suspects / Contacts to a confirmed CRE Case.

Flow Chart 2: Management of Contact of Confirmed CRE Case
CONTACT OF A CONFIRMED CRE CASE

Identify Contact of a Confirmed CRE Case

Send Rectal Swab No Rectal Swab Sent
due to early discharge

or tranfer

1st Rectal Swab Positive 1st Rectal Swab Negative
(Day 1)
Tag patient
Patient is still Patient has been
• Notification: hospitalized discharged
Fill up MDRO – MRSAB
Surveillance form - Continue contact Tag patient as “CRE Contact”
precaution
• Infection Control If readmitted
Precautions - Minimize patient within 1 year
movement
• Tag patient for To repeat rectal swab
minimum 1 year Repeat Rectal on admission
Swab at Day 7

Positive Negative Positive Negative

Tag CRE Patient Off contact Tag CRE Patient Off contact
(Flow Chart 1) status (Flow Chart 1) status

** Guidelines recommend repeating rectal swab at Day 7 as it improves detection rate
** In resource limited setting a repeat rectal swab at Day 7 is recommended in high risk
contacts

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Diagram 3: Implementation of Infection Control Precautions for CRE Suspects / Contact
Patient placement
• Ideally patient should be placed in a single room with attached
bathroom facilities, especially those cases that fit high risk of
onwards transmission.
• However, if this is not possible, to aim functional isolation i.e. to keep
patient where he is and to tighten infection control without physical
barrier.
- Do not transfer patient / minimize patient movement
- Dedicated equipment (i.e., stethoscope, blood pressure cuff,
thermometer, glucometer). If not possible, to disinfect after use.
- Dedicated nursing staff
- Not to put together the confirm case with the contact/ suspect
case.
Hand hygiene is to be practiced according to WHO 5 moments of hand
hygiene
• Clean and disinfect the environmental surfaces which are
frequently touched with hospital-approved disinfectants daily
• Terminal cleaning shall be performed upon patient discharge /
transfer

Tag patient as “CRE contact” in medical record/ BHT/ follow up card
(physically or electronically)

Notify the receiving facilities if patients are to be transferred to other
facilities

Daily Chlorhexidine 2% bath to all affected patients

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Patient Movement (Patient movement for radiological procedure / surgical intervention / hemodialysis)
A. Notification

▪ All confirmed CRE case need to be notified to the respective receiving department.

B. Patient placement
▪ The patient should be isolated if possible while waiting for procedure to be done and should not
be allowed to mix with other patients
▪ If isolation is not possible then patients with CRE should be placed away from other patients (e.g. at
the end of the row) and a dedicated toilet (example: handicapped toilet) should be identified.

C. Personal Protective Equipment
Staff who accompany the patient during the transportation should:

▪ Wear isolation gown or apron and gloves when undertaking procedures (i.e., intravenous cannula
insertion) or assisting a patient to toilet.

▪ Remove the isolation gown / apron and gloves and perform hand hygiene before exiting the
immediate patient care area.

▪ Gloves must be changed during patient care.

D. Movement of patients
▪ Patients should be advised to remain in the isolation room if possible.
▪ Open wound should be covered with impermeable dressing before transport.

E. Equipment and instruments / devices
▪ Equipment (e.g. blood pressure cuff, tourniquet, glucometer) preferably should be dedicated for
the one patient’s use.
▪ Such items should be appropriately cleaned, disinfected and stored between admissions.
▪ Transport trolley or wheelchair should be cleaned with disinfectant after use.
▪ Patients undergoing endoscopic / surgical procedures should be done as the last case / at
dedicated Operation Theatre whenever is applicable.

F. Terminal cleaning
▪ Terminal cleaning of the area should be done after operation or procedure.

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Outbreak Management Of CRE

In HCTM,

I. At least 2 or more confirmed cases of CRE in which at least one case is locally acquired AND there is
a plausible epidemiological link eg: proximity of cases / sharing of staff / equipment or from a
possible environmental source.

II. Increasing number of unlinked transmissions detected in a particular ward / area.

General recommendations:
▪ Timely notifications to Infection Control Unit, Management and relevant departments.
▪ Collect and provide the data to Infection Control Unit, Management, relevant departments
and state.
▪ Screen CRE contacts
▪ Strengthen infection control precautions (Refer Diagram 2).
▪ Education to healthcare workers, patients, relatives / care takers including concessional
workers.
▪ Review compliance audit on hand hygiene practices, standard and transmission-based
precautions, environmental cleaning and disinfection processes.
▪ For further details of outbreak management refer Policies & Procedures on Infection Prevention
and Control Third Edition.

Screening recommendation:
▪ Ensure all the CRE contacts are identified and screened according to Flow Chart 2.
▪ If there is ongoing CRE transmission despite adherence to general recommendations above,
consider
▪ Point prevalence screening of the affected ward or,
▪ Extended screening strategy for high risk patients
▪ Environmental and staff screening is usually not recommended unless persistent transmission
despite all above measures implemented.

Multidisciplinary approach involving administrator of the hospital, infection control unit and respective departments
in order to control the outbreak.

▪ Identify an isolation ward to admit all confirmed CRE cases.
▪ The suspect / contact should not be admitted together with confirmed CRE cases.

Laboratory Detection and Confirmation Methods

The ability of clinical microbiology laboratories to reliably detect Carbapenem resistant Enterobacterales
(CRE) is an important element of the effort to prevent and contain the spread of these pathogens and an
integral part of antimicrobial stewardship.

Centers for Disease Control and Prevention (CDC) define CRE as Enterobacterales that are resistant
to imipenem, meropenem, doripenem, ertapenem, meropenem/vaborbactam, or imipenem/relebactam
by standard susceptibility testing methods (specifically, minimum inhibitory concentrations of ≥4mcg/mL
for doripenem, imipenem, meropenem, meropenem/ vaborbactam, and imipenem/relebactam or ≥2
mcg/mL for ertapenem) OR by production of a carbapenemase (e.g, NDM, KPC, VIM, IMP, OXA-48)
demonstrated using a recognized test (examples: polymerase chain reaction, metallo-β-lactamase test,
Carba-NP).

Carbapenem resistance among Enterobacterales can be divided into:

1. Non-carbapenemase-producing CRE (non CP-CRE):
Some CRE possess a β-lactamase (e.g. hyperproduction AmpC or extended-spectrum β-lactamase

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(ESBL)), combine with altered membrane permeability, which can render an organism
nonsusceptible to carbapenems.
2. Carbapenemase-producing CRE (CP-CRE):
Some CRE possess a carbapenemase (carbapenemase-producing CRE or CP-CRE) that directly
breaks down carbapenems. Carbapenemase genes (e.g NDM, KPC, OXA-48, IMP and VIM) can be
spread rapidly between bacteria with potential for widespread transmission of carbapenem
resistance. Therefore, CP-CRE is of epidemiological concern and their detection may warrant
implementation of more intensive infection control interventions with potential transmission through
colonization screening.
In HCTM, CRE surveillance includes CP-CRE and Non CP-CRE data
Some Enterobacterales (e.g., Proteus spp., Morganella spp., Providencia spp.) have intrinsic elevated
minimum inhibitory concentrations (MICs) to imipenem by mechanism other than production of
carbapenamases. Meropenem, ertapenem, and/or doripenem should be tested for these organisms to
determine if these organisms meet the CRE definition.

Note :
1. All Enterobacterales isolated from CRE screening rectal swab should be screened for CP-CRE, as

Enterobacterales isolated from contact maybe different from the index case.
2. The detection of carbapenemase genes can be done by various methods (examples: polymerase

chain reaction, rapid molecular, lateral flow test, metallo-β-lactamase test or Carba-NP).

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Laboratory Detection of Carbapenem-resistant Enterobacteriaceae (CRE)

LABORATORY DETECTION OF CARBAPENEM RESISTANT ENTEROBACTERALES (CRE)

Specimen

Enterobacterales

Disc Diffusion

Nonsusceptible (either I/R) to one or more carbapenems
Immediately inform treating specialist
and infection control coordinator for
local control and investigation

Probable CRE

MIC Carbapenem
Modified Carbapenem Inactivation Method (mCIM)

Resistant/Intermediate Resistant/Intermediate to at Sensitive to all
to at least one of Carbapenems least one of Carbapenems Carbapenems
AND AND AND
mCIM positive mCIM negative mCIM negative

Carbapenemase Producing - Non-CP-CRE
CRE (CP-CRE)

Inform treating specialist Inform treating specialist
and infection control and infection control
coordinator coordinator

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CHAPTER 5.0 : VIRUSES
Introduction
There are several portals of entry for viruses, locations through which viruses gain entry into the body. The
mucosal epithelium acts as the main barrier against pathogen entry. The site of infection or body system
involved in disease is determined by viral pathogenicity and affinity for specific body tissues. Based on the
portal of entry and routes of transmission, viral infections can be classified into several categories as shown
in the table below, with the examples of infections they cause.
(Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Section B: Chapter 3:
Transmission Based Precautions)of

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on Source Virus

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Gastrointestinal route: Faecal-oral transmission
• Viruses that can be transmitted by faecal-oral route can cause gastrointestinal infections and other
systemic manifestations e.g. central nervous system infection (e.g. polio), respiratory tract
infections.
• Faecal-oral route of transmission is predominantly often via contaminated hands and food. Thus,
infection control strategies should focus on contact with focally contaminated items and include
gowns, gloves, and hand hygiene.
• Masks are only advised to be worn during close contacts or high-risk procedures and when taking
care of vomiting patients.
• The majority of gastrointestinal infections are mild, self-limiting, and do not require any specific
therapy.

Respiratory route: droplet and airborne transmission
• Route of transmission for respiratory viruses is mainly via droplets. These are respiratory particles
>5 m containing infectious agents, produced during talking, coughing, sneezing and some
procedures. Droplets are larger and do not remain suspended in the air or travel long distances.
• Certain pathogens are transmitted by airborne transmission. These are particles <5 m in size
containing infectious agents, which remain suspended in the air for long periods of time, produced
during talking, coughing, sneezing and aerosol-generating procedures.
• Infection control measures should be aimed at aerosol or airborne transmission and direct contact
and may include isolation, masks, gowns, gloves, and hand hygiene.
• During aerosol generating procedures, use of N95 respirator and eye protection is recommended.

(Please also refer to: Interim Measles Infection Prevention Recommendations in Healthcare Settings, CDC
available at https://www.cdc.gov/infectioncontrol/guidelines/measles/index.html)

Skin / Mucous membrane route: Direct contact and indirect contact
• Direct contact transmission occurs when there is physical contact between an infected person and
a susceptible person, involving physical contact with blood, body fluids or body lesions.
• Indirect contact with secretions or body fluids occur via contaminated objects or environment, i.e.
from a reservoir to contaminated surfaces, or via vectors such as arthropod vectors. Healthy people
touch the contaminated objects with their hands, and then touch their eyes, nose or mouth (contact
with mucous membranes).
• Note: Respiratory viruses are mainly transmitted by the droplet route but can be spread by contact
with infectious respiratory secretions.
• Many viral infections can cause skin lesions, vesicles, exanthema or others. Transmission may
occur via skin or mucous membrane, and some also by respiratory route.
• Less frequently occurring viruses that can cause nosocomial infections include those causing
haemorrhagic fevers such as filoviruses (Marburg and Ebola) and arenaviruses (Lassa, Machupo,

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Junin). These viruses require strict isolation because they are transmitted by blood and body fluids
and have high virulence.

Genital tract
• Viral infections that are transmitted via the genital tract as a result of sexual activity are sexually
transmitted infections.
• Preventive measures include safer sex practices, using barrier protection and avoid sex with
individuals with genital sores, rash, discharge, or other symptoms.
• Vaccination is available for HPV and hepatitis B.

Parenteral/ Blood-borne transmission
• Routes of transmission are blood and body fluids, including breast milk.
• The risk of infection after a needle-stick injury is 5 to 40% for HBV, 1 to 10% for HCV, and < 0.5%
for HIV.
• Standard precautions should be practiced when handling blood and body secretions in all patients
and attention given to save disposal of needles and sharps.

(Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Section F: Chapter 2:
Post Exposur Prophylaxis For Blood Borne Pathogen)

Transplant: solid organ and haemopoetic transplant
• Although infrequent, virus transmission through transplant has been documented. The rate is low
compared to other portals of entry.
• Transplant recipients are given potent immunosuppressive therapy. Viruses can re-emerge and
cause disease in these immunocompromised hosts.
• Pre-transplant screening has significantly reduced the risk of receiving contaminated blood products
and organs.

Vaccination
Vaccination is available for polioviruses, hepatitis A, hepatitis B, varicella, influenza, measles, mumps,
rubella, rabies, HPV, COVID-19.

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CHAPTER 6.0 FUNGAL INFECTION

Introduction

1. The incidence of fungal infections has increased in recent years as the immunocompromised population
increases.

2. Risk factors for systemic fungal infections include neutropaenia, long-term central venous catheter
access, exposure to broad-spectrum antibiotics, all forms of vascular catheterization, mechanical
ventilation, blood transfusions, haemodialysis, diabetes mellitus, steroid use, immunosuppression,
parenteral feeding, and presence of urinary catheters.

3. Incidence of Candida bloodstream infection (BSI) is 17 cases per 1000 ICU admission and more than
half (59.8%) were due to non-albicans Candida species (Ministry of Health Malaysia 2019).

4. Hospital construction and renovation have been associated with an increased risk for nosocomial fungal
infection, particularly aspergillosis.

Candida Infection

1. Candida infections including candidaemia are usually caused by the patients’ normal flora but they can
also be transmitted via the hands of healthcare workers.

2. Candiduria is especially common in patients receiving prolonged urinary catheterization and broad
spectrum antimicrobial agents. This may be caused by a coloniser.

3. Isolation of Candida from respiratory specimens is virtually due to colonization or contamination of the
specimens.

4. Isolation of Candida from any sterile site should be considered a significant finding in an ICU patient.
Heavy colonization puts patients at risk for infection and should be considered in the decision to treat.

5. Identification to species level and susceptibility testing of Candida isolates may be helpful in patient
management. Isolation of multidrug resistant isolates such as Candida auris should promptly alert the
infection control team to institute appropriate infection control measures, e.g. hand hygiene and other
contact precautions.

Aspergillus infection

1. Aspergillus spp. are ubiquitous and can be cultured from the hospital environment (unfiltered air,
ventilation systems, dust dislodged during hospital construction, carpeting, food and ornamental plants).

2. Route of acquisition includes inhalation of fungal conidia, ingestion of contaminated food, contamination
of adhesive tape or gauze used with intravascular catheters and contamination of patient care items.

3. Contaminated air or ventilation systems have been associated with outbreaks of nosocomial
aspergillosis.

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Infection Prevention and Control Precautions
1. Proper containment shall be practiced during construction and renovation of hospital buildings (Refer

to Policies and Procedures on Infection Prevention and Control HCTM ; Section B: Chapter 7:
Outbreak Management).
2. Catheter insertion (IVC and urinary) must be performed only when it is indicated.
3. Removal of existing intravascular catheter in patients with fungaemia including candidaemia or acute
haematogenously disseminated candidiasis is suggested.
4. Remove CBD in patients with candiduria if possible.
5. The usage of very broad-spectrum antibiotics (particularly the carbapenems) should be reviewed
periodically, with a goal to de-escalate as soon as clinically permissible and if backed by bacteriological
culture results.

Infection Control and Ventilation Requirements for Patients undergoing allogeneic haematopoietic
stem cell transplant.
1. Patients undergoing allogeneic haematopoietic stem cell transplant should remain in a Protective

Environment (PE) room except for required procedures that cannot be performed in the room, and they
should use respiratory protection such as a well-fitting N95 (or KN95, which has seen a huge surge in
popularity due to the Covid-19 pandemic) respirator when leaving the PE.
2. Protective Environment room must be equipped with a ventilation system to maintain positive room air
pressure (Please refer to Chapter on Isolation Room).
3. Maintain airflow patterns and monitor these on a daily basis.
4. Minimize exposures of severely immunocompromised patients to activities that might cause
aerosolisation of fungal spores. Avoid carpeting in patient rooms or hallways, upholstered furniture and
furnishings, and fresh or dried flowers or potted plants in PE rooms or areas. When vacuum cleaning is
needed, the vacuum should preferably be equipped with HEPA filters.
5. Horizontal surfaces should be wet-dusted daily with cloth moistened with approved hospital disinfectant
and detergent. Methods that stir up dust should be avoided.
6. Engineering features should include central or point-of-use HEPA (99.97% efficiency) filters that can
remove particles > 0.3 μm in diameter for air supply; well-sealed rooms; properly constructed windows,
doors, and intake and exhaust ports; smooth ceilings free of fissures, open joints, and crevices; walls
sealed above and below the ceiling.

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Investigation for source of nosocomial fungal infections outbreaks
Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Section B: Chapter 7:
Outbreak Management)
1. If no epidemiologic evidence exists of ongoing transmission of fungal disease, conduct an environmental

assessment to find and eliminate the source.
2. Collect environmental samples from potential sources of airborne fungal spores, preferably by using a

high-volume air sampler rather than settle plates.
3. If either an environmental source of airborne fungi or an engineering problem with filtration or pressure

differentials is identified, promptly perform corrective measures to eliminate the source and route of
entry.
4. If an environmental source of airborne fungi is not identified, review infection-control measures, including
engineering controls, to identify potential areas for correction or improvement.
5. If possible, perform molecular subtyping of Aspergillus spp. or any suspected fungus isolated from
patients and the environment to compare their strain identities.

(Refer to Policies and Procedures on Infection Prevention and Control HCTM ; Section B: Chapter 3:
Transmission Based Precautions)of

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SECTION F: OCCUPATIONAL SAFETY AND HEALTH FOR HEALTHCARE
WORKER

CHAPTER 1.0 : DEFINITION
INTRODUCTION
The healthcare sector is one field that exposes workers to a hazardous environment. Healthcare workers
are very vulnerable to exposure to occupational infections that can be transmitted through inhalation,
needle-stick injury, ingestion of contaminated material, and body contact. The healthcare workers are the
intermediaries for delivering the service thus consistent evaluation of the workplace and developing health
safety practices are crucial to ensure the performance of an organization is not interrupted.
Malaysia's Ministry of Health aims to create awareness and reduce the risk of exposure to microbiological
hazards in healthcare settings via sharps injury, mucosal exposure, and other healthcare-associated
infection. Infectious disease physicians and Occupational Health physicians must therefore disseminate
information throughout the hospital about the prevention and timely care of sharps incidents and other
Healthcare-Associated Infection (HCAI). Due to the nature of the work activities involving patients and this
unavoidable circumstance, healthcare personnel are exposed to biological hazards.Therefore, infection
prevention controls (IPCs) are essential strategies to prevent occupational infection among healthcare
workers (HCWs) since they are the front-liner to assist the community and the importance to protect
themselves.
All new HCWs must attend an infection control briefing, while regular training sessions should be the plan
for all HCWs which includes:

a) The risk associated with blood and body-fluid exposure.
b) The correct use and disposal of sharps.

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DEFINITIONS

Sharps
Includes all sharps instruments/devices used in healthcare facilities (e.g. all types of needles, scalpel,
trochar, broken glass, lancet and other sharps devices.

Blood Borne Pathogens
Are infectious microorganisms in human blood that can cause disease in humans. These pathogens include
but are not limited to, Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV).

Healthcare-Associated Infection
Refers to infection acquired from healthcare facilities via contact, droplets or airborne transmission.

Mucosal splash
Bloodborne pathogens may also be transmitted through the mucous membranes. A splash of contaminated
blood to eyes, nose, or mouth is considered an exposure event and could result in transmission.

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CHAPTER 2.0 : POST EXPOSURE PROPHYLAXIS FOR BLOOD BORNE PATHOGEN
Following a sharps injury or a mucosal splash, the healthcare worker (HCW) affected needs to be assessed
immediately to determine the risk of contracting blood-borne infections, as well as to be given confidential
counselling and to be followed-up accordingly. This assessment will determine the needs of vaccination
and/or post-exposure prophylaxis (PEP).
Table 1 below shows the baseline blood investigation and management for the affected HCW:

Table 1: Baseline blood investigation and management for affected HCW

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Table 2 below shows the roles and responsibilities of Incidence Officer / Ward Sister, Emergency
Department Medical Officer, Occupational Health & Safety Unit (Doctor & Nurse) and Physician in managing
HCW who sustains a sharps injury or mucosal splash.

Table 2: Roles and responsibilities in managing affected HC

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For affected HCW, please follow these steps immediately after a sharp’s injury or mucosal splash:
• Expose the cuts under running water and wash with soap and water
• Flush splashes to the mucosa or the skin with water
• Irrigate the affected eyes with clean saline
• Report the incident to your Incident Officer / Ward Sister or On-Call Sister (out of hours)
• Seek medical treatment immediately

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CHAPTER 3.0 : HEALTHCARE WORKERS SCREENING FOR TUBERCULOSIS

INTRODUCTION
Employers, employees, and self-employed persons in Malaysia have a duty of care to their safety and
health, as well as the safety and health of others at their workplace, under the OCCUPATIONAL SAFETY
AND HEALTH ACT 1994 (OSHA). Employers must identify workplace hazards, analyse the risks associated
with those hazards, and control those risks under OSHA 1994. Recent increases in the prevalence of
tuberculosis (TB) among Ministry of Health staff have raised concerns about the probability of occupational-
related Mycobacterium tuberculosis transmission in health care settings (nosocomial transmission).
OBJECTIVES
Overarching goal is to develop a guideline for the prevention and control of tuberculosis infections among
healthcare workers.
Specified objectives are as follow:

1. To protect healthcare workers against tuberculosis infection at work
2. To limit the risk of tuberculosis (TB) transmission from patients to healthcare workers (HCWs)
and vice versa in a healthcare context.
3. To promote and strengthen tuberculosis control strategies in healthcare facilities.

HEALTHCARE WORKERS' SCREENING FOR TUBERCULOSIS ( TB )
The recommended HCW classifications for tuberculosis screening are as follows:

I. Pre-placement for newly employed HCWs.
II. In-service HCW screening on a regular basis based on job description and work location.
III. Pre-retirement/pre-transfer for employees who are about to retire or transfer out of a high-

risk location.

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CONTROL STRATEGIES FOR TUBERCULOSIS PREVENTION IN HEALTHCARE FACILITIES
The control measures are based on a three-level hierarchy of controls:

I. Environmental controls;
● Internal controls;
● External controls.

II. Administrative safeguards (managerial).
III. Personal protective equipment (PPE).

TUBERCULOSIS INFECTION AMONG HCWS

A. Notification and management of HCWs with occupational-related TB
After the attending medical officer certifies the HCWs are TB positive. They should be managed according
to Clinical Practice Guidelines for the control and management of tuberculosis. The attending medical officer
must notify the case through E - Notification to MOH Malaysia, WEHU L1/L2 (JKKP7), and TB 10A1.
The TB committee of the HCTM must be alerted immediately. Notification of the occupational safety and
health (OSH) unit and the person in charge of the concerned department is required for further action.
The department will do contact tracing and the OSH unit will conduct a tuberculin skin test. If the tuberculin
skin test returned a positive result (> 15mm), the medical officer will order a CXR. The attending medical
officer shall certify the HCWs' tuberculosis status. If the HCWs are confirmed to be tuberculosis positive,
appropriate management shall be initiated (Refer Figure 1: Flow chart management of Tuberculosis among
HCWs in HCTM)

B. Investigation of TB among HCWs
Following that, the OSH unit will conduct a workplace investigation to determine the likely source of infection
and will recommend a mitigation plan for further improvement. The inquiry details must be completed using
the investigation form using Format Penyiasatan Kes Tuberkulosis Di Kalangan Kakitangan
Kementerian Kesihatan Malaysia (appendix 16) from the Malaysian Guidelines On Tuberculosis
Prevention And Management For Healthcare Personnel (Refer Figure 1 : Flow chart management of
Tuberculosis among HCWs in HCTM).

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.
Figure 1 : Flow chart management of Tuberculosis among HCWs in HCTM

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CONTROL MEASURES FOR TUBERCULOSIS
1. Health-care facility environmental control measures
Certain regions of the healthcare facility may be considered high-risk, and environmental measures should
be prioritized.
Table 3 : Common high-risk areas at health facilities:

To limit the amount of aerosolized infectious droplet nuclei in the workplace, a variety of simple to complex
environmental controls can be used:
• keeping windows open to allow natural ventilation
• Control the source of infection by using local exhaust ventilation and broad ventilation to dilute and remove
contaminated air.

More complicated and expensive approaches include using ‘High Efficiency Particulate Air’ (HEPA) filtration
and negative pressure rooms and using ultraviolet germicidal irradiation (UVGI) to disinfect the air. A HEPA
filter is an air filter that removes ≥99.97% of particles ≥0.3 µm (including Mycobacterium tuberculosis–
containing droplet nuclei) at a specified flow rate of air. A previous modeling study reported that
supplementation of mechanical ventilation with HEPA filters could reduce XDR-TB incidence. It can be used
in conjunction with or in addition to other recommended ventilation measures.HEPA filters can be free
standing (portable room-air recirculation unit) or permanently attached to floors or ceilings to prevent
tampering.

Negative pressure rooms are used for respiratory isolation, which is known as airborne infection
isolation i.e. the isolation of patients infected with microorganisms that spread via airborne droplet nuclei <
5 μm in diameter, such as Mycobacterium tuberculosis.

Airflow in alI rooms should be at least 12 air exchanges per hour (ACH). Directional airflow from the
clean air intake region should be maintained across the HCW and patient. The air is filtered before being
vented outdoors. Ultraviolet Germicidal Irradiation can be used to sterilize the air. UVGI kills or inactivates
microorganisms by exposing them to an effective dosage of ultraviolet-C (UV-C) radiation at 253.7

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nanometers (nm), rendering them unable to multiply and form colonies. UVGI is more useful in a high-risk
environment that meets the unique requirements of its use.
2. Administrative control
Administrative controls are crucial in reducing the risk of Mycobacterium Tuberculosis exposure among
HCWs and patients. The following activities are included in administrative controls:
a. Control of tuberculosis in healthcare facilities:

• In a hospital with a high number of TB cases among HCWs, forming a team is highly suggested.
The occupational safety and health unit should be in charge of coordinating this group.
• Provide training to those who will be in charge of executing and enforcing the TB Infection Control
Program.
• Assign one person as the TB resource person, with a backup, to whom inquiries and problems
should be sent

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CHAPTER 4.0 : IMMUNISATION FOR HEALTHCARE WORKERS

Healthcare facilities are considered high-risk workplaces because of the high degree of exposure to
hazardous agents and in hospitals, healthcare professionals make up the majority of the workforce. The
spread of infectious diseases among them could cause the services to be disrupted. Infected health care
workers may be the source of infection spread to patients. Vaccination of HCW against vaccine-preventable
infections is therefore strongly advised. The major objectives are to:

a) To protect against vaccine-preventable diseases;
b) To prevent sickness absence due to vaccine-preventable diseases.
c) To safeguard patients, particularly those who are most vulnerable.

Current policy and practices in Malaysia

Hepatitis B, Influenza, Measles, Mumps, Rubella, Tetanus, Diphtheria, Pertussis, Varicella, and Typhoid are
among the immunizations recommended for HCW. In the Ministry of Health, HCWs are vaccinated against
Hepatitis B, influenza, and Typhoid (for food handlers). To determine the vaccine's efficacy, post-vaccination
serologic testing for Hepatitis B antibodies is required. For newly employed HCWs who do not have proven
immunization, the MMR (Measles, Mumps, and Rubella) vaccine and Tdap (Tetanus, Diphtheria, and
Pertussis) vaccine are recommended. At the same time, infection prevention practices in all health facilities
must be enhanced and remain the most important method for preventing disease transmission.

Hepatitis B vaccination for healthcare workers

Hepatitis B virus infection is a major occupational hazard to HCWs and are at a high risk of contracting the
hepatitis B virus (HBV). Due to the significant risk of HBV infection among HCWs, systematic pre-exposure
vaccination and the use of basic precautions to avoid exposure to blood and other potentially infectious body
fluids have been recommended. Hence, HBV immunization status and anti-HBs titer among HCWs must be
evaluated for all new clinical healthcare employees. Those who are yet to receive hepatitis B vaccination
must be vaccinated according to the hepatitis B immunization schedule and blood screening are taken if
necessary (Refer Figure 2: Flow chart of vaccination to HCTM HCWs).

Moreover, besides screening for hepatitis B, HCWs who will be placed at the high-risk location supposedly
be screened for hepatitis C virus (HCV) and human immunodeficiency virus (HIV) as well. If the healthcare
workers are found to have an infectious disease based on the blood screening results, the appropriate action
and care following the investigation will be taken to ascertain the infectious status of healthcare workers are
controlled and safe for them to practise in daily work. HCWs with blood borne infections must obtain a
certification of fitness to practise by appropriate bodies before starting their duty. They are recommended to
be assigned to the non-risky work location in ensuring the safety and health of healthcare workers and
patients.

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Figure 2.0 : Flow chart of vaccination for HCTM HCWs
Influenza immunization among healthcare workers
Influenza is a highly contagious disease that kills 4.0–8.8 people per 100 000 people worldwide each year.
Due to greater exposure to patients, health care professionals are at a higher risk of contracting influenza
virus infection, which could spread to vulnerable people. Vaccination is the most effective way to prevent
influenza. Thus, annual influenza immunization for healthcare professionals is recommended by the WHO.
Hence, to prevent occupational exposure towards infection of influenza, healthcare workers at our facility
are recommended to get their yearly influenza vaccination to safeguard healthcare workers as well as the
patient (Refer Figure 2 : Flow chart of vaccination for HCTM HCWs).

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Figure 4.1: Flow chart of vaccination for HCTM HCWs
Meningococcal and pneumococcal immunization for healthcare workers
At the moment, vaccination with a quadrivalent meningococcal vaccine (against serogroups A, C, W and Y)
is mandatory for anyone, including HCWs, who intend to attend congregation, serve pilgrims, or dwell in
Hajj zones, whether as pilgrims or seasonal workers. Hence, all HCWs who will be going for hajj or
pilgrimage to Mecca are required to take meningococcal and penumococcal immunization (Refer Figure 2 :
Flow chart of vaccination for HCTM HCWs.

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SECTION G: ANTIMICROBIAL STEWARDSHIP

CHAPTER 1.0 : Antimicrobial Resistance Surveillance

Antimicrobial resistance (AMR) has emerged as a major public health problem all over the world. AMR
surveillance data will help to formulate, monitor and identify the prevailing and emerging problem in a
healthcare facility. It is a laboratory-based surveillance, derived from routine antibiotic susceptibility testing
of bacterial isolates grown from clinical specimens. The susceptibility data are transferred to the WHONET
database for storage and analysis.

The interpretive criteria for susceptibility are based on standardised guidelines as outlined by CLSI. When
the interpretation zones are not available in CLSI, EUCAST guidelines are used. AMR surveillance data :

• provides information on the epidemiology of antibiotic resistance in the hospital and allows
monitoring of changes in resistance pattern.

• serves as a guide to formulating antibiotic treatment protocol.

AMR Surveillance Activity

National Surveillance of Antibiotic Resistance, Malaysia (NSAR)
Surveillance reports are submitted to the national committee every year for targeted organisms as the
following, Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus spp., Acinetobacter baumanii,
E.coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Salmonella typhi. Salmonella spp. and Neisseria
gonorrhoeae.

Local Antibiogram
Periodic antibiograms are produced based on specimen types (eg. blood, urine, pus & respiratory samples)
and/or organisms. Antibiograms are analysed as one isolate per patient in the WHONET software. The
report is submitted to the respective clinical disciplines via AMS committee and HICC, periodically.

POINT PREVALENCE SURVEY (PPS)
Point Prevalence Survey (PPS) is commonly used within stewardship programmes to assess the quality of
antimicrobial prescribing at institutional level in accordance with local stewardship activities. PPS is an one-
day hospital wide cross-sectional survey to analyse antimicrobial prescribing patterns. To date, PPS is
conducted in 21 MOH hospitals and 3 university hospitals including HCTM. At institutional level, sequential
PPS audit allows hospitals to measure the changes in practice and to determine impact of interventions and
resistance. Harmonised data collection at national level is pivotal to inform effective policies and
interventions in optimising antimicrobial use.

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OBJECTIVE
1. To determine the prevalence of patients on antibiotics, which includes:
a. prevalence of antibiotic based on type and group of antibiotics
b. prevalence of antibiotic based on indication category (empirical, definitive, prophylaxis)
2. To identify the prescribing pattern and behavior which includes, but not limited to:
a. documentation of antimicrobial therapy when prescribing
b. relevance of culture and sensitivity test before initiation of antimicrobial therapy
c. compliance to the antimicrobial therapy guideline
d. appropriateness of antimicrobial therapy
e. appropriateness of duration of antimicrobial therapy
f. appropriateness of identification of hospital/healthcare acquired infection (HCAI)

WORKFLOW OF POINT PREVALENCE SURVEY (PPS)
In HCTM UKM, PPS audit involves multidisciplinary teams which mainly consist of doctors, nurses,
pharmacists, clinical microbiologists, and infection control unit. A multidisciplinary approach is essential in
ensuring accuracy of the assessment of compliance to antimicrobial therapy guidelines and appropriateness
of antimicrobials prescribing.
As it is a hospital-wide point prevalence study, it is compulsory to involve all in-patients receiving treatment
in the hospital at the time of audit. It involves collection of data of in-patients on antimicrobials (numerator)
and the total number of in-patients (denominator). Ideally, the recommended sampling time of in-patients
should be within one day. Nevertheless, it could be done over a predetermined period to ensure each patient
is only surveyed once despite transferring between wards. This practice is usually done concurrent with the
schedule set by Ministry of Health

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The workflow of data collection is shown in algorithm 1 and 2.
ALGORITHM 1

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ALGORITHM 2

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CHAPTER 2.0 ANTIMICROBIAL UTILIZATION SURVEILLANCE
In general, the drug consumption can be expressed in cost, number of units, number of prescriptions or
physical quantity of the drugs. However, the variables can vary among countries and institutions over time.
Therefore, as a standardization of measurement for nationwide comparison, defined daily dose (DDD) is
used.

DEFINED DAILY DOSING (DDD)
Define daily dosing is defined as the average maintenance dose per day for a drug used for its main
indication in adults, with reference to the value set by WHO. It provides a fixed unit of measurement that is
independent of the price, currencies, package size and strength. It is helpful to compare across institution
and evaluate the trend of drug utilization over time.
The DDD may be revised due to changes of dosage over time in conditions of new and updated research
findings.
The objective of the defined daily dosing on antimicrobial agents:

● To evaluate the change or trend in antimicrobial agents utilization over time
● To compare antimicrobial agents usage locally and internationally
● To determine the trend of usage of antimicrobial agents in various ward setting (ICU, medical,

surgery and orthopaedic team)

The data generated by defined daily dosing was very helpful in evaluating the prescribing pattern of
antimicrobial agents over time. Besides that, it can be used to evaluate the appropriateness of prescribing
of antimicrobial agents especially those of broad-spectrum.
In HCTM UKM, the dispensing data of antimicrobial agents for each adult ward was collected for the purpose
of surveillance on antibiotic utilization. This is used as an indicator to evaluate the prescribing pattern of
antimicrobials.
DDD is measured in unit of DDD per 1000 patient- days, using average patients stays duration as
denominator. The antimicrobial utilization are reported in unit of in DDD per 1000 patients days for hospital,
and disciplines of Medical, Surgical and Orthopaedics bi-annually. The reports are to be submitted for
National Antibiotic Utilization Surveillance, Hospital administration, and disseminated to head of
departments as well presented at AMS and infection control committee meetings.

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CHAPTER 3 POLICY & GUIDELINES ON ANTIMICROBIAL STEWARDSHIP (AMS)

ANTIBIOTIC POLICY AND GUIDELINES

The antibiotic guide and policies are endorsed by HCTM UKM Drugs and Therapeutics Committee and the
hospital director.

The following is included as guiding principles for antibiotic prescribing:
• Written indications for antimicrobials prescription.
• Appropriate microbiology investigations prior to antimicrobial commencement.
• Prescribe antimicrobials as guided by the Hospital guideline and/or National Antibiotic Guidelines where
applicable.
• Formulation of a list of restricted antimicrobials and the procedures for obtaining approval.
• That prescribers review the patient’s clinical response while on antimicrobial therapy with a view to
streamline therapy as more clinical information becomes available.

Antimicrobial treatment protocols are developed by HCTM AMS committee, based on antibiogram according
to disciplines such as medical, orthopedic and general intensive care. For infection not covered by the said
treatment protocol, national policy and guideline may be reviewed and adapted if deemed necessary. The
local treatment protocols are accessible on hospital website and locally developed smart phone application
entitled “HCTM Formulary”

ANTIMICROBIAL POLICY

A. FORMULARY RESTRICTION AND PREAUTHORIZATION/APPROVAL SYSTEM
Selected antimicrobials are restricted to or require authorization from infectious disease consultants, and
some from specialists. This list is determined and endorsed by Hospital Drugs & Therapeutic committee
(JKTU)
Dispensing by pharmacy is made only after screening and verifying by pharmacy staff of the completed
preauthorization form, named as JKTU form. The list of restricted antimicrobials is subjected to review and
modification with consideration on acquisition cost, antimicrobial spectrum and potential of resistance and
abuse.
Out-patient IV Antibiotic uses are limited only for Hemodialysis patients for completion of treatment for
catheter related blood stream infection, CRBSI. The choice of antibiotic is guided by the common organisms
which are CoNs, MSSA, Enterobacter sp, Pseudomonas sp, such as Vancomycin, Ceftazidime, Cefazolin,
Sulphamethoxazole/Trimethoprim and Gentamicin.
Details of restrictions and criteria of prescribing are stated in the HCTM Formulary smart phone application.

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B. MONITORING & REVIEW OF ANTIBIOTIC PROTOCOL/POLICY
Antimicrobial guideline/policy/protocol are reviewed as needed upon the utilization trend derived from the
annual drug expenditure reports/point prevalence survey / antimicrobial usage surveillance / antibiogram.

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