Healthcare-associated infections: prevention and control in primary and community care

This guideline covers preventing and controlling healthcare-associated infections in children, young people and adults in primary and community care settings. It provides a blueprint for the infection prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment.

# Recommendations
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Standard principles
Recommendation 1.1.1.2 in the section on general advice, and recommendations 1.1.3.1,1.1.3.3, 1.1.3.4, 1.1.3.6, 1.1.3.10 and 1.1.3.11 in the section on use of personal protective equipment, are in accordance with the following health and safety legislation (current at the time of publication, March 2012):
Health and Safety at Work Act 1974
Management of Health and Safety at Work Regulations 1999
Health and Safety Regulations 2002,
Control of Substances Hazardous to Health Regulations 2002,
Personal Protective Equipment Regulations 2002
Health and Social Care Act 2008.

## General advice
Everyone involved in providing care should be:
educated about the standard principles of infection prevention and control and
trained in hand decontamination, the use of personal protective equipment, and the safe use and disposal of sharps. 
Wherever care is delivered, healthcare workers must have available appropriate supplies of
materials for hand decontamination
sharps containers
personal protective equipment. 
Educate patients and carers about:
the benefits of effective hand decontamination
the correct techniques and timing of hand decontamination
when it is appropriate to use liquid soap and water or handrub
the availability of hand decontamination facilities
their role in maintaining standards of healthcare workers' hand decontamination. 

## Hand decontamination
Hands must be decontaminated in all of the following circumstances:
immediately before every episode of direct patient contact or care, including aseptic procedures
immediately after every episode of direct patient contact or care
immediately after any exposure to body fluids
immediately after any other activity or contact with a patient's surroundings that could potentially result in hands becoming contaminated
immediately after removal of gloves. 
Decontaminate hands preferably with a handrub (conforming to the British standard BS EN 1500:2013 ), except in the following circumstances, when liquid soap and water must be used:
when hands are visibly soiled or potentially contaminated with body fluids or
in clinical situations where there is potential for the spread of alcohol-resistant organisms (such as Clostridium difficile or other organisms that cause diarrhoeal illness). 
Healthcare workers should ensure that their hands can be decontaminated throughout the duration of clinical work by:
being bare below the elbow when delivering direct patient care (for the purposes of this guideline, bare below the elbow means: not wearing false nails, nail polish, a wristwatch or stoned rings; wearing short-sleeved garments or being able to roll or push up sleeves)
removing wrist and hand jewellery
making sure that fingernails are short, clean and free of nail polish
covering cuts and abrasions with waterproof dressings. 
An effective handwashing technique involves three stages: preparation, washing and rinsing, and drying. Preparation requires wetting hands under tepid running water before applying liquid soap or an antimicrobial preparation. The handwash solution must come into contact with all of the surfaces of the hand. The hands must be rubbed together vigorously for a minimum of 1015 seconds, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers. Hands should be rinsed thoroughly before drying with good quality paper towels. 
When decontaminating hands using an alcohol handrub, hands should be free from dirt and organic material. The handrub solution must come into contact with all surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has evaporated and the hands are dry. 
An emollient hand cream should be applied regularly to protect skin from the drying effects of regular hand decontamination. If a particular soap, antimicrobial hand wash or alcohol product causes skin irritation an occupational health team should be consulted. 

## Use of personal protective equipment
Selection of protective equipment must be based on an assessment of the risk of transmission of microorganisms to the patient, and the risk of contamination of the healthcare worker's clothing and skin by patients' blood, body fluids, secretions or excretions. 
Gloves used for direct patient care:
must conform to current EU legislation (CE marked as medical gloves for single use under BS EN 455 Parts 14  and in accordance with the following health and safety legislation : Health and Safety at Work Act 1974, Management of Health and Safety at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and Social Care Act 2008) and
should be appropriate for the task. 
Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin or mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or to sharp or contaminated instruments.
Gloves mustbe worn as single-use items. They must be put on immediately before an episode of patient contact or treatment and removed as soon as the activity is completed. Gloves must be changed between caring for different patients, and between different care or treatment activities for the same patient. 
Ensure that gloves used for direct patient care that have been exposed to body fluids are disposed of correctly, in accordance with current national legislation (for guidance see NHS England's document on Management and disposal of healthcare waste, HTM 07-01) or local policies (see section 1.1.5 on waste disposal). 
Alternatives to natural rubber latex gloves must be available for patients, carers and healthcare workers who have a documented sensitivity to natural rubber latex. 
Do not use polythene gloves for clinical interventions. 
When delivering direct patient care:
wear a disposable plastic apron if there is a risk that clothing may be exposed to blood, body fluids, secretions or excretions or
wear a long-sleeved fluid-repellent gown if there is a risk of extensive splashing of blood, body fluids, secretions or excretions onto skin or clothing. 
When using disposable plastic aprons or gowns:
use them as single-use items, for one procedure or one episode of direct patient care and
ensure they are disposed of correctly (see section 1.1.5 on waste disposal). 
Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or excretions splashing into the face and eyes. 
Respiratory protective equipment, for example a particulate filter mask, must be used when clinically indicated. 

## Safe use and disposal of sharps
Sharps should not be passed directly from hand to hand, and handling should be kept to a minimum. 
Used standard needles:
must not be bent or broken before disposal (however, it is acceptable to bend needles when they are part of an approved sharps safety device)
must not be recapped.In dentistry, if recapping or disassembly is unavoidable, a risk assessment must be undertaken and appropriate safety devices should be used (see the Health and Safety  Regulations 2013). 
Used sharps must be discarded immediately by the person generating the sharps waste into a sharps container conforming to current standards (which at the time of publication 
Sharps containers:
must be located in a safe position that avoids spillage, is at a height that allows the safe disposal of sharps, is away from public access areas and is out of the reach of children
must not be used for any other purpose than the disposal of sharps
must not be filled above the fill line
must be disposed of when the fill line is reached
should be temporarily closed when not in use.For guidance see NHS England's document on Management and disposal of healthcare waste (HTM 07-01). 
Use sharps safety devices if a risk assessment has indicated that they will provide safer systems of working for healthcare workers, carers and patients. 
Train and assess all users in the correct use and disposal of sharps and sharps safety devices. 

## Waste disposal
Healthcare waste must be segregated immediately by the person generating the waste into appropriate colour-coded storage or waste disposal bags or containers defined as being compliant with current national legislation (for guidance see NHS England's document on Management and disposal of healthcare waste, HTM 07-01) and local policies. 
Healthcare waste must be labelled, stored, transported and disposed of in accordance with current national legislation (for guidance see NHS England's document on Management and disposal of healthcare waste, HTM 07-01) and local policies. 
Educate patients and carers about the correct handling, storage and disposal of healthcare waste. 

# Long-term urinary catheters

## Education of patients, their carers and healthcare workers
Patients and carers should be educated about and trained in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital. 
Community and primary healthcare workers must be trained in catheter insertion, including suprapubic catheter replacement and catheter maintenance. 
Follow-up training and ongoing support of patients and carers should be available for the duration of long-term catheterisation. 

## Assessing the need for catheterisation
Indwelling urinary catheters should be used only after alternative methods of management have been considered. 
The patient's clinical need for catheterisation should be reviewed regularly and the urinary catheter removed as soon as possible. 
Catheter insertion, changes and care should be documented. 

## Catheter drainage options
Following assessment, the best approach to catheterisation that takes account of clinical need, anticipated duration of catheterisation, patient preference and risk of infection should be selected. 
Intermittent catheterisation should be used in preference to an indwelling catheter if it is clinically appropriate and a practical option for the patient. 
Offer a choice of either single-use hydrophilic or gel reservoir catheters for intermittent self-catheterisation. 
Select the type and gauge of an indwelling urinary catheter based on an assessment of the patient's individual characteristics, including:
age
any allergy or sensitivity to catheter materials
gender
history of symptomatic urinary tract infection
patient preference and comfort
previous catheter history
reason for catheterisation. 
In general, the catheter balloon should be inflated with 10 ml of sterile water in adults and 35 ml in children. 
In patients for whom it is appropriate, a catheter valve may be used as an alternative to a drainage bag. 

## Catheter insertion
All catheterisations carried out by healthcare workers should be aseptic procedures. After training, healthcare workers should be assessed for their competence to carry out these types of procedures. 
Intermittent self-catheterisation is a clean procedure. A lubricant for single-patient use is required for non-lubricated catheters. 
For urethral catheterisation, the meatus should be cleaned before insertion of the catheter, in accordance with local guidelines/policy. 
An appropriate lubricant from a single-use container should be used during catheter insertion to minimise urethral trauma and infection. 

## Catheter maintenance
Indwelling catheters should be connected to a sterile closed urinary drainage system or catheter valve. 
Healthcare workers should ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons (for example changing the bag in line with the manufacturer's recommendations). 
Healthcare workers must decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a patient's catheter, and must decontaminate their hands after removing gloves. 
Patients managing their own catheters, and their carers, must be educated about the need for hand decontamination before and after manipulation of the catheter, in accordance with the recommendations in the section on standard principles. 
Urine samples must be obtained from a sampling port using an aseptic technique. 
Urinary drainage bags should be positioned below the level of the bladder, and should not be in contact with the floor. 
A link system should be used to facilitate overnight drainage, to keep the original system intact. 
The urinary drainage bag should be emptied frequently enough to maintain urine flow and prevent reflux, and should be changed when clinically indicated. 
The meatus should be washed daily with soap and water. 
To minimise the risk of blockages, encrustations and catheter-associated infections for patients with a long-term indwelling urinary catheter:
develop a patient-specific care regimen
consider approaches such as reviewing the frequency of planned catheter changes and increasing fluid intake
document catheter blockages. 
Bladder instillations or washouts must not be used to prevent catheter-associated infections. 
Catheters should be changed only when clinically necessary or according to the manufacturer's current recommendations. 
When changing catheters in patients with a long-term indwelling urinary catheter:
do not offer antibiotic prophylaxis routinely
consider antibiotic prophylaxis for patients who:
have a history of symptomatic urinary tract infection after catheter change or
experience trauma (frank haematuria after catheterisation or two or more attempts of catheterisation) during catheterisation. At the time of publication (March 2012), no antibiotics have a UK marketing authorisation for this indication. Informed consent should be obtained and documented. 

# Enteral feeding

## Education of patients, their carers and healthcare workers
Patients and carers should be educated about and trained in the techniques of hand decontamination, enteral feeding and the management of the administration system before being discharged from hospital. 
Healthcare workers should be trained in enteral feeding and management of the administration system. 
Follow-up training and ongoing support of patients and carers should be available for the duration of home enteral tube feeding. 

## Preparation and storage of feeds
Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution. 
The system selected should require minimal handling to assemble, and be compatible with the patient's enteral feeding tube. 
Effective hand decontamination must be carried out before starting feed preparation. 
When decanting, reconstituting or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used. 
Feeds should be mixed using cooled boiled water or freshly opened sterile water and a no-touch technique. 
Feeds should be stored according to the manufacturer's instructions and, where applicable, food hygiene legislation. 
Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in a refrigerator, and used within 24 hours. 

## Administration of feeds
Use minimal handling and an aseptic technique to connect the administration system to the enteral feeding tube. 
Ready-to-use feeds may be given for a whole administration session, up to a maximum of 24 hours. Reconstituted feeds should be administered over a maximum 4-hour period. 
Administration sets and feed containers are for single use and must be discarded after each feeding session. 

## Care of insertion site and enteral feeding tube
The stoma should be washed daily with water and dried thoroughly. 
To prevent blockages, flush the enteral feeding tube before and after feeding or administering medications using single-use syringes or single-patient-use (reusable) syringes according to the manufacturer's instructions. Use:
freshly drawn tap water for patients who are not immunosuppressed
either cooled freshly boiled water or sterile water from a freshly opened container for patients who are immunosuppressed. 

# Vascular access devices

## Education of patients, their carers and healthcare workers
Before discharge from hospital, patients and their carers should be taught any techniques they may need to use to prevent infection and safely manage a vascular access device. 
Healthcare workers caring for a patient with a vascular access device should be trained, and assessed as competent, in using and consistently adhering to the infection prevention practices described in this guideline. 
Follow-up training and support should be available to patients with a vascular access device and their carers. 

## General asepsis
Hands must be decontaminated (see section 1.1.2 on hand decontamination) before accessing or dressing a vascular access device. 
An aseptic technique must be used for vascular access device catheter site care and when accessing the system (the Aseptic Non Touch Technique (ANTTTM) is an example of an aseptic technique for vascular access device maintenance which is widely used in acute and community settings and represents a possible framework for establishing standardised guidance on aseptic technique. 

## Vascular access device site care
Decontaminate the skin at the insertion site with chlorhexidine gluconate in 70% alcohol before inserting a peripheral vascular access device or a peripherally inserted central catheter.In 2012, an MHRA safety alert for chlorhexidine was issued related to the risk of adverse events. 
Use a sterile transparent semipermeable membrane dressing to cover the vascular access device insertion site. 
Consider a sterile gauze dressing covered with a sterile transparent semipermeable membrane dressing only if the patient has profuse perspiration, or if the vascular access device insertion site is bleeding or oozing. If a gauze dressing is used:
change it every 24 hours, or sooner if it is soiled and
replace it with a sterile transparent semipermeable membrane dressing as soon as possible. 
Change the transparent semipermeable membrane dressing covering a central venous access device insertion site every 7 days, or sooner if the dressing is no longer intact or moisture collects under it. 
Leave the transparent semipermeable membrane dressing applied to a peripheral cannula insertion site in situ for the life of the cannula, provided that the integrity of the dressing is retained. 
Dressings used on tunnelled or implanted central venous catheter sites should be replaced every 7 days until the insertion site has healed, unless there is an indication to change them sooner. 
Healthcare workers should ensure that catheter-site care is compatible with catheter materials (tubing, hubs, injection ports, luer connectors and extensions) and carefully check compatibility with the manufacturer's recommendations. 
Decontaminate the central venous catheter insertion site and surrounding skin during dressing changes using chlorhexidine gluconate in 70% alcohol, and allow to air dry. Consider using an aqueous solution of chlorhexidine gluconate if the manufacturer's recommendations prohibit the use of alcohol with their catheter. In 2012, an MHRA safety alert for chlorhexidine was issued related to the risk of adverse events. 
Individual sachets of antiseptic solution or individual packages of antiseptic-impregnated swabs or wipes should be used to disinfect the dressing site. 

## General principles for management of vascular access devices
Decontaminate the injection port or vascular access device catheter hub before and after accessing the system using chlorhexidine gluconate in 70% alcohol. Consider using an aqueous solution of chlorhexidine gluconate if the manufacturer's recommendations prohibit the use of alcohol with their catheter. In 2012, an MHRA safety alert for chlorhexidine was issued related to the risk of adverse events. 
In-line filters should not be used routinely for infection prevention. 
Antibiotic lock solutions should not be used routinely to prevent catheter-related bloodstream infections (CRBSI). 
Systemic antimicrobial prophylaxis should not be used routinely to prevent catheter colonisation or CRBSI, either before insertion or during the use of a central venous catheter. 
Preferably, a single lumen catheter should be used to administer parenteral nutrition. If a multilumen catheter is used, one port must be exclusively dedicated for total parenteral nutrition, and all lumens must be handled with the same meticulous attention to aseptic technique. 
Preferably, a sterile 0.9 percent sodium chloride injection should be used to flush and lock catheter lumens. 
When recommended by the manufacturer, implanted ports or opened-ended catheter lumens should be flushed and locked with heparin sodium flush solutions. 
Systemic anticoagulants should not be used routinely to prevent CRBSI. 
If needleless devices are used, the manufacturer's recommendations for changing the needleless components should be followed. 
When needleless devices are used, healthcare workers should ensure that all components of the system are compatible and secured, to minimise leaks and breaks in the system. 
When needleless devices are used, the risk of contamination should be minimised by decontaminating the access port with either alcohol or an alcoholic solution of chlorhexidine gluconate before and after using it to access the system.In 2012, an MHRA safety alert for chlorhexidine was issued related to the risk of adverse events. 
In general, administration sets in continuous use need not be replaced more frequently than at 72-hour intervals unless they become disconnected, or a catheter-related infection is suspected or documented. 
Administration sets for blood and blood components should be changed every 12 hours, or according to the manufacturer's recommendations. 
Administration sets used for total parenteral nutrition infusions should generally be changed every 24 hours. If the solution contains only glucose and amino acids, administration sets in continuous use do not need to be replaced more frequently than every 72 hours. 
Avoid the use of multidose vials, in order to prevent the contamination of infusates. 

# Terms used in this guidance

## Aseptic technique
An aseptic technique ensures that only uncontaminated equipment and fluids come into contact with susceptible body sites. It should be used during any clinical procedure that bypasses the body's natural defences. Using the principles of asepsis minimises the spread of organisms from one person to another.

## Direct patient care
'Hands on' or face-to-face contact with patients. Any physical aspect of the healthcare of a patient, including treatments, self-care and administration of medication.

## Hand decontamination
The use of handrub or handwashing to reduce the number of bacteria on the hands. In this guideline this term is interchangeable with 'hand hygiene'.

## Handrub
A preparation applied to the hands to reduce the number of viable microorganisms. This guideline refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of hygienic handrubs using a reference of 60% isopropyl alcohol).

## Healthcare worker
Any person employed by the health service, social services, a local authority or an agency to provide care for a sick, disabled or elderly person.

## Healthcare waste
In this guideline, healthcare waste refers to any waste produced by, and as a consequence of, healthcare activities.

## Personal protective equipment
Equipment that is intended to be worn or held by a person to protect them from risks to their health and safety while at work. Examples include gloves, aprons, and eye and face protection.# Recommendations for research
The GDG has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

# Standard principles of infection prevention and control
What are the barriers to compliance with the standard principles of infection prevention and control that patients and carers experience in their own homes?

## Why this is important
Recent changes to the delivery of healthcare mean that care is increasingly delivered within a patient's home environment. Infection prevention in this setting is just as important as in hospital. There are currently approximately 6 million unpaid carers in the UK, a number that is likely to increase with an aging population. The association between carer training and infection rates is unknown. No evidence of surveillance of healthcare-associated infections in the community is currently available in the UK.
A qualitative study is needed to investigate the themes surrounding the barriers to patient and carer compliance with the standard principles of infection prevention in their own homes. It would be important to assess whether lack of awareness or knowledge is a barrier. If patients and carers have received education, this should be assessed to see if this was applicable to the patient's home setting. Areas of low compliance in the home environment need to be identified. The findings could have far-reaching implications for discharge planning and duty of care.

# Hand decontamination
When clean running water is not available, what is the clinical and cost effectiveness of using wipes, gels, handrubs or other products to remove visible contamination?

## Why this is important
Community healthcare workers often encounter challenges in carrying out hand decontamination when there is no access to running water. This particularly affects ambulance service staff, who often provide emergency care at locations where running water is not available. No evidence from randomised controlled trials is available on the most effective way for community-based healthcare workers to remove physical contamination, such as blood, from their hands in the absence of running water. In recent years, hand decontamination products that can be used without running water, such as gels, handrubs and wipes, have become available. However, their efficacy and suitability in actual clinical practice for use with visibly dirty hands has not been determined. A randomised controlled trial is required to compare hand wipes (alcohol and antiseptic), hand gels and other hand decontamination products that can be used without running water, to determine the most effective way to remove physical dirt in the absence of running water, in order to make a recommendation for their use in real situations. The primary outcome measure should be colony-forming units on the basis of the adenosine triphosphate (ATP) surface test.

# Intermittent urinary catheters: catheter selection
For patients performing intermittent self-catheterisation over the long term, what is the clinical and cost effectiveness of single-use non-coated versus single-use hydrophilic versus single-use gel reservoir versus reusable non-coated catheters with regard to the following outcomes: symptomatic urinary tract infections, urinary tract infection-associated bacteraemia, mortality, patient comfort and preference, quality of life, and clinical symptoms of urethral damage?

## Why this is important
Long-term (more than 28 days) intermittent self-catheterisation is performed by many people living in the community. It is important that the choice between intermittent catheters is informed by robust evidence on clinical and cost effectiveness.
The cost-effectiveness model developed for this guideline combined evidence of clinical effectiveness, costs and quality of life with respect to symptomatic urinary tract infection and associated complications. The results of the analysis showed that reusable non-coated catheters were the most cost-effective option for intermittent self-catheterisation. However, the clinical evidence informing this model was of low to very low quality. Currently, non-coated catheters are considered to be single-use devices. In order to make an 'off-licence' recommendation for the use of these catheters, better quality evidence is needed.
A four-arm randomised controlled trial is required. The trial population should be diverse, including wheelchair users, people with spinal cord injuries and people over 16 who regularly self-catheterise. The primary outcome measures should be incidence of symptomatic urinary tract infections, urinary tract infection-associated bacteraemia, mortality, patient comfort and preference, quality of life, clinical symptoms of urethral damage, and costs.

# Indwelling urinary catheters: catheter selection
For patients using a long-term indwelling urinary catheter, what is the clinical and cost effectiveness of impregnated versus hydrophilic versus silicone catheters in reducing symptomatic urinary tract infections, encrustations and/or blockages?

## Why this is important
Long-term indwelling catheters (both urethral and suprapubic) are commonly used in both hospital and community care settings. Long-term catheterisation carries a significant risk of symptomatic urinary tract infection, which can lead to more serious complications. Several different types of impregnated and hydrophilic long-term indwelling catheters on the market claim to be more effective than non-coated catheters, but are also more expensive.
The clinical evidence review for the guideline revealed an absence of evidence for the effectiveness of indwelling catheters over the long term. A comparison of impregnated (for example, with silver), hydrophilic and silicone catheters is needed. The primary outcome measures should be symptomatic urinary tract infections, encrustations, blockages, cost/resource use and quality of life. Secondary outcome measures should include the mean number of days the catheter remains in situ (mean dwell time) and patient comfort.

# Indwelling urinary catheters: antibiotic prophylaxis
When recatheterising patients who have a long-term indwelling urinary catheter, what is the clinical and cost effectiveness of single-dose antibiotic prophylaxis in reducing symptomatic urinary tract infections in patients with a history of urinary tract infections associated with catheter change?

## Why this is important
The immediate clinical and economic impact of urinary tract infection is so great that patients at risk of infection are sometimes offered the option to receive prophylactic antibiotics. However, the widespread use of antibiotics, including their prophylactic use, has been identified as a major factor in the increasing levels of antibiotic resistance observed across England and Wales. There is currently an absence of evidence about the short-term and long-term effects of prophylactic antibiotic use during catheter change. The GDG identified this as an important area for research to establish the benefits and harms of this practice in order to develop future guidance (the recommendation on this topic in the current guideline was based on GDG consensus).
A randomised controlled trial or cohort trial comparing single-dose antibiotic prophylaxis with selected major antibiotic groups is needed. The primary outcome measures should be symptomatic urinary tract infection, cost and quality of life. This is an important area for patients as it could minimise the inappropriate use of antibiotics

# Vascular access devices: skin decontamination
What is the clinical and cost effectiveness of 2% chlorhexidine in alcohol versus 0.5% chlorhexidine in alcohol versus 2% chlorhexidine aqueous solution versus 0.5% chlorhexidine aqueous solution for cleansing skin (before insertion of peripheral vascular access devices  and during dressing changes of all VADs) in reducing VAD-related bacteraemia and VAD site infections?

## Why this is important
The effective management of VADs is important for reducing phlebitis and bacteraemia. In the community, compliance is improved when a single solution is used for all aspects of VAD-related skin care. There is no direct evidence comparing different percentages of chlorhexidine in aqueous and alcohol solutions, and little evidence on the use of such solutions in the community. A randomised controlled trial is required to compare the clinical and cost effectiveness of the different solutions available. The trial should enrol patients in the community with a VAD. The protocol would need to use the same skin preparation technique regardless of solution, and could also investigate the effects of decontamination technique and drying time. The primary outcome measures should be rate of VAD-related bacteraemia, rate of VAD site infections, mortality, cost and quality of life. Secondary outcome measures should include visual infusion phlebitis (VIP) score, insertion times and skin irritation.# Context
A wide variety of healthcare is delivered in primary and community care settings. Healthcare-associated infections arise across a wide range of clinical conditions and can affect patients of all ages. Healthcare workers, family members and carers are also at risk of acquiring infections when caring for patients.
Healthcare-associated infections can occur in otherwise healthy individuals, especially if invasive procedures or devices are used. For example, indwelling urinary catheters are the most common cause of urinary tract infections, and bloodstream infections are associated with vascular access devices.
Healthcare-associated infections are caused by a wide range of microorganisms. These are often carried by the patients themselves, and have taken advantage of a route into the body provided by an invasive device or procedure. Healthcare-associated infections can exacerbate existing or underlying conditions, delay recovery and adversely affect quality of life.
Patient safety has become a cornerstone of care, and preventing healthcare-associated infections remains a priority. It is estimated that 300,000 patients a year in England acquire a healthcare-associated infection as a result of care within the NHS. In 2007, meticillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridium difficile infections were recorded as the underlying cause of, or a contributory factor in, approximately 9000 deaths in hospital and primary care in England.
Healthcare-associated infections are estimated to cost the NHS approximately 1 billion a year, and 56 million of this is estimated to be incurred after patients are discharged from hospital. In addition to increased costs, each one of these infections means additional use of NHS resources, greater patient
discomfort and a decrease in patient safety. A no-tolerance attitude is now prevalent in relation to avoidable healthcare-associated infections.
In 2012, this guideline updated and replaced the clinical guideline on infection control: prevention of healthcare-associated infection in primary and community care (CG2). We updated and replaced the recommendations to reflect the many changes that have happened in the NHS to help ensure patients' interests are at the centre of all activities. These changes include the launch of the NHS Constitution for England, which defines the rights and pledges that every patient can expect regarding their care. The Care Quality Commission (CQC), the independent regulator of all health and adult social care in England, which helps to ensure that health and social care is safe and monitors how providers comply with established standards. In addition, the legal framework that underpins the guidance has changed since 2003.
The 2012 guidance was also needed to reflect the fact that, due to the rapid turnover of patients in acute care settings, complex care is increasingly being delivered in the community. New standards for the care of patients and the management of devices are needed to prevent related healthcare-associated infections that could reinforce the principles of asepsis.
The 2012 guideline also addressed areas in which clinical practice for preventing healthcare-associated infections in primary and community care have changed, where the risk of healthcare-associated infections is greatest or where the evidence has changed (see update information for more details). Where high-quality evidence is lacking, the Guideline Development Group (GDG) highlighted areas for further research.
This guideline assumes that all providers of healthcare in primary and community care settings are compliant with current code of practice on preventing and controlling infections. It aims to help build on advice given in the code and elsewhere to improve the quality of care and practice in these areas over and above current standards.
The GDG recognises the important contribution that surveillance makes to monitoring infection, but it is not within the scope of this guideline to make specific recommendations about this subject.
Medical Device Regulations
The Medical devices regulations implement the EC Medical Devices Directives into UK law. They place obligations on manufacturers to ensure that their devices (including medical gloves, needles and other devices discussed in this guideline) are safe and fit for their intended purpose before they are CE marked and placed on the market in any EC member state. Guidance on the MHRA's adverse incident reporting system is available for reporting adverse incidents involving medical devices.