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Prevention by breaking the chain of infection

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Nurses are at the heart of the fight against antimicrobial resistance, which requires multifocal measures to prevent and control infections


We rely on antimicrobials to fight infections, but some microorganisms have become resistant to these agents. Antimicrobial resistance is a global threat, and nurses have a crucial role to play in the fight against it. They are constantly in contact with patients and conduct many interventions – each contact and intervention is an opportunity to prevent the rise of AMR. To do this, they need to understand how the chain of infection works and how it can be broken, therefore preventing infection.

Citation: Shaw K (2016) Prevention by breaking the chain of infection. Nursing Times; 112, 39/40: 12-14.

Author: Karen Shaw is infection prevention and control lead for antimicrobial resistance and healthcare associated infections programme at Public Health England.


The availability of antimicrobials to treat infections is at the heart of modern healthcare. It allows those who need them to live longer and healthier lives, and enables health professionals to safely deliver interventions, such as surgery and chemotherapy. However, bacteria and other microorganisms evolve and become resistant to antimicrobials. This is problematic, as antimicrobial resistance (AMR) is developing faster than new antimicrobials (O’Neill, 2014). In the UK, infections caused by resistant Gram negative organisms are increasing; the key bacteria causing increasing infections are E Coli, Klebsiella pneumonia and Pseudomonas aeruginosa. The WHO stresses that without urgent global action the world is headed for a ‘post-antibiotic era’ (WHO, 2014). To put a halt to AMR, countries need to put in place key measures, which include enhancing infection prevention and control (IPC), and prescribing antibiotics correctly and only when needed (antimicrobial stewardship) (WHO, 2015). Nurses and midwives are at the heart of these measures, who can use every opportunity to prevent infections and advocate appropriate antibiotic use.

Infection prevention and control

Healthcare workers have a responsibility to prevent infection, but there are common misconceptions about IPC, such as assuming it is only about hand hygiene and cleaning. For nurses and midwives, it is important to understand how their role fits into the wider picture of AMR prevention, as well as the components of IPC (see Box 1).

Box 1. IPC components

  • Engagement of senior members of staff and leadership;
  • Training and education to increase staff competence in knowledge of infections, their prevention and the control of outbreaks;
  • Surveillance of infection and resistance, auditing of clinical practice and feedback to staff;
  • Following evidence-based guidelines for patient management and device care;
  • Optimising the use of antimicrobials;
  • Implementing aseptic techniques and safe clinical practices, including for device selection, insertion and management;
  • Ensuring clean and safe environments, including decontamination of reusable medical devices, cleaning, the built environment, and water and food safety;
  • Occupational health and vaccination (including for relevant health and care staff);
  • Microbiology and virology laboratory support and appropriate diagnostics;
  • Links to public health, health protection and other support services

IPC is essential and relevant in all health and social care settings, including acute hospitals, care homes, general practice, mental health and community hospitals and centres, learning disability units, schools and prisons. All inpatients and service users are susceptible to acquiring infections. We need to work together to understand the risk factors and implement the measures required to prevent infections. We need to strengthen our engagement across health and social care to prevent and control infections more effectively.

Surveillance data

Public Health England monitors antimicrobial-resistant organisms and key infections that occur in healthcare environments through surveillance programmes and provides reports on the numbers and trends of infections and resistance over time. This allows healthcare providers to know what the problems are and how well the control measures are working.

In England, surveillance data has shown a 6.6% decrease in the rate of total metacillin-resistant S aureus bacteraemia reported since October/December 2012 compared with January/March 2016, which reflects a general decrease since April 2007. Decreases have also been seen in rates of C difficile infections (CDIs): comparing January/March 2015 with January/March 2016, there has been a 14.4% decrease in the rates of CDI cases. CDI rates that are attributable to NHS trusts have also decreased by 14.6% during the same period (PHE, 2016a).

However, over the last four years, there has been an 18% increase in the number of E coli bloodstream infections (PHE, 2016a). In 2015/16, 38,132 patients had an E coli blood stream infection – 12,594 more than all CDIs and S aureus infections combined. The focus is now, therefore, on reducing these infections.

Reducing the rates of infections

Various strategies and interventions have been implemented in England that have had a significant impact on reducing MRSA bloodstream infections and CDI (Duerden et al, 2015; Holmes et al, 2015; PHE, 2016c). Rather than a single intervention, a number of multimodal interventions implemented over a period of time have led to these reductions such as:

  • Monitoring infections through surveillance to better understand the data;
  • Setting targets to reduce infections
  • Disseminating guidelines;
  • The health and social care act (2008) code of practice for the prevention and control of infections;
  • Introducing patient safety alerts;
  • Reviewing infections to understand their root cause;
  • Implementing action plans, deep cleans and improvement programmes (Duerden et al, 2015).

The focus on IPC has led the government to set out new ambitions in order to reduce Gram negative bacteraemias (DH, 2016c):

  • A 50% reduction in healthcare-associated Gram negative bloodstream infections (GNBSIs) by 2020;
  • A 50% reduction in the number of inappropriate antibiotic prescriptions by 2020.

IPC is an essential element of all interventions and care provided. IPC interventions (particularly those targeted at routine care practices, environmental cleaning, disinfection and sterilisation, and education of staff) minimise the spread of infection, therefore reducing the need for antimicrobials (Dar et al, 2016).

The chain of infection

Surely, prevention must be one of the most important ways nurses can tackle the global threat of AMR, so why do we not focus more on this? Why is prevention not highlighted more as a fundamental strategy for tackling resistance?

For a microorganism to spread and potentially lead to an infection, certain conditions need to be met. There must be an interaction between the micro-organism, the host and the environment.

When the microorganism leaves the host (or reservoir) through a way out (known as the portal of exit), it passes on (via a mode of transmission) and enters (through a portal of entry) into a susceptible host. This is called the chain of infection (CDC, 2016), which is shown in Fig 1 (attached). Each step is a link in this chain, and if all the links are present, then an infection will develop. If one or more links are broken then the infection will not occur. This is relevant not only to AMR organisms but to all infections.

Nurses and midwives play a central role in breaking the chain of infection: they are in contact with people all the time and therefore, have the opportunity to prevent infections at every contact and intervention. Almost half the health and social care workforce is made up of nurses or midwives (48%) and can therefore have a significant impact on infection prevention (NHS Confederation, 2016). Examples of how nurses can break the chain of infection are listed in Table 1 (attached), which can be found in the PDF version of this article at

Infection Prevention Week

International Infection Prevention Week is held in the third week of October. In 2016, it is planned for 16-22 October (APIC, 2016). It is important that, as nurses and midwives, we remember how crucial our work is in tackling AMR. The recently published framework Leading Change, Adding Value outlines how nurses can meet the challenge of AMR (NHSE, 2016).

Promoting a culture of improving the population’s health is a core part of practice, which aims to:

  • Increase the visibility of nursing and midwifery leadership and input in prevention;
  • Assist individuals, families and communities so they can make informed choices about their health;
  • Promote research and evidence-based tools;
  • Enhance skills in, and knowledge of, AMR and IPC;
  • Use technology to improve outcomes;
  • Ensure the right staff are in the right place at the right time. (NHS, 2016).

Taking an active role in optimising antibiotic usage and breaking the chain of infection at every interaction is fundamental. By understanding the chain of infection, the portals of exit and entry, and the modes of transmission, nurses and midwives are in a unique position to influence breaking the chain of infection.

Every prevented infection lowers the need for and use of antibiotics, which lessens the development of resistance. The Nursing and Midwifery Council Code outlines that nurses and midwives ‘keep to and promote recommended practice in relation to controlling and preventing infection’ (NMC, 2015). Together, we can make a significant impact in reducing AMR.

Key points

  • Antimicrobial resistance is a serious issue that requires concerted action globally
  • Every infection prevented reduces the need for, and use of, antibiotics  
  • Infection prevention and control is the responsibility of all health professionals
  • Breaking the chain of infection reduces incidence
  • Nurses are well placed to use every patient contact and intervention to reduce the risk of infection
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