IPC guidelines and policies are contained in the Hospital Infection Control Manual, which is distributed to all areas of the hospital. Copies of the manual are maintained under the custody of department / unit heads, and head nurses, and are available for reference within the respective clinical and service areas. 

Certification is issued by HICU after successful completion of the required IPC training and assessment (Exam). A minimum passing score of 90% is required. Certificates are valid for one (1) year from the date of issuance and will be sent to the individual's institutional email. 

• Standard Precautions apply to ALL patients at all times and include hand hygiene, appropriate PPE, respiratory etiquette, and safe injection practices. 

• Transmission-based Precautions (Contact, Droplet, Airborne) are additional measures used for patients with known or suspected infectious conditions that require extra protection. Click link for examples.

Contact Precautions and cohorting should be implemented for patients who are colonized or infected with multidrug-resistant organisms (MDROs) or other pathogens transmitted by direct or indirect contact such as: C.difficile infection, poliomyelitis, rotavirus, hepatitis A, RSV, parainfluenza, HSV, and scabies. 

MDROs are bacteria that are resistant to at least one agent in three or more antimicrobial classes, making infections difficult to treat and increasing the risk of transmission in healthcare settings. Common MDROs of concern in the hospital include:

• Multidrug-resistant Acinetobacter baumannii 

• Multidrug-resistant Pseudomonas aeruginosa

• Carbapenem resistant Enterobacterales (ex. Escherichia coli, Klebsiella spp., Enterobacter spp.)

• Extended-spectrum beta-lactamase (ESBL) producing Enterobacterales

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Vancomycin-resistant Enterococcus spp. (VRE)

If an MDRO is identified, the following steps should be taken promptly:

1. Notify HICU

   • The microbiology laboratory informs HICU once an MDRO is identified. 

   • If test results are from an outside facility, the physician must notify HICU via local 3238.

2. Implement contact precautions at once

   • The head nurse arranges isolation, cohorting, or transfer to  designated areas as advised by HICU

   • The nurse-in-charge posts contact precautions signage at the room entrance or at the head/foot of the patient's bed.  

   • The physician or nurse updates the RADISH tag to indicate that Contact Precautions are in place. 

   • The physician informs and educates the patient and watchers about the need for additional precautions and limit visitors as appropriate.

3. Ensure proper PPE and infection control measures

   • Enforce strict hand hygiene. Ensure alcohol-based handrub is readily available.

   • Use gloves and gown for all patient interactions. Use a surgical mask when MDROs are isolated from respiratory secretions.

   • Dispose PPE properly after use; do not reuse PPE for the same or other patients.

   • Maintain patient-dedicated items at the bedside (e.g. BP cuff, thermometer, pulse oximeter).

4. Ensure enhanced environmental cleaning

   • Clean and disinfect high-touch surfaces every shift (eg. bed rails, door knobs, light switch).

   • Perform thorough terminal cleaning after patient discharge or transfer.

5. Refer to Infectious Diseases (ID)

   • Refer to ID for antibiotic guidance and co-management when infection is clinically suspected.

   • Colonization alone does not require treatment with antibiotics. If the need for treatment is unclear, consult ID.

   • For ESBL-producing organisms, referral may be required only for antibiotic approval (AMS). 

These steps should be followed regardless if the MDRO represents true infection or colonization.

Early notification and prompt implementation of IPC measures are essential to prevent transmission.

According to CDC, aaerosol-generating procedures (AGPs) are medical procedures that can produce small respiratory droplets or aerosols, potentially increasing the risk of infection transmission to nearby healthcare workers. There is no definitive or exhaustive list of AGPs due to limited evidence.

AGPs commonly include:

• Procedures involving the airway: bronchoscopy, laryngoscopy, endotracheal intubation, laryngeal mask airway insertion

• Ventilation support: noninvasive ventilation (bag-mask ventilation, BiPAP, CPAP), high-frequency oscillatory ventilation

• Airway clearance and resuscitation: airway suctioning, chest physiotherapy with cough induction, cardiopulmonary resuscitation (CPR).

The WHO also considers sputum induction and tracheostomy as aerosol-generating procedures.

Appropriate IPC measures, including the use of recommended PPE, should be implemented when performing or assisting with aerosol-generating procedures.

Cleaning refers to the physical removal of dirt, organic matter, and microorganisms from surfaces or equipment using water, detergent, and mechanical action. Although cleaning does not necessarily kill microorganisms, it significantly reduces their number and is an essential first step in infection prevention.

Disinfection involves the use of chemical agents to kill or inactivate microorganisms on surfaces or equipment after cleaning. Disinfectants are effective only when applied to clean surfaces, as the presence of organic matter can reduce their effectiveness. 

Contact time refers to the amount of time a disinfectant must remain on a surface—without being wiped away or disturbed—to effectively kill microorganisms. Adhering to the recommended contact time is critical for disinfection to be effective.

• Cleaning should always be performed before disinfection, especially for visibly soiled surfaces or equipment.

• High-touch surfaces (e.g. bed rails, doorknobs, bedside tables, medical equipment) require regular cleaning and disinfection.

• The appropriate disinfectant and contact time must be followed in accordance with hospital policy and manufacturer's instructions.

• Proper cleaning and disinfection reduces the risk of indirect transmission of pathogens in healthcare settings.

The following restricted antimicrobials require prior approval from the Infectious Diseases (ID) service before use in PGH patients, in accordance with the hospital's Antimicrobial Stewardship Program:

• Restricted antimicrobials: Aztreonam, Cefepime, Ceftazidime-avibactam, Ceftolozane/tazobactam, Colistin, Ertapenem, Imipenem/cilastatin, Linezolid, Meropenem, Minocycline, Piperacillin-tazobactam, Polymyxin B, Tigecycline, Vancomycin

• Restricted antivirals: Remdesivir, Molnupiravir

• Restricted antifungals: Amphotericin B, Caspofungin, Micafungin, Voriconazole

How to request for approval: 

1. Accomplish the Request for Use of Restricted Antimicrobial via RADISH. 

2. Notify and coordinate with the ID service for review and approval prior to continued administration. 

Special considerations for sepsis:

For patients with sepsis or septic shock, an initial loading dose of a restricted antimicrobial may be administered. However, subsequent doses will require ID approval. 

The Department of Health (DOH) mandates reporting of notifiable diseases under the Republic Act No. 11332, which requires prompt and accurate reporting by all health professionals, facilities, and institutions. Notifiable diseases include: 

• Acute bloody diarrhea, acute flaccid paralysis (AFP), 

• Acute meningitis-encephalitis syndrome (AMES), 

• Acute viral hepatitis, adverse event following immunization (AEFI), 

• Chikungunya, 

• Cholera, 

• COVID-19, 

• Dengue, 

• Diphtheria, 

• Hand-foot-and-mouth disease (HFMD),  

• Influenza-like illness (ILI), 

• Leptospirosis, 

• Measles, 

• Melioidosis, 

• Meningococcal disease, 

• Mpox, 

• Tetanus, 

• Pertussis, 

• Rabies, 

• Rotavirus, 

• Rubella, 

• Severe acute respiratory infection (SARI), 

• Typhoid and paratyphoid fever

How to Report

Please follow the step by step reporting process via RADISH as demonstrated  here. For urgent concerns or cases requiring immediate action, you may contact HICU directly through local 3238.

Hepatitis B vaccine, namely Engerix-B, Recombivax HB, and Twinrix, consists of three intramuscular doses administered on a 0-, 1-, and 6-month schedule. 

When the Hepatitis B vaccine schedule is interrupted, the vaccine series does not need to be restarted. For Engerix-B and Recombivax HB, if the series is interrupted after the 1st dose, the 2nd dose should be administered as soon as possible, and the 2nd and 3rd doses should be separated by at least 8 weeks. If only the 3rd dose has been delayed, it should be administered as soon as possible. 

For Engerix-B and Recombivax HB, the minimum interval between the first and second doses is 4 weeks. The final dose of vaccine must be administered at least 8 weeks after the second dose and should follow the first dose by at least 16 weeks. Vaccine doses administered 4 or fewer days before the minimum interval or age are considered valid. Doses received 5 or more days before the minimum interval or age should be repeated using the correct schedule. Because of the unique accelerated schedule for Twinrix, the 4-day “grace period” does not apply to the first three doses of this vaccine when administered on a 0-, 7-, 21–30-day, and 12-month schedule.