Our Infection Control Protocols

WHO's 5-moments hand hygiene protocol is applied in every patient room: 1) before patient contact, 2) before aseptic procedure, 3) after body fluid exposure, 4) after patient contact, 5) after leaving patient surroundings.

Alcohol-based hand sanitizer (≥60% ethanol or isopropanol) is mounted at every room entrance and exit. Visibly dirty hands → water + soap (at least 40-60 seconds, WHO 11-step wash).

Electronic auditing: sensor-based dispenser usage is logged, monthly compliance reports per physician/nurse. Target: ≥90% (JCI standard).

Hand jewelry and accessories prohibited: rings, watches, bracelets banned in clinical areas — they create a bacterial reservoir. Nails under 0.5 cm, no excessive polish.

Surgical scrub: standard 5-minute brushing (chlorhexidine 4% or povidone-iodine 7.5%) or 1.5-2-minute alcohol-based surgical rub. Surgeon and OR personnel before each case.

Training: every 6 months refresher training for all clinical staff (1 hour) + annual fluorescent UV-light audit.

Spaulding classification applied: critical (surgical instruments, biopsy forceps) → sterilization mandatory. Semi-critical (endoscopes) → high-level disinfection. Non-critical (stethoscope) → low-level disinfection.

Steam autoclaving (134°C, 4 min or 121°C, 30 min) is the standard for most instruments. Biological indicator (Geobacillus stearothermophilus) and chemical indicator test before each case.

Delicate instruments (endoscopic cameras, narrow-lumen tools) processed with EtO (ethylene oxide) or plasma sterilization — low-temperature alternatives.

Flexible endoscopes processed with automated washer-disinfectors (AERs): peracetic acid or ortho-phthalaldehyde high-level disinfectant. ASGE guideline compliance. Traceability record for each endoscope.

Sterilized instruments stored with traceable packaging — barcode labeled, expiration date 6 months (closed container) or 30 days (peel-pouch). Which instrument used on which patient, which sterilization batch entered circulation is tracked.

Single-use alternatives: when lumen interior is hard to wash, endoscopic accessories (biopsy forceps, balloon catheters) are used as single-use.

CSSD (Central Sterilization & Supply Department): sterilization done in a separate area — dirty area + clean area separation, one-way workflow (dirty → clean → sterile, no return).

HEPA filtration: all OR suites connected to HEPA-filtered (≥99.97% at 0.3 μm) positive-pressure ventilation. Inward air flow from adjacent corridors is prevented.

Air changes: minimum 20 changes per hour (ISO standard, ASHRAE 170 recommendation). Air temperature 20-22°C, humidity 30-60%.

Laminar air flow (LAF): for critical cases (e.g., large head & neck reconstruction), an additional laminar-flow ceiling panel — clean air curtain over the operative field.

Aerosol-generating procedures: laser surgery, tonsillectomy, vocal cord surgery, etc. — N95 mask + face shield + smoke evacuator mandatory. Post-COVID protocol expanded.

Air quality monitoring: quarterly particle count (0.5 and 5 μm), monthly microbiological culture (settle plate and active air sampling). Results reported to the Hospital Infection Committee.

Traffic control: number of personnel entering/exiting the OR is logged for each case. As the count rises, bacterial load increases — unnecessary traffic is minimized.

Surgical mask use: all OR personnel (surgeon, anesthesia, nurse, technician) wear masks. Mask not removed until the patient is awake.

Surgical site infection (SSI) prevention with standardized preop antibiotic prophylaxis. SHEA/IDSA guidelines followed.

Clean cases (thyroidectomy, mastoidectomy, septoplasty): cefazolin 2g IV 30-60 min before, BMI ≥30 → 3g. Penicillin allergy: vancomycin or clindamycin.

Clean-contaminated cases (neck dissection + oral cavity entry, total laryngectomy, parotidectomy): cefazolin + metronidazole OR ampicillin-sulbactam 3g, BMI ≥30 → 4.5g. Re-dose every 4 hours for long cases.

Contaminated cases (e.g., acute sinusitis surgery, drained abscess): ampicillin-sulbactam or clindamycin + ciprofloxacin. Treatment duration 5-7 days per case.

Stewardship: prophylaxis duration kept under 24 hours (NCCN/SHEA recommendation). Unnecessary extension → antibiotic resistance and C. difficile risk. Surgeon and infectious diseases consult decide jointly.

Surgeon-specific SSI rate: tracked by National Healthcare Safety Network (NHSN) criteria. Quarterly surgeon-based SSI report compared to national average.

High-risk patient: diabetes, smoking, BMI ≥35, immune suppression, chronic renal failure — individualized prophylaxis planned, post-op antibiotic treatment may extend 48-72 hours.

CDC/NHSN definitions used: superficial SSI (skin + subcutaneous), deep SSI (fascia + muscle), organ/space SSI (bone, cavity). Reporting within 30 days (no implant) or 90 days (bone implant or prosthesis).

Clinical reporting channels: post-discharge follow-up call (postop day 30), clinic check-up visit, patient self-presentation, antibacterial prescription issue → enters the registry.

Our SSI rate (anonymous aggregate data, by case): septoplasty 0.3-0.5%, thyroidectomy 0.5-1%, mastoidectomy 1-2%, neck dissection 2-5%, total laryngectomy 5-15%. All rates within international academic literature range.

Transparency: annual SSI report published by hospital Infection Committee. Surgeon-based rates reported anonymously to the Turkish MoH SAS (Health Services Accreditation System).

Outbreak protocol: if SSI rate for one surgeon or one procedure deviates ≥2x from baseline, cases undergo root-cause analysis by the Infection Committee. Instruments, OR personnel, patient bed, antibiotic supply chain are examined.

Patient notification: if SSI occurs, the patient is informed, re-treatment cost is covered (if our origin is confirmed, within first 30 days). For international patients, travel cost is evaluated separately.

Risk screening: patients from abroad, hospitalized or on antibiotics within the last 12 months are screened for nasal MRSA (PCR or culture) and perirectal VRE before admission.

MRSA positive → contact isolation room, intranasal mupirocin 2% for 5 days + chlorhexidine 4% bath for 5 days + vancomycin preferred for surgical prophylaxis.

ESBL/carbapenem-resistant Enterobacteriaceae (CRE) screening: rectal swab culture. Positive → protective isolation, additional antibiotic (meropenem, polymyxin-B) on standby.

C. difficile: every diarrhea episode in patients on antibiotics >3 days gets C. diff test (PCR + toxin assay). Positive → isolation + oral vancomycin or fidaxomicin.

Antibiotic stewardship program: hospital Infectious Diseases department reviews all long-term antibiotic use. De-escalation or stop decision at 48-72 hours.

Nurse-physician training: every 6 months refresher on MDRO and precaution bundles (contact, droplet, airborne).

Family/companion education: visual poster explains the protocol for entering/exiting the isolation room. Child visits restricted in MDRO cases.

Pre-admission screening: hospital stays, antibiotic use, MRSA/CRE history in your country within the last 12 months are queried during the tele-consult. Positive history → additional screening within 24h of arrival in Istanbul.

COVID-19/respiratory viruses: assessment per country epidemiology. Surgery postponed if active symptoms. PCR test for asymptomatic patient is case-specific (from a high-risk country, ASA III+).

TB screening: chest CT + IGRA test for patients with active or past TB history. Active TB → surgery postponed 3 months.

Case-specific cost: if SSI occurs, the patient's re-travel cost to Istanbul is evaluated separately. If insurance policy provides reimbursement, invoice issued in appropriate format.

Language barrier and education: isolation precautions explained with visual poster + brochure in patient's language. Interpreter ready in 8 languages (TR/EN/DE/AR/RU/FR/IT/ES).

Companion protocol: family member may be an MDRO carrier → isolation rules active for shared living areas in first 24 hours. Daily status update via WhatsApp group.

Emergency intervention: if infection signs appear in your home city after post-op discharge: 24/7 WhatsApp coordinator + coordination with nearest reference hospital + (if needed) travel logistics for re-admission to Istanbul.