Identification of Infectious Disease Processes
16.3%of exam
Surveillance and Epidemiologic Investigation
16.3%of exam
Preventing/Controlling Transmission
16.3%of exam
Employee/Occupational Health
8.1%of exam
Management, Communication, Education
10.4%of exam
Education and Research
8.9%of exam
Environment of Care
10.4%of exam
Cleaning, Disinfection, Sterilization
13.3%of exam
Quick Facts
- Credential
- CIC
- Board
- CBIC
- Items
- 150 (135 scored)
- Time
- 3 h, two sections
- Navigation
- Forward only, no flags
- Pass
- Scaled 700 (300-900)
- Pass rate
- 64% in 2025
- Fee
- $445 application
- Delivery
- Prometric / ProProctor
- Retake
- 90 days, max 4/year
- Valid
- 5 years, 40 IPUs
- Outline
- 2021, new Feb 2027
Chain of Infection
Agent, Reservoir, Exit, Mode, Entry, Host
Agent: the pathogenReservoir: where it livesExit: how it leavesMode: how it travelsEntry: how it arrivesHost: who is susceptible
Sensitivity vs Specificity
Sensitivity
- True positive rate
- Negative rules out
- Prevalence independent
Specificity
- True negative rate
- Positive rules in
- Prevalence independent
Catch sick vs confirm sick
Chain of Infection
- Infectious agent
- Pathogen causing disease
- Reservoir
- Where the agent lives
- Portal of exit
- How the agent leaves
- Mode of transmission
- Contact, droplet, airborne, vehicle
- Portal of entry
- How it enters host
- Susceptible host
- Person at risk
- Break any link
- Transmission stopsKey
Colonization vs Infection
Colonization
- No tissue invasion
- No clinical signs
- Can still transmit
Infection
- Tissue invasion
- Host response present
- Counted as case
Present vs invading
Disease Process Concepts
- Colonization
- Present, no tissue invasion
- Infection
- Invasion plus host response
- Contamination
- Organism on surface only
- Pseudo-outbreak
- Lab artifact, no illness
- Incubation period
- Exposure to first symptom
- Communicable period
- Window of transmissibility
- Virulence
- Severity of disease produced
- Infectivity
- Ability to enter, multiply
- Pathogenicity
- Share of infected sickened
Test Performance Measures
- Sensitivity
- True positive rate
- Specificity
- True negative rate
- SnNout
- Sensitive test rules out
- SpPin
- Specific test rules in
- PPV
- Positive means true disease
- NPV
- Negative means truly well
- Prevalence effect
- Low prevalence lowers PPV
- Diagnostic stewardship
- Test only symptomatic patients
Epi Curve Shapes
Spike, plateau, waves
Spike: point sourcePlateau: continuous sourceWaves: propagated spread
Incidence vs Prevalence
Incidence
- New cases only
- Population at risk
- Measures risk
Prevalence
- New plus existing
- Point or period
- Measures burden
Risk vs burden
Surveillance Metric Picker
- Measuring new HAI risk→Incidence rate(Per 1,000 device days)
- Snapshot of burden→Point prevalence(One day count)
- Comparing to national baseline→SIR(Observed over predicted)
- Judging device use→SUR(Device days ratio)
- Foodborne cluster on unit→Attack rate(Ill over exposed)
- Fewer than 1 predicted→No SIR reported(Estimate unstable)
- Linking cases to strain→Molecular typing(Confirms relatedness)
Epidemiology Measures
- Incidence
- New cases, population at-risk
- Prevalence
- All cases, one time
- Attack rate
- Ill divided by exposed
- Device utilization ratio
- Device days over patient days
- Device-associated rate
- Infections per 1,000 device days
- SIR
- Observed over predicted infections
- SUR
- Observed over predicted device days
- Point prevalence survey
- Snapshot on one day
- Denominator
- Population or days at-risk
NHSN HAI Concepts
- CLABSI
- Line >2 days, no source
- CAUTI
- Catheter >2 days plus symptoms
- SSI
- Infection after operative procedure
- SSI window
- 30 or 90 days
- VAC
- Sustained oxygenation worsening
- IVAC
- VAC plus fever, antimicrobial
- PVAP
- IVAC plus qualifying microbiology
- Date of event
- First qualifying element appears
- Present on admission
- Not counted as HAI
- LabID event
- Lab-based MDRO or C. difficile
Outbreak Investigation Toolkit
- Confirm outbreak
- Compare against baseline rate
- Case definition
- Person, place, time, criteria
- Line list
- One row per case
- Epi curve
- Cases plotted over time
- Point source
- Single sharp peak
- Continuous source
- Plateau while exposure persists
- Propagated
- Peaks one incubation apart
- Analytic study
- Case-control or cohort
- Molecular typing
- Confirms strain relatedness
- Control measures
- Start before study finishesTrap
Five Moments
Patient, aseptic, fluid, patient, surroundings
1: before touching patient2: before aseptic task3: after fluid risk4: after touching patient5: after touching surroundings
Airborne vs Droplet
Airborne
- Small particles, long distance
- N95 respirator
- Negative pressure room
Droplet
- Large droplets, short range
- Surgical mask
- Normal room, door open
Respirator vs surgical mask
Precaution Picker
- Suspected pulmonary tuberculosis→Airborne(N95, AIIR, door closed)
- Measles→Airborne(Immune staff preferred)
- Varicella→Airborne plus contact(Both, not contact alone)
- Disseminated zoster→Airborne plus contact(Any immune status)
- Localized zoster, immunocompetent→Standard(Cover the lesions)
- Influenza or pertussis→Droplet(Surgical mask on entry)
- Neisseria meningitidis→Droplet(Not airborne)
- Mumps or rubella→Droplet(Not airborne)
- C. difficile→Contact(Soap, water, bleach)
- Norovirus outbreak→Contact(Alcohol rub insufficient)
- MRSA, VRE, CRE→Contact(Gown and gloves)
- RSV in infant→Contact(Add droplet if splashing)
- Stem cell transplant patient→Protective environment(Positive pressure room)
Precaution Categories
- Standard
- Every patient, every time
- Contact
- Gown and gloves
- Droplet
- Surgical mask on entry
- Airborne
- N95 plus negative-pressure room
- Protective environment
- Positive pressure, HEPA supply
- Layering rule
- Transmission-based adds to standard
Doffing Order
Gloves, gown, eyewear, mask last
Dirtiest comes off firstMask outside the roomHand hygiene immediately after
PPE Rules
- Donning order
- Gown, mask, eyewear, gloves
- Doffing order
- Gloves, gown, eyewear, mask
- Mask removal
- Outside the room
- Gloves
- Never replace hand hygiene
- N95
- Fit-tested, seal check each use
- Gown
- Fluid-resistant, single patient use
- Eye protection
- Goggles or face shield
- Patient transport
- Patient wears the mask
Hand Hygiene
- Moment 1
- Before touching a patient
- Moment 2
- Before clean, aseptic procedure
- Moment 3
- After body fluid risk
- Moment 4
- After touching a patient
- Moment 5
- After touching patient surroundings
- Alcohol rub
- Preferred, faster, less drying
- Soap and water
- Visibly soiled, spores, norovirus
- Artificial nails
- Prohibited in high-risk units
Organism Precaution Map
- Tuberculosis
- Airborne
- Measles
- Airborne
- Varicella
- Airborne plus contact
- Disseminated zoster
- Airborne plus contact
- Localized zoster, immunocompetent
- Standard, cover lesions
- Influenza
- Droplet
- Pertussis
- Droplet
- Neisseria meningitidis
- DropletTrap
- Mumps, rubella
- Droplet
- C. difficile
- Contact plus soap
- Norovirus
- Contact
- RSV
- Contact
- MRSA, VRE, CRE
- Contact
- Scabies, lice
- Contact
OSHA Bloodborne Numbers
- Standard
- 29 CFR 1910.1030
- Exposure control plan
- Reviewed at least annually
- Hepatitis B vaccine
- Free within 10 working days
- Training
- At assignment, then annually
- Sharps injury log
- Employers over 10 employees
- Medical records
- Employment plus 30 years
- Training records
- Kept 3 years
- Device selection
- Frontline worker input required
Exposure Follow-up
- HIV PEP
- Start hours, take 28 days
- HBV, unvaccinated source-positive
- HBIG plus vaccine series
- HBV timing
- Ideally within 24 hours
- Hepatitis C
- No PEP, test and treat
- Anti-HBs immunity
- At least 10 mIU/mL
- Source testing
- Test source, consent permitting
- Sharps injury
- Wash, report, evaluate promptly
TB Screening Program
- Baseline
- Risk assessment, symptoms, test
- Baseline TST
- Two-step when TST used
- IGRA
- Blood test, one visit
- Routine annual testing
- No longer recommendedUpdated
- Annual education
- Required for all personnel
- After exposure
- Test baseline, 8-10 weeks
- Fit test
- Before use, then annually
Program and Regulation
- Risk assessment
- Ranks risks by priority
- IPC plan
- Goals from ranked risks
- CMS Conditions of Participation
- Enforceable federal requirement
- Joint Commission
- Voluntary, may carry deemed status
- CDC/HICPAC guidelines
- Recommendations, not law
- Stewardship core elements
- Seven CDC hospital elements
- Cost avoidance
- Infections prevented times cost
- Cost savings
- Real budget line reduction
- PDSA
- Plan, Do, Study, Act
Education vs Competency Validation
Education
- Transfers knowledge
- Attendance or post-test
- Classroom or module
Competency validation
- Observed performance
- Defined criteria
- Return demonstration
Knows vs can do
Education and Research
- Andragogy
- Adults are self-directed learners
- Readiness to learn
- Driven by role demands
- Education
- Knowledge, measured by post-test
- Competency validation
- Observed return demonstration
- Cognitive domain
- Knowledge and reasoning
- Psychomotor domain
- Physical skill performance
- Affective domain
- Attitudes and values
- Evidence hierarchy top
- Systematic review of RCTs
- Research trigger
- Intent to generalize knowledge
- Quality improvement
- Local, usually no IRB
AIIR vs Protective Environment
AIIR
- Negative pressure
- Protects everyone else
- Infectious patient inside
Protective environment
- Positive pressure
- Protects the patient
- HEPA-filtered supply air
Keep in vs keep out
Environment of Care
- AIIR
- Negative pressure, door closed
- AIIR air changes
- 12 new, 6 existing
- Pressure monitoring
- Daily while room occupied
- Protective environment
- Positive pressure, HEPA supply
- ICRA matrix
- Activity type by patient risk
- Aspergillus risk
- Construction dust, immunocompromised patients
- Water management
- ASHRAE 188 Legionella program
- Legionella conditions
- Stagnation, tepid water, low residual
- Contact time
- Surface stays visibly wet
- Bleach for C. difficile
- 1:10 dilution, EPA List K
- Regulated medical waste
- Pourable, drippable, caked blood
ACH Clearance Times
- 2 ACH, 99%
- 138 minutes
- 6 ACH, 99%
- 46 minutes
- 6 ACH, 99.9%
- 69 minutes
- 12 ACH, 99%
- 23 minutes
- 12 ACH, 99.9%
- 35 minutes
- 15 ACH, 99.9%
- 28 minutes
- 20 ACH, 99.9%
- 21 minutes
- Use
- Wait time after airborne case
Spaulding C-S-N
Critical sterilize, Semicritical high-level, Noncritical low-level
Critical: sterile tissueSemicritical: mucous membranesNoncritical: intact skin
High-level Disinfection vs Sterilization
High-level disinfection
- Many spores survive
- Semicritical devices
- Liquid chemical, minutes
Sterilization
- All spores killed
- Critical devices
- Validated, monitored cycle
Spores survive vs none
Reprocessing Picker
- Visibly soiled instrument→Clean first(Soil blocks sterilants)
- Enters sterile tissue→Sterilize(Critical item)
- Enters the bloodstream→Sterilize(Implants, surgical instruments)
- Touches mucous membranes→High-level disinfection(Semicritical item)
- Flexible GI endoscope→High-level disinfection(Leak test, brush channels)
- Bronchoscope→High-level disinfection(Sterilize when feasible)
- Covered vaginal probe→High-level disinfection(Cover is not enough)
- Touches intact skin→Low-level disinfection(Noncritical item)
- Blood pressure cuff→Low-level disinfection(EPA-registered wipe)
- Needed immediately, no spare→IUSS(Never routine implants)
Spaulding Classification
- Critical
- Sterile tissue or bloodstream
- Critical process
- Sterilization required
- Semicritical
- Contacts mucous membranes
- Semicritical process
- High-level disinfection minimum
- Noncritical
- Intact skin only
- Noncritical process
- Low-level disinfection
- Class driver
- Intended use, not nameTrap
- Cleaning first
- Always precedes disinfection, sterilization
BI Spore Match
Steam Geobacillus, dry heat Bacillus
Geobacillus: steam sterilizationGeobacillus: hydrogen peroxideBacillus atrophaeus: dry heatBacillus atrophaeus: ethylene oxide
Biological vs Chemical Indicator
Biological indicator
- Live resistant spores
- Proves lethality
- Releases implant loads
Chemical indicator
- Color change
- Proves exposure only
- Never proves sterility
Killed vs exposed
Disinfection Levels and Agents
- High-level
- Kills all but many spores
- High-level agents
- Glutaraldehyde, OPA, peracetic acid
- Intermediate-level
- Tuberculocidal claim, no spores
- Intermediate agents
- Alcohol, phenolics, iodophors, chlorine
- Low-level
- Vegetative bacteria, some viruses
- Low-level agents
- Quaternary ammonium compounds
- Dividing line
- Tuberculocidal separates intermediate, low
- Sterilization
- Kills all microbial life
Sterilization Monitoring
- Biological indicator
- Only proof of lethality
- Steam, hydrogen peroxide
- Geobacillus stearothermophilus
- Dry heat, ethylene oxide
- Bacillus atrophaeus
- Chemical indicator
- Proves exposure, not sterility
- Bowie-Dick
- Daily air removal test
- Bowie-Dick setup
- Empty chamber, first cycle
- Gravity steam
- 121 C, 30 minutes wrapped
- Prevacuum steam
- 132 C, 4 minutes wrapped
- IUSS
- Emergency only, never implantsTrap
- Implant loads
- Quarantine until BI result
- Event-related sterility
- Package integrity, not date
Common Traps
Droplet is not airborne
Meningococcus, pertussis: droplet ≠ Tuberculosis, measles: airborne
Varicella needs both
Airborne plus contact ≠ Not contact alone
Zoster depends on spread
Localized: standard, cover lesions ≠ Disseminated: airborne plus contact
CLABSI day count
Line >2 calendar days ≠ Insertion day is day 1
Bacteriuria is not CAUTI
Positive culture alone: bacteriuria ≠ CAUTI needs qualifying symptom
IUSS misuse
Not for inventory shortages ≠ Not for routine implants
Chemical indicator is not proof
Color change: exposure only ≠ Biological indicator proves kill
Pass rate is 64%
CBIC reports 64% (2025) ≠ Not the quoted 75%
Alcohol rub is not universal
Spores need soap, water ≠ C. difficile, norovirus: wash
Prevalence moves PPV only
Sensitivity fixed by test ≠ Low prevalence lowers PPV
No going back
Forward only, no flags ≠ Answer before moving on
Last Minute
- 1.150 items, 135 scored
- 2.Two 90-minute sections, forward only
- 3.Pass = scaled 700 (300-900)
- 4.Top three domains: 22 items each
- 5.Standard precautions apply to everyone
- 6.Airborne = TB, measles, varicella
- 7.Droplet = flu, pertussis, meningococcus
- 8.Contact = MDRO, C. difficile
- 9.Critical sterilize; semicritical high-level
- 10.Clean before you disinfect
- 11.BI proves kill; CI proves exposure
- 12.CLABSI needs line >2 days
- 13.SIR = observed over predicted
- 14.Incidence = risk; prevalence = burden
- 15.12 ACH: 35 minutes to 99.9%
- 16.Fit test yearly; seal check daily
- 17.HBV vaccine within 10 days
- 18.Retake after 90 days, max four
- 19.Recert: 40 IPUs or retake
- 20.New content outline February 2027
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