Rudolph's Pediatrics, 22nd Ed.

CHAPTER 225. Infection Control

Margaret C. Fisher

Hospital infection control programs protect patients and staff from acquiring or transmitting infectious diseases.1-4 Through surveillance and reporting, nosocomial infections are identified and policies are developed to limit such infections. The Joint Commission and Joint Commission International inspects hospitals and other health care delivery systems to ensure that appropriate infection control practices are being followed. Infection control is a major patient safety effort that involves all health care providers.5-7

Infection control is equally important in the outpatient setting.8-17 Although less is written about outpatient clinics and offices, the practice of infection control remains an integral part of patient care in these settings. The goal is the same as for inpatients: protection of staff and patients from acquiring and transmitting infectious diseases.

TRANSMISSION

To practice effective infection control, one must understand the routes of transmission of infectious agents.21 By far, the most common route of transmission is via hands. Hands come into contact with a variety of contaminated objects or body sites; organisms are moved on the hands from one person to the next and from one body site to another. Because hands are frequently implicated in the transmission of bacteria, fungi, parasites, and viruses, hand-washing is central to all infection control programs.22-26

Some pathogens are aerosolized in small or larger droplets. Small droplets can be carried by air currents and remain suspended; large droplets require relatively close contact (within a few feet) in order for the droplet to move from one person to the next.21 Body fluids, such as oral secretions, nasal discharge, or urine, may be common modes for transmission of infection, both among children and between children and health care workers. Direct contact between children and caregivers transmits skin organisms such as bacteria, fungi, and mites.

A variety of fomites can be involved in the transmission of infectious agents. Stethoscopes, pagers,27,28 cell phones, thermometer boxes, and computer mice have been shown to be colonized by pathogens; toys in the hospital or in offices harbor pathogens as well.29,30 These pathogens go from the fomites to a hand and on to another person. Most of the time, this does not result in disease; however, these fomites serve as reservoirs of pathogens.31 Artificial nails and nail extenders have been implicated in the spread of pathogens in nurseries.32

SITE OF ACQUISITION

The site and frequency of infection will depend on the host and the pathogens in the environment. Hospitalized children may be exposed to other ill children in the hospital room, surgical or radiology suites, hallways, and playrooms. Procedures and examinations increase the chances for acquisition of microbes that can cause infection.42 Children at highest risk for infection are those with underlying immune problems and those who require intensive care.42,43Infection rates vary from 1 to 3 per 100 discharges in those receiving care on the pediatric ward, and from 30 to 50 per 100 discharges from newborn intensive care units.

Infection rates in outpatients have not been extensively studied. In general, children who visit doctors’ offices have had better outcomes and fewer infections than those who do not receive regular care. Nonetheless, the opportunity to acquire infection exists in the outpatient setting. The healthy child who comes for a routine office visit may be exposed to infectious agents while in the waiting room, during play with other patients, in the examination room, and during procedures.8

COMMON ETIOLOGIES

The most common cause of infection in the hospitalized child is viral illness, which is acquired from other patients, visitors, and hospital staff. Nosocomial respiratory infections are most common during the winter and are due to seasonal viruses such as influenza and respiratory syncytial virus. Patients who require respiratory support are at risk for bacterial pneumonia (see Chapter 223).44,45 Endotracheal tubes bypass the normal body defenses, and drugs, such as morphine, impair pulmonary macrophage function.34 Tubes can occlude the orifices of the sinus ostia and Eustachian tubes, increasing the risk for hospital-acquired sinusitis and otitis media.

Bacteremia is usually a complication of intravenous therapy; the site and duration of catheterization and the underlying illness of the patient are the primary factors determining the frequency of bacteremia (see Chapter 223).46-53The convenience of intravascular catheters carries with it the concomitant risk of infection; in contrast to adults, in whom peripheral venous catheters are changed every 3 to 4 days, infants’ limited vascular access often prevents routine rotation of sites.

Nosocomial urinary tract infections occur in patients who are catheterized and in those with obstruction to urine flow.44,54 Catheterization to obtain urine for analysis or culture carries with it a 1% risk of subsequent infection. Indwelling urinary catheterization is complicated by infection at a rate of 3% to 5% per day, and all long-term indwelling urinary catheters become colonized. Infection of the lower urinary tract can be complicated by spread to the kidneys and bloodstream. Common causes of infection in the urinary tract include those organisms colonizing the perineum: Enterobacteriaceae (ie, E coli, Klebsiella spp), enterococci, and Candida spp.

Gastrointestinal infections can be acquired nosocomially after ingestion of contaminated foods or medicines, or after transfer of viruses or bacterial pathogens on hands or instruments.42 Outbreaks of colitis due to Clostridium difficile and transmission of vancomycin-resistant Enterococcus have been traced to use of electronic thermometers. In these cases, the thermometer box becomes contaminated during use and allows spread of the pathogen from patient to patient. Children with rotavirus infection are often asymptomatic; thus, any children hospitalized or visiting offices during the winter and spring may be shedding rotaviruses. These viruses are transmitted from child to child by the fecal-oral route and from child to child by the unwashed hands of caregivers.

Hospital-acquired skin infections generally complicate surgery and burns.33,57

PREVENTION

General guidelines, as well as guidelines to prevent specific infections, have been promulgated by groups of experts in infection control.33,83-86 A partial list of such guidelines and policies is provided in Table 225-1. There are additional guidelines designed to protect health care workers; these deal with immunizations and postexposure care.87-91 The Health-care Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) publish guidelines and policies to decrease the incidence of infection.21 These policies address infection in the inpatient setting and in clinics and offices. The policies are updated on a regular basis, generally every 3 to 5 years. CDC recommendations are published in the Morbidity and Mortality Weekly Report, whereas AAP recommendations appear in Pediatrics. The policies are available on the Web sites of the CDC (www.cdc.gov/ncidod/dhqp/index.html) and AAP (www.aap.org).

HAND HYGIENE AND ENVIRONMENTAL CONTROLS

Hand hygiene is central to infection control.22,58-64 Hands should be washed with soap and water whenever visibly contaminated with dirt or proteinaceous material, including blood and body fluids. Alcohol hand rubs are preferred for use in direct patient care; however, these rubs are not effective in the presence of dirt or large amounts of proteinaceous material. Hand-washing also is preferred for care-givers of patients with Clostridium difficile colonization or disease; alcohol does not kill spores, and the friction of hand washing is more effective in removing spores. Patients and parents should be encouraged to wash their hands and to demand hand hygiene of all caregivers. Staffing levels should be appropriate for the number of patients and level of care; outbreaks in nurseries and critical care areas have coincided with overcrowding and understaffing.65

Table 225-1. Guidelines for Prevention of Specific Infections

HICPAC Publications (www.cdc.gov/ncidod/dhqp/hicpac_pubs.html)

Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007 (www.cdc.gov/ncidod/dhqp/gl_isolation.html)

Published 2007

Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006 (www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf)

This guideline replaces Preventing the Spread of Vancomycin Resistance-HICPAC Recommendations.

Influenza Vaccination of Health-Care Personnel (www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm)

MMWR Recomm Rep 2006;55(RR02):1-16

Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee (www.cdc.gov/ncidod/dhqp/pdf/hicpac/PublicReportingGuide.pdf)

Am J Infect Control. 2005;33:217

Guideline for Preventing Healthcare-Associated Pneumonia (www.cdc.gov/ncidod/dhqp/gl_hcpneumonia.html)

Published 2004

Guideline for Environmental Infection Control in Health-Care Facilities, 2003 (www.cdc.gov/ncidod/dhqp/gl_environinfection.html)

Published 2003

Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program (www.cdc.gov/mmwr/preview/mmwrhtml/rr5207a1.htm)

MMWR Recomm Rep. 2003;52(RR07):1-16

Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 (www.cdc.gov/ncidod/dhqp/gl_intravascular.html)

MMWR Recomm Rep. 2002;51(RR10):1-36

Guideline for Hand Hygiene in Healthcare Settings, 2002 (www.cdc.gov/handhygiene/)

Published 2002

Guideline for Infection Control in Health Care Personnel, 1998 (www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html)

Am J Infect Control. 1998;26:289-354

Guideline for the Prevention of Surgical Site Infection, 1999 (www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html)

Infect Control Hosp Epidemiol. 1999;20:247-280

Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) (www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm)

MMWR Recomm Rep. 1997;46(RR18):1-42

Committee on Infectious Diseases

Infection Prevention and Control in Pediatric Ambulatory Settings (http://pediatrics.aappublications.org/cgi/reprint/120/3/650)

Pediatrics 2007;120(3):650-665

Environmental controls are important in preventing infection.83,92 Airflow for inpatient and outpatient areas can contribute to spread of airborne pathogens. Disinfection and cleaning are important in keeping the environment free of pathogens. Furniture and floors must be cleaned regularly; the type of furnishings and equipment are selected with consideration of cleaning and durability. Toys in the health care environment must be cleaned regularly as well.93Water sources must be free of pathogens. Linens and patient clothing must be processed in ways that prevent transmission of pathogens to health care personnel and patients. Medical waste must be identified and handled appropriately.94 Disinfection and sterilization is necessary for materials that bypass the skin or mucous membranes.95-97

ISOLATION AND PERSONAL PROTECTIVE EQUIPMENT

Isolation procedures for hospitalized children involve use of standard precautions for all patients and additional transmission-based precautions for those infected with agents transmitted by the airborne, droplet, and contact routes, as well as those colonized or infected by multidrug-resistant bacteria.21 Standard precautions are appropriate in all health care settings.8 The basis of standard precautions is the assumption that every person is potentially infected or colonized with an organism that could be transmitted. Hand hygiene; personal protective equipment, including gloves, gowns, mask, eye protection, and face shields; care of soiled equipment; environmental controls; laundry; injection practices; patient resuscitation; patient placement; and respiratory hygiene are all part of standard precautions. Hand hygiene should be performed before and after all patient contacts. Gloves should be worn when touching blood, body fluids, secretions, excretions, and items contaminated with any of these fluids. Masks, eye protection, and face shields should be worn whenever it is likely that splashes or sprays of body fluids will be generated. Gowns are used to protect the skin and clothing. Patient care equipment should be handled in a manner that does not allow skin or mucous membrane exposure or contamination of clothing. Used linens should be handles and transported in a manner that prevents skin and mucous membrane exposure. Every effort should be made to prevent injuries caused by needles, scalpels, and other sharp items used in patient care. Needles must be disposed of properly: they should not be recapped; instead, used needles should be stored in puncture-proof containers. Mouthpieces, resuscitation bags, and other ventilation devices should be available in all patient care areas so that mouth-to-mouth resuscitation is not necessary. Every health care area must have environmental controls with procedures for routine care, cleaning, and disinfection of environmental surfaces.

Airborne precautions are used to prevent truly airborne pathogens such as Mycobacterium tuberculosis, measles virus, and varicella zoster virus. Airborne precautions require a single room with negative airflow (ie, the air comes from the hallway into the room and exits to the outdoors or to a high-efficiency particulate air filtration system). Use of N95 or N100 respirators that have been fitted for the provider is necessary for caregivers of patients with active tuberculosis who are contagious. Droplet precautions are used for care of children with illness transmitted by droplets, such as influenza, pertussis, or adenovirus. Patients are placed in a single room or cohorted with a patient with the same infection; masks are worn when entering the room to provide care. Contact precautions are used for patients with infections transmitted by contact and for those infected or colonized with resistant bacteria. Gloves and gowns are used for patient care.

Policies for outpatient care of children colonized with resistant bacteria have not been standardized. Bacteria such as methicillin-resistant Staphylococcus aureus can be acquired from respiratory therapy equipment in children requiring home care for tracheostomies. Some experts recommend strict isolation of these patients in offices and outpatient clinics, whereas others believe that this is necessary only during hospitalization. Whenever possible, children colonized with resistant bacteria should be placed in an examination area as soon as feasible, thus minimizing time in the waiting area and direct contact with other patients.

Respiratory hygiene81 has been recommended to decrease the transmission of droplet and airborne pathogens. Patients with respiratory infections should be identified; if possible, they should not spend time in the waiting areas. Use of masks should be considered. Tissues should be available in waiting areas for use by children and families. Alcohol hand rub solutions for disinfecting hands should be present in all patient care settings. If feasible, these solutions should be available in waiting areas.

Table 225-2. Illness in Health Care Personnel

ANTIBIOTICS AND PROPHYLAXIS

Judicious use of antimicrobial agents71-77 is important to prevent the emergence and spread of resistant organism. Antimicrobial stewardship is a term applied to programs used to help physicians use antibiotics appropriately. Multidisciplinary teams of infectious disease specialists, microbiologists, infection control practitioners, and pharmacists work together to help the physician make the best choice of antibiotic for their patient. Guidelines for management of multidrug-resistant organisms in health care settings have been developed; surveillance, screening, isolation, and judicious antibiotic use are important procedures to follow.78,79

Prophylactic antibiotics have been used in an attempt to prevent infections related to surgery and catheterization. The timing of surgical prophylaxis is important; the antibiotic should be in the tissues at the time of skin incision.33There is no evidence that continuing antibiotic prophylaxis beyond the surgical procedure is useful; in fact, this increases the risk for adverse effects of the antibiotics and alteration of normal bacterial flora. Surgical prophylaxis should be limited to cases where the risk of infection justifies the use of an antibiotic; in general, if bowel is entered or mucous membranes are crossed, prophylaxis is indicated. The choice of antibiotic is based on the expected pathogens and the susceptibilities of these organisms. If surgery involves infected tissues, then the antibiotics are therapeutic rather than prophylactic. Antibiotics have been used in an attempt to prevent infection following vascular or urinary bladder catheterization; generally, these are effective for short periods. Prolonged therapy ensures that resistant flora will evolve.46,80

HEALTH CARE PERSONNEL

Because health care workers are capable of transmitting disease, each office or hospital should have written policies regarding exclusion of staff members with contagious illnesses (Table 225-2). Respiratory infections are not usually a reason for exclusion. Emphasis should be placed on hand hygiene and use of tissues to prevent transmission of respiratory viruses to patients and other staff members.

Skin testing for tuberculosis is recommended at the time of employment for hospital personnel; it should be considered for offices where the employees have risk factors for tuberculosis or where the background rate of infection is high. Yearly influenza vaccination of all health care workers is highly recommended. Hepatitis B vaccination is recommended for health care personnel who perform tasks that may involve exposure to blood or body fluids. Measles, mumps, rubella (MMR) vaccination is recommended for health care personnel born after in or after 1957. All health care workers should be immune to varicella, tetanus, diphtheria, pertussis, and meningococcus.

Another method of decreasing nosocomial infection is to improve host defenses. Immunization is one way to improve and broaden the immunity of both patients and caregivers.98 Nutrition is important for immune function. Use of the gastrointestinal tract is the optimal way to deliver such nutrition; when this is not possible, parenteral nutrition should be considered. Minimizing tubes and catheters improves host defenses but is not always an option. Devices should be removed as soon as possible. Finally, there is evidence that pain and stress adversely affect the immune system.99 Pain management and child–life interactions to decrease stress are likely to help both the patient and their immune function.