Infection Prevention and Control

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Chapter 166 Infection Prevention and Control

Michael J. Chusid, Mary M. Rotar

Infection prevention and control (IPC) is playing an ever more important role in pediatric medicine. To be fully effective, such programs require a functional infrastructure that addresses collaboration with the public health system, widespread immunizations, and use of appropriate techniques to prevent transmission of infection within the general population and within health care institutions. The increased focus upon preventing nosocomial infection is emphasized by the fact that 5 of the 16 elements of the Joint Commission’s 2009 National Patient Safety Goals relate to prevention of health care–associated infection (HAI): hand hygiene, unanticipated death or major permanent loss of function associated with a health care-associated infection, central line–associated bloodstream infections, surgical site infections, and infections with multidrug-resistant organisms. Additionally, governmental agencies and insurance providers have reduced or eliminated payment to institutions for expenses associated with certain HAIs.

HAIs or nosocomial infections refer to infections acquired during hospitalization or acquired in other health care settings, such as nursing homes or ambulatory surgical care centers. An estimated 3-5% of children admitted to hospitals acquire an HAI. HAI rates are highest in patients undergoing invasive procedures. Infections can also be acquired in emergency departments, physicians’ offices, daycare, and long-term care settings. Medical device–associated infections occur in both the home and hospital. Adequate education of home health providers as well as of families is essential to prevent or minimize device-associated infections as ever-greater numbers of children are sent home from the hospital with intravenous catheters and other medical devices.

Susceptibility to HAI includes host factors, recent invasive procedures, presence of catheters or other devices, prolonged use of antibiotics, contaminated physical environment, and exposure to other patients, visitors, or health care providers with active contagious diseases or colonized with invasive microorganisms. Host factors increasing the risk for HAI include anatomic abnormalities (dermal sinuses, cleft palate, obstructive uropathy), abnormal skin, organ dysfunction, malnutrition, and underlying diseases or comorbidities. Invasive procedures can introduce potential pathogens by breaching normal anatomic host barriers. Intravenous and other catheters provide direct access to usually sterile sites for usually minimally pathogenic organisms, as well as adherent surfaces for microbial binding, and can disrupt patterns of normally protective flow of mucus (e.g., nasotracheal tubes and sinus ostia). Antibiotics can alter the composition of bowel flora and encourage the multiplication and emergence of toxigenic or invasive organisms already present in small numbers in the gut, such as Clostridium difficile and Salmonella.

Transmission of infectious agents occurs by various routes, but by far the most common and important route is via the hands. Medical equipment, toys, and hospital and office furnishings can become microbially contaminated and thus have a role in transmission of potential pathogens. Pagers, phones, computer keyboards, and even neckties become easily colonized. These inanimate objects serve as reservoirs for bacteria. There is increasing recognition of the importance of the health care environment in the acquisition of organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), C. difficile, and respiratory syncytial virus (RSV). Thermometers and other kinds of equipment that come in contact with mucous membranes pose special risks. Some agents are disseminated by airborne transmission, such as varicella virus, measles virus, and Mycobacterium tuberculosis. Food can be contaminated and has been involved in hospital outbreaks of nosocomial infection. The hospital physical environment can also serve as a risk factor for infection, particularly for immunocompromised patients. In particular, rainwater or plumbing leaks have been associated with bacterial and fungal infections, new construction or renovation with airborne fungal infection, and contamination of an institution’s potable water supply with bacterial, fungal, and atypical mycobacterial nosocomial infections.

Common causes of HAI in children are seasonal viruses such as rotavirus and respiratory viral agents, staphylococci, and gram-negative bacilli. Fungi and multidrug-resistant organisms are common causes of infection in immunocompromised children and in those who require intensive care and prolonged hospitalization. Common sites of infection are the respiratory tract, gastrointestinal (GI) tract, bloodstream, skin, and urinary tract.

HAIs cause considerable morbidity and occasional mortality of hospitalized children. Infections prolong hospital stays and increase health care costs. Surveillance, the initial step in identifying such infections and suggesting methods for prevention, is the responsibility of infection preventionists. Within hospitals, oversight of such surveillance is usually the responsibility of the infection prevention and control committee, a multidisciplinary group that collects and reviews surveillance data, establishes institutional policies, and investigates intra-institutional infection outbreaks. The chair of the committee is often an infectious disease specialist. Surveillance in outpatient settings and during home care is often less well defined. Local, state, and federal health departments play important roles in identifying and controlling outbreaks and in establishing public health policy.

Hand Hygiene

The most important tool in any infection control program is good hand hygiene. Although much attention is directed at the type of cleansing agent employed, the most important aspect of hand washing is placing the hands under water and using friction with or without soap. Studies show that a 15-second scrub removes the majority of transient flora but does not alter hand permanent flora. A variety of hand gels and rubs can be used in place of hand washing. Waterless hand hygiene products increase hand hygiene compliance and save time; these agents are the preferred agents for routine hand hygiene when hands are not visibly soiled. These products are effective in killing most microbes but do not remove dirt or debris. They also are ineffective against C. difficile spores. Hands should be cleaned before and after every patient encounter. In hospital hand washing compliance studies, physicians are usually the least compliant group studied, and compliance programs must pay special attention to this group of caregivers.

Standard Precautions

Standard precautions, formerly known as universal precautions, are intended to protect health care workers from pathogens and should be used whenever there is direct contact with patients. Infected patients are often contagious before symptoms of disease develop, and asymptomatic, infected patients are quite capable of transmitting infectious agents. Standard precautions involve the use of barriers—gloves, gowns, masks, goggles, and face shields—as needed, to prevent transmission of microbes associated with contact with blood and body fluids (Table 166-1).

Table 166-1 RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR CARE OF ALL PATIENTS IN ALL HEALTH CARE SETTINGS

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COMPONENT	RECOMMENDATIONS
Hand hygiene	After contact with blood, body fluids, secretions, excretions, or contaminated items; immediately after removing gloves; before and after patient contact Alcohol-containing antiseptic hand rubs preferred except when hands are visibly soiled with blood or other proteinaceous materials or if exposure to spores (e.g., Clostridium difficile, Bacillus anthracis) is likely to have occurred; in those cases, soap and water preferred
PERSONAL PROTECTIVE EQUIPMENT (PPE)
Gloves	For touching blood, body fluids, secretions, excretions, or contaminated items; for touching mucous membranes and nonintact skin Employ hand hygiene before and after glove use
Gown	During procedures and patient-care activities when contact of clothing or exposed skin with blood or body fluids, secretions, and excretions is anticipated
Mask, eye protection (goggles), face shield	During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, or secretions, such as suctioning and endotracheal intubation For patient protection, use of a mask by the person inserting an epidural anesthesia needle or performing myelograms when prolonged exposure of the puncture site is likely
Soiled patient-care equipment	Handle in a manner that prevents transfer of microorganisms to others and to the environment Wear gloves if equipment is visibly contaminated Perform hand hygiene
ENVIRONMENT
Environmental control	Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas
Textiles (linens) and laundry	Handle in a manner that prevents transfer of microorganisms to others and the environment
PATIENT CARE
Injection practices (use of needles and other sharps)	Do not recap, bend, break, or handle used needles; if recapping is required, use a one-handed scoop technique only Use needle-free safety devices when available, placing used sharps in puncture-resistant container Use a sterile, single-use, disposable needle and syringe for each injection Single-dose medication vials preferred
Patient resuscitation	Use mouthpiece, resuscitation bag, and other ventilation devices to prevent contact with mouth and oral secretions
Patient placement

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