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

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 Prioritize for single-patient room if patient is at increased risk for transmission, is likely to contaminate the environment, is unable to maintain appropriate hygiene, or is at increased risk for acquiring infection or developing adverse outcome following infection
Respiratory hygiene and cough etiquette (source containment of infectious respiratory secretions in symptomatic patients) beginning at the initial point of encounter Instruct symptomatic persons to cover nose or mouth when sneezing or coughing and to use tissues with disposal in no-touch receptacle
Employ hand hygiene after soiling of hands with respiratory secretions
Wear surgical mask if tolerated or maintain spatial separation (>3 ft if possible)

From Pickering LK, editor: Red book 2009: Report of the Committee on Infectious Diseases, ed 28, Elk Grove Village, IL, 2009, American Academy of Pediatrics, p 150.

Isolation

Isolation of patients infected with certain pathogens decreases the risk of nosocomial transmission of organisms to staff and other patients. The specific type of isolation depends on the infecting agent and potential route of transmission. Transmission by contact is the most common mode of pathogen transmission and involves direct contact with the patient or contact with a contaminated intermediate object. Contact isolation requires the use of gown and gloves when in contact with the patient or immediate surroundings. Transmission by droplets involves the propulsion of infectious large particles over a short distance (<3 ft), with deposition on another’s mucous membranes or skin. Droplet isolation requires the use of gloves and gowns, as well as masks and eye guards when closer than 3 ft to the patient. Airborne transmission occurs by dissemination of evaporated droplet nuclei (≤5 µm) or dust particles carrying an infectious agent. Airborne isolation requires the use of masks and negative-pressure air handling systems to prevent spread of the infectious agent. In the case of active pulmonary tuberculosis in older children and adults, the use of special high-density masks (N-95) or self-contained breathing systems (PAPR) is recommended. Positive-pressure HEPA-filtered air handling systems are used in some institutions for housing seriously immunocompromised patients.

Standard precautions are indicated for all patients and are appropriate for use in the office as well as the hospital. Additionally, for hospitalized patients, further transmission-based precautions are indicated for certain infections (Table 166-2). For contact and droplet isolation, single rooms are preferred but not required. Cohorting children infected with the same pathogen is acceptable, but the etiologic diagnosis should be confirmed by laboratory methods before exposing infected children to one another. Transmission-based isolation precautions should be continued for as long as a patient is considered contagious.

Table 166-2 SELECTED DISEASES AND INDICATIONS FOR TRANSMISSION-BASED ISOLATION IN ADDITION TO STANDARD PRECAUTIONS

CLINICAL SYNDROME OR CONDITION LIKELY PATHOGENS EMPIRICAL PRECAUTIONS
DIARRHEA
Acute diarrhea with a likely infectious cause in an incontinent or diapered patient Salmonella, Shigella, Escherichia coli O157:H7, rotavirus, hepatitis A Contact
Diarrhea in any patient, especially adults, with a history of recent antibiotic use Clostridium difficile Contact
MENINGITIS
  Neisseria meningiditis, Haemophilus influenzae type b Droplet × 24 hr
Antibiotic therapy
Streptococcus pneumoniae Standard
EXANTHEMS
Petechial or ecchymotic with fever N. meningiditis Droplet
Vesicular    
Chickenpox Varicella-zoster virus Airborne and contact
Zoster (localized in an immunocompetent patient) Varicella-zoster virus Standard
Zoster (disseminated or in an immunocompromised patient) Varicella-zoster virus Airborne and contact
Maculopapular with coryza and fever Rubeola Airborne
Erythema infectiosum Parvovirus B19 Standard
Parvovirus B19 in an immunocompromised patient Parvovirus B19 Droplet
Roseola Human herpesvirus 6 Standard
Rubella Rubella virus Droplet
RESPIRATORY TRACT INFECTIONS
Paroxysmal or severe persistent cough >1 wk Bordetella pertussis Droplet
Bronchiolitis and croup, other lower respiratory tract infections in infants and young children Respiratory syncytial or parainfluenza virus Contact + Droplet
Influenza Influenza virus Droplet
Atypical pneumonia Mycoplasma pneumoniae Droplet
Afebrile pneumonia in young infants Chlamydia trachomatis Standard
Diphtheria (pharyngeal) Corynebacterium diphtheriae Droplet
Pneumonic plague Yersinia pestis Droplet
Pneumococcal pneumonia S. pneumoniae Standard
Group A streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children Group A streptococcus Droplet
SKIN DISEASES
Skin infections that are highly contagious or that can occur on dry skin (cutaneous diphtheria; herpes simplex virus, neonatal or mucocutaneous; impetigo; major or draining abscesses; cellulitis; decubiti; furunculosis; zoster disseminated or in an immunocompromised host)   Contact
URINARY TRACT INFECTIONS
All   Standard
OTHER INFECTIONS
Infection or colonization with multidrug-resistant organisms Resistant bacteria Contact
Invasive N. meningiditis disease (meningitis, pneumonia, and sepsis) N. meningiditis Droplet × 24 hr
Antibiotic therapy
Invasive H. influenzae type b disease (meningitis, pneumonia, epiglottitis, and sepsis) H. influenzae type b Droplet × 24 hr
Antibiotic therapy
Viral infections spread by droplet transmission (adenovirus, influenza, mumps, parvovirus B19 in an immunocompromised patient, rubella)   Droplet

Adapted from Garner JS; The Hospital Infection Control Practices Advisory Committee: Guidelines for isolation precautions in hospitals. Infect Control Hosp Epidemiol 17:5–80, 1996.

The use of isolation techniques in outpatient settings has not been well studied. Professional offices should establish procedures to ensure that proper cleaning, disinfection, and sterilization methods are employed. Many practices and clinics provide separate waiting areas for sick and well children. Triage of patients is essential to ensure that contagious children or adults are not present in waiting areas. Outbreaks of measles and varicella in patients within the waiting area have been reported where the air exhaust from examination rooms is allowed to enter the waiting area. Cleaning the clinic environment is important, especially in “high touch” areas. Toys and items that are shared among patients should be cleaned between uses; if feasible, disposable toys should be used. Toys contaminated with blood or body fluids should be autoclaved or discarded.

Additional Measures

Other preventive measures include aseptic technique, catheter care, prudent use of antibiotics, isolation of contagious patients, cleaning of the environment, disinfection and sterilization of medical equipment, reporting of infections, safe handling of needles and other sharp instruments, and establishment of employee health services. Aseptic technique must be used for all invasive procedures, including catheter placement and manipulation. The use of barrier techniques at the time of intravenous catheter placement has reduced the rate of catheter-related bloodstream infections by half. Appropriate catheter use also includes limiting the duration and number of catheters as much as possible and removing catheters as soon as they become unnecessary.

Surgical Prophylaxis

Surgical antibiotic prophylaxis should be employed when there is a high risk of postoperative infection or when the consequences of such infection would be catastrophic. The choice of prophylactic antibiotic depends on the surgical site and type of surgery (Table 166-3). A useful classification of surgical procedures based on infectious risk recognizes four preoperative wound categories: clean wounds, clean-contaminated wounds, contaminated wounds, and dirty and infected wounds. Clinical recommendations regarding antibiotic prophylaxis have been made by the American College of Surgeons, the Surgical Infection Society, and the American Academy of Pediatrics.

Table 166-3 COMMON SURGICAL PROCEDURES FOR WHICH PERIOPERATIVE PROPHYLACTIC ANTIBIOTICS ARE RECOMMENDED

SURGICAL PROCEDURE LIKELY PATHOGENS POTENTIAL DRUG
CLEAN WOUNDS
Cardiac surgery (e.g., open heart surgery)
Vascular surgery
Neurosurgery
Orthopedic surgery (e.g., joint replacement)		 Skin flora, enteric gram-negative bacilli Cefazolin or vancomycin
CLEAN CONTAMINATED WOUNDS
Head and neck surgery involving the oral cavity or pharynx Skin flora, oral anaerobes, oral streptococci Cefazolin or clindamycin
Gastrointestinal and genitourinary surgery Enteric gram-negative bacilli, anaerobes, gram-positive cocci Cefazolin
If colon is involved, consider bacterial reduction with PO neomycin and erythromycin
CONTAMINATED WOUNDS
Traumatic wounds (e.g., compound fracture) Skin flora Cefazolin
DIRTY WOUNDS
Appendectomy, penetrating abdominal wounds, colorectal surgery Enteric gram-negative bacilli, anaerobes, gram-positive cocci Cefoxitin or
Clindamycin plus gentamicin

Clean wounds are uninfected operative wounds where no inflammation is noted and respiratory, alimentary, and genitourinary tracts and the oropharynx are not entered. These are often nonemergent procedures with primary closure or drained with a closed system. Operative incisional wounds after nonpenetrating trauma are included in this category. For clean wounds, prophylactic antimicrobial therapy is not recommended except in patients at high risk for infection and in circumstances under which the consequences of infection are potentially life threatening, such as implantation of a prosthetic foreign body such as a prosthetic heart valve or CSF shunt, open heart surgery for repair of structural defects, surgery in patients who are immunocompromised as a result of an inherited disease or are receiving corticosteroids or chemotherapy for malignancy, and newborn infants.

Clean-contaminated wounds are operative wounds in which the respiratory, alimentary, or genitourinary tract is entered under controlled conditions and that do not have unusual bacterial contamination preoperatively. These wounds occur in operations that involve the biliary tract, appendix, vagina, and oropharynx where no evidence of infection or major break in technique is encountered, as well as in urgent or emergency surgery in an otherwise clean procedure. In procedures involving clean-contaminated wounds, the risk for bacterial contamination and infection is variable. Recommendations for pediatric patients derived from data on adults suggest that antibiotic prophylaxis be provided for procedures in children with obstructive jaundice, certain alimentary tract procedures, and urinary tract surgery or instrumentation in the presence of bacteriuria or obstructive uropathy.

Contaminated wounds include open, fresh, and accidental wounds; major breaks in otherwise sterile operative technique; gross spillage from the GI tract; penetrating trauma occurring <4 hr earlier; and incisions in which acute nonpurulent inflammation is encountered.

Dirty and infected wounds include penetrating traumatic wounds >4 hr earlier, those with retained devitalized tissue, and those in which clinical infection is apparent or in which the viscera have been perforated. In contaminated and dirty or infected wound procedures, antimicrobial therapy is indicated and might need to be continued for 5-10 days. In these cases, antibiotic therapy is considered therapeutic rather than truly prophylactic.

Prophylactic antibiotics should be administered, preferably intravenously, within an hour before the skin incision is made, with the intent of having peak serum concentrations of the drug around the time of incision. Adequate plasma and tissue concentration of the drugs should be maintained until the incision is closed. Repeat doses may be necessary if surgery is prolonged and/or the antibiotic being employed has a short intravascular half life. Continuation of prophylactic therapy after the procedure is not recommended. In cases of contaminated surgical sites, antibiotics are continued as therapy for infection at the site. For patients undergoing colonic procedures, additional oral antibiotics may be used and should also be given on the day before surgery.

The selection of antibiotic regimen for prophylaxis is based on the procedure, the likely contaminating organisms, and drug. Because of the variety of antibiotics available, >1 regimen is acceptable (see Table 166-2).

Employee Health

Employee health is important because employees are at risk for acquiring infection from patients, and infected employees pose a potential risk to patients. This risk is minimized by use of standard precautions and hand hygiene before and after all patient contacts. Within hospitals, employee health services or departments of occupational safety and health manage employee health issues. New employees should be screened for the presence of infectious diseases. Their immunization history should be noted, and necessary immunizations should be offered.

All health care workers (medical and nonmedical, paid or volunteer, full time or part time, student or nonstudent, with or without patient care responsibilities) who work within facilities providing health care, inpatient or outpatient, should be immune to measles, rubella, and varicella. All workers who are at risk of exposure to blood or body fluids should be immunized against hepatitis B. In pediatric institutions, employees with patient contact should be urged to receive the adult pertussis vaccine. Annual influenza immunization is strongly recommended for all health care workers, and institutions are being ranked publically regarding employee immunization rates as a measure of quality of care. This program reduces staff illness and absenteeism and decreases HAI. Immunizations should be encouraged and should be provided free of charge whenever possible.

All health care workers with duties involving face-to-face contact with patients with suspected or confirmed tuberculosis (including transport staff) should be included in a tuberculosis screening program at the time of hiring and may require periodic retesting if the workplace is determined to be a high-prevalence environment for tuberculosis. Each medical office and hospital must comply with the rules developed by the Occupational Safety and Health Administration. Each office and hospital should have written policies about exclusion of infected and ill staff from direct patient care. Staff should be encouraged to not report for work if they are sick. Regular educational sessions should be performed to ensure that staff are aware of prevention and control methods and that they adhere to such policies.

Bibliography

Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of bloodstream infections associated with catheters in pediatric intensive care unit: stepwise approach. BMJ. 2007;334:362-365.

Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR. 2005;54(RR-17):1-140.

Joint Commission. 2009 hospitals and critical access hospital national patient safety goals (website). www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed August 2, 2010

Pronovost P, Needham D, Berenholtz S, et al. an intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.

Rutala WA, Weber DJ. Disinfection and sterilization in health care facilities: what clinicians need to know. Clin Infect Dis. 2004;39:702-709.

Siegel JD, Rhinehart E, Jackson M, et al. The Healthcare Infection Control Practices Advisory Committee: Management of multidrug-resistant organisms in healthcare settings, 2006 (website). www.cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf. Accessed August 2, 2010

Siegel JD, Rhinehart E, Jackson M, et al. The Healthcare Infection Control Practices Advisory Committee: 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings, June 2007 (website). www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed August 2, 2010

Yogaraj JS, Elward AM, Fraser VJ. Rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics. 2002;110(3):481-485.

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