Control of Nosocomial Infections

Mark W. Kline

The goals and methods of infection control in hospitalized children are no different, in theory, from those in hospitalized adults. In practice, however, the higher percentage of children admitted to hospitals with overt, asymptomatic, or incubating infection, the increased morbidity of certain pathogens in some children, and the close contact required in the care of any young child necessitate modifying traditional methods of hospital infection control. General guidelines by which any hospital or patient care facility may establish a system of infection control are published regularly by the Centers for Disease Control and Prevention (CDC), the American Hospital Association, and the American Academy of Pediatrics. These guidelines, along with state and local requirements and those of the Joint Commission on the Accreditation of Hospitals, are the basis for an effective infection control program.

EPIDEMIOLOGY OF NOSOCOMIAL INFECTIONS IN CHILDREN

Infection that was neither present nor in incubation at the time of hospital admission but was acquired by a patient during a hospital stay is termed nosocomial. In general, nosocomial infection rates are lower for children than for adults hospitalized in comparable facilities. For children, attack rates are highest among infants, lowest among adolescents, and intermediate among toddlers and school-aged children. Nosocomial infection rates are highest in large teaching hospitals and lowest in nonteaching hospitals, a finding reflecting, in part, the severity of underlying illnesses and the extent to which invasive diagnostic or therapeutic procedures are performed in the various settings. Children hospitalized in neonatal or pediatric intensive care units are at particularly high risk for acquiring a nosocomial infection.

Virtually any microorganism can act as a nosocomial pathogen under circumstances conducive to its growth and transmission. Staphylococcus aureus and coagulase-negative staphylococci lead the list of bacterial isolates found in pediatric and newborn services, followed by Escherichia coli, Pseudomonas aeruginosa, and miscellaneous enteric gram-negative bacteria. Candida is the leading fungal isolate. Viruses are a major cause of nosocomial disease in children. Overall, rotavirus may be second only to S. aureus as a cause of nosocomial infection in children. Other viral agents, including respiratory syncytial virus, parainfluenza virus, adenovirus, and enteroviruses, contribute substantially to the rate of nosocomial respiratory and gastrointestinal illnesses. Outbreaks of infections in hospitals occasionally are caused by viruses associated with exanthematous diseases of childhood, including measles, varicella, and rubella.

Direct person-to-person transmission (contact or airborne) is the major mode of spread for most nosocomial pathogens. Prevention of direct transmission is complicated by the social nature of children in hospitals, fecal incontinence and lack of personal hygiene among young children, and mouthing behavior. Intimate contact with visiting parents and siblings provides a portal of entry for infectious agents from the community. Hospital personnel may be intermediaries in the chain of transmission within the hospital by hand carriage of nosocomial pathogens. For this reason the CDC recommends against health care workers’ having acrylic nails or long nails (longer than 1/4″), especially in intensive care unit settings.

The inanimate environment is implicated less frequently than is person-to-person spread in nosocomial infections. Some respiratory and enteric pathogens in particular, however, may contaminate and survive on surfaces for long periods. Toys may act as vectors for the spread of infection. Building construction has been implicated in the dissemination of fungal spores and disease among immunocompromised patients in hospitals.

GOALS OF INFECTION CONTROL

Any hospital infection control program should attempt to achieve the following: prevent nosocomial infections and cross-infections (infections spread specifically between patients); provide isolation when required, without denying the patient appropriate care; prevent the spread of disease among patients, hospital employees, and visitors; and educate all potential contacts on means of preventing the spread of infections.

INFECTION CONTROL TEAM

The infection control team is charged most immediately with carrying out the infection control program. Local and state law and the size and character of an institution (e.g., acute versus chronic care patient mix) help to determine the size of the infection control team. The team consists of an infection control committee, which sets general policy, receives information, and gives direction to the other members of the team, the hospital epidemiologist, and the infection control practitioner.

An infection control committee generally has representation from all the hospital services involved in direct patient care (i.e., the various medical and surgical services and nursing staff), from hospital services involved in the hospital environment (e.g., housekeeping and laundry), and from other services relevant to patient care and health (e.g., dietary service). Many hospitals either employ a person specially trained in hospital epidemiology or designate a member of the infection control committee to work with both the committee and the infection control practitioner.

The infection control practitioner in most hospitals is a nurse with special training or experience in hospital infection control and epidemiology. This individual has a pivotal role in the daily functioning of the infection control and surveillance
programs. The duties and responsibilities of the infection control nurse are quite broad. He or she makes regular rounds through the hospital and seeks out suspected cases of nosocomial infection or cross-infection. The infection control nurse answers questions regarding isolation and other infection control practices during these rounds. He or she works closely with the microbiology laboratory so culture results from individual patients and environmental culture results are incorporated into the general infection control plan. The nurse acts as a liaison for any of the hospital services and personnel who have questions regarding infection control issues. The infection control nurse coordinates all activities relating to infection

surveillance. Finally, he or she reports on these various activities to the infection control committee. The infection control nurse usually is a full voting and participating member of the infection control committee.

TABLE 145.1. STANDARD PRECAUTIONS*

Hand washing
Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn.
Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments.
It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
Use a plain (nonantimicrobial) soap for routine hand washing.
Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances (e.g., control of outbreaks or hyperendemic infections), as defined by the infection control program.
Gloves
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items.
Put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.
Remove gloves promptly after use before touching noncontaminated items and environmental surfaces; before going to another patient, wash hands immediately to avoid transfer of microorganisms to other patients or environments.
Mask, eye protection, and face shield
Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Gown
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions.
Select a gown that is appropriate for the activity and amount of fluid likely to be encountered.
Remove a soiled gown as promptly as possible, and wash hands to avoid transfer of microorganisms to other patients or environments.
Patient care equipment
Handle used patient care equipment soiled with blood, body fluids, secretions, and excretions in a manner
that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments.
Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately.
Ensure that single-use items are discarded properly.
Environmental control
Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are followed.
Linen
Handle, transport, and process used linen soiled with blood, body fluids, secretions, or excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing and avoids transfer of microorganisms to other patients and environments.
Occupational health and blood-borne pathogens
Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles.
Never recap used needles or otherwise manipulate them using both hands or any other technique that involves directing the point of a needle toward any part of the body; rather, use either a one-handed scoop technique or a mechanical device designed for holding the needle sheath.
Do not remove used needles from disposable syringes by hand and do not bend, break, or otherwise manipulate used needles by hand.
Place used disposable needles and syringes, scalpel blades, and other sharp items in appropriate puncture-resistant containers, which are located as close as is practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.
Patient placement
Place a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control in a private room.
If a private room is not available, consult with infection control professionals regarding patient placement or other alternatives.

*Standard precautions apply to all patients regardless of their diagnosis or presumed infection status. Standard precautions apply to any planned or potential contact with (a) blood, (b) all body fluid secretions and excretions except sweat, regardless of whether they contain visible blood; (c) nonintact skin; and (d) mucous membranes. Reprinted from Garner JS, Hospital Infection Control Practices Advisory Committee. Guidelines for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53.

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