Infection Prevention and Control

Infection prevention and control ( IPC ) programs have an important role in pediatric medicine. To be fully effective, IPC 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 healthcare institutions. The national focus on preventing healthcare-associated infection (HAI) is exemplified by The Joint Commission's 2017 National Patient Safety Goals, with 5 of the 16 elements related to reduction and prevention of HAI. Governmental agencies and insurance providers have reduced or eliminated payment to institutions for expenses associated with certain HAIs, and a host of national organizations have been established to monitor and report rates of HAI at healthcare facilities.

HAIs or nosocomial infections refer to infections acquired during hospitalization or acquired in other healthcare settings, such as nursing homes or ambulatory surgical care centers. An estimated 3–5% of children admitted to hospitals acquire an 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 the hospital. Adequate education of home health providers as well as of families is essential to prevent or minimize device-associated infections, since increasing numbers of children are sent home from the hospital with intravenous (IV) catheters and other medical devices in place.

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 healthcare providers with active contagious infections 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. IV and other catheters provide direct access to sterile anatomic 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). Antibiotic use 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 spp.

Transmission of infectious agents occurs by various routes, but by far the most common and important route is 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 contaminated. These inanimate objects serve as fomites for bacteria. There is increasing recognition of the importance of the healthcare environment in the acquisition of organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), multidrug-resistant gram-negative bacilli (MDR-GNB), C. difficile, and respiratory syncytial virus (RSV). Thermometers and other equipment that come in contact with mucous membranes pose special risks. Some agents are easily 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. 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. Widespread outbreaks of infection have been associated with mycobacterial contamination of equipment during the manufacturing process.

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 as well as those requiring intensive care and prolonged hospitalization. Common sites of infection are the respiratory tract, gastrointestinal (GI) tract, bloodstream, skin, and urinary tract.

Liberalization of visitation policies and in-hospital animal visitation has increased the likelihood of HAI acquisition. The use of contaminated pharmaceutical products such as injectable depot corticosteroids has led to outbreaks of fatal fungal HAIs.

HAIs cause considerable morbidity and occasional mortality of hospitalized children. Infections prolong hospital stays and increase healthcare 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 intrainstitutional 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.