Paediatric Infection Control Jodie Burr Infection Control Coordinator Women’s and Children’s Hospital

Primary Role of Infection Control Prevent nosocomial infections Reduce mortality, morbidity, and cost Educate and advise staff patients their families the community Surveillance of nosocomial infections Policy development, implementation and assessment

IC Issues specific to Paediatrics Communicable diseases affect a higher % of paediatric patients than adults Developmental immunity (increased susceptibility) - acquire – spread

IC Issues specific to Paediatrics Paediatric personnel are at a greater risk for exposure to communicable diseases - immune status Type and amount of physical contact (eg feeding, diapering)

IC Issues specific to Paediatrics May lack the mental / physical ability to adhere to IC principles lack of hygiene unable to understand / comply with IC principles

IC Issues specific to Paediatrics More likely to have contact with contaminated environmental surfaces and objects

IC Issues specific to Paediatrics Parents and siblings may have the same infectious agent involved in patient care – education about transmission and IC principles

IC Issues specific to Paediatrics Types of pathogens and sites of nosocomial infection differ from adults. Most common nosocomial infections (paediatrics): Viral infections of the upper respiratory tract Viral infections of the gastrointestinal tract Most common nosocomial infections (adults): UTI

IC Issues specific to Paediatrics Neonatal and ICU Bacteraemias are the most common source of nosocomial infection Adult ICU The lower respiratory tract is the most common source of nosocomial infection Alexis, M. Steps to Reduce Nosocomial Infections in Children, Infectious Medicine, 2002, 19 (9):414-424

Incidence of Nosocomial Infection Incidence varies by age and hospital unit: Range: 0.2% - 23.5% Paediatric ICU 23.5% Haematology Unit 8.2% Neonatal Unit 7.0% General Paediatric Unit 1.0% Highest in children aged 23 months or younger Alexis, M. Steps to Reduce Nosocomial Infections in Children, Infectious Medicine, 2002, 19 (9):414-424

Additional Length of Stay Duration of hospitalisation is longer for children with nosocomial infections Paediatric ICU 26.1 days vs 10.6 days General Paediatric Units 9.2 days vs 3.5 days Attributable cost of infection $13,000 Alexis, M. Steps to Reduce Nosocomial Infections in Children, Infectious Medicine, 2002, 19 (9):414-424

Spread of Infection Sources of infections The host’s own (endogenous) flora The hand’s of health care workers Inanimate objects (fomites) After being exposed to an infectious agent: Some people already have immunity and therefore don’t develop an infection Some people become asymptomatic carriers Other people develop clinical disease (ie infection)

Spread of Infection The Susceptible Host Varies with age Underlying medical conditions Nutritional status Drug therapy Trauma Surgical procedures Invasive or indwelling devices Therapeutic and diagnostic procedures

Spread of Infection 3 main routes of transmission Contact Direct / Indirect Most frequent means of transmission Droplet Generated during coughing, sneezing, talking and during certain procedures such as suctioning Airborne Generated by coughing, sneezing, OR by mechanical respiratory aerosolisers, OR by air currents

Standard Precautions Apply to: Blood Non-intact skin Mucus membranes All body fluids (including sweat) Regardless of whether there is visible blood or body fluids

Hand Hygiene The single most effective method in the prevention of disease transmission Healthcare workers think they wash their hands more than what they do 80 % hospital acquired infections are thought to be transmitted by hands

Hand Hygiene Soap and Water mechanical removal of most transient flora and soil minimal microbial kill no sustained activity 15 seconds

Hand Hygiene Antimicrobial Soaps removes soil, removes transient and reduces resident flora may have sustained activity 15 seconds (antiseptic handwash) 60 seconds (clinical handwash) 2 minutes (surgical scrub)

Hand Hygiene Alcohol Handrubs / Gels very rapid kill destroys transient and reduces resident flora no residual activity (except with antiseptic) will not remove or denature soiling 15 seconds

Personal Protective Equipment Eye and/or facial protection (glasses, goggles, face shields) Gloves Gowns Masks Assess the likely hood of contamination and prepare accordingly

Assessment of Risk Factors Your knowledge or experience with the situation or procedure The likely hood of exposure to blood or body fluids at the time The patients ability to cooperate through out the procedure

Additional Precautions May include: Single room accommodation (ensuite for some) Special ventilation (negative, positive pressure) Special room cleaning Dedicated patient equipment Rostering of immune staff Extended sterilization (or use of disposable equipment) Cohorting may be considered

Multi-resistant organisms (MRO) MRSA: Methicillin resistant Staphylococcus aureus VISA: Vancomycin intermediate Staphylococcus aureus VRSA: Vancomycin resistant Staphylococcus aureus VRE: vancomycin resistant enterococci ESBL: Extended spectrum beta-lactamase MRGN: Multi-resistant gram negative MRPA: Multi-resistant Pseudomonas aeruginosa MRAB: Multi-resistant Acinetobacter baumanii

Multi-resistant organisms (MRO) Difficult to treat and control Have the ability to cause infections, particularly in susceptible people Have the ability to cause wound infections, bacteraemias and IV line sepsis Can cause significant morbidity and mortality Increased community awareness and expectations

Factors that contribute to the acquisition of MROs Staff - inadequate handwashing Environmental - inadequate cleaning Prolonged or inappropriate antibiotic treatment Close proximity to a MRO patient Extended hospital stay Co-morbidities ICU / Burns Unit

Respiratory Syncitial Virus Highly contagious and nosocomial infection common Causes upper and lower respiratory infection Usually occurs during winter No vaccine at present Can be re-infected during the same season Transmitted by contact or droplet Can survive for several hours in the environment

Respiratory Syncitial Virus

Rotavirus Highly contagious and nosocomial infection is common Usually a winter disease but pattern changing Onset is sudden and lasts for 4 - 6 days Mainly infants and children up to 3 years affected Transmitted usually through contact Can survive in environment for several hours

Rotavirus

Pertussis Bacterial infection caused by Bordetella pertussis Most dangerous to under 3 year olds Contagious for 3 weeks or for 5 days after commencing erythromycin Transmitted by contact and droplet Symptoms - runny nose, cough, which may develop into a whooping cough High particulate mask when in contact with patient

Pertussis

Meningococcal Disease Bacterial infection caused by Neisseria meningitidis Transmitted by contact or droplet Non infectious after 24 hours of appropriate antibiotic therapy Significant contacts traced and may be given prophylaxis

Meningococcal Disease

Measles Complications more common and severe in chronically ill and very young children Transmitted by droplet and contact with respiratory secretions Infectious for 4 days before and after rash Vaccination available Notifiable disease

Measles

Rubella In early pregnancy risk of teratogenic damage to fetus Infectious for 7 days before and 7 - 15 days after onset of rash Infants with congenital rubella may shed virus for several months or years Transmitted by droplet route Vaccination available Notifiable disease

Rubella

Varicella Zoster Virus Chicken Pox Highly contagious Most cases in children, over 90% of adult population is immune Transmitted by droplet and contact Infectious 2 days prior and 4 - 6 days after rash Now a notifiable disease Vaccination now available

Varicella or Chicken-pox

Congenital varicella Caused by maternal varicella in early pregnancy (ie <20 weeks) Risk of acquiring congenital varicella syndrome is 1 - 2% Range and severity of symptoms vary greatly depending on when maternal varicella infection occurred intrauterine growth retardation, skin abnormalities, incomplete development of fingers/toes. Brain degeneration, nervous system damage, eye abnormalities

Congenital varicella

Parvovirus B19 Usually a mild rash disease Also called Fifth Disease or “Slapped - Cheek” Infectious prior to the rash Transmitted by droplet route

Parvovirus B19