Infection control practices in different pediatric clinical settings

Seminars in the
Field of
Pediatric
Nursing

Infection control
practices in
different pediatric
clinical settings

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Infection control practices in different pediatric clinical settings

OUTLINE:
- Introduction
- Terminology
- Body defense
- The Chain of Infection
- Routes of Transmission of Infection
o Contact transmission
o Droplet transmission
o Airborne transmission
- Stages of infection process
- Transmission of infection in pediatric ambulatory care settings
- Factors influencing risk of transmission
- Nosocomial Infection- Hospital acquired infection
- National Guidelines Infection Prevention &Control 2020
o Key components of an IPC healthcare facility structure
o Infection Prevention and Control Committee
o The role and responsibilities of the IPC Committee
o Infection prevention and control team
o Roles and responsibilities of the IPC Doctor
o Infection Prevention and Control Nurse
o Role and responsibilities of the IPC Nurse
- Principles of Current Infection Control Guidelines (Infection control
practices)
o Inanimate Environment and Infection
o Toys and transmission of infection

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Infection control practices in different pediatric clinical settings
o Hand hygiene
o Patient placement
o Needle and syringes
o Skin disinfection
o Single-dose vials
o Multi-dose vials
o Avoid double- dipping
o Injection Preparation Area
o Safe disposal of sharps
o Disinfection and Sterilization
o Environmental Cleaning
o Management of Healthcare Waste
- Protection of Healthcare Workers
- Recommendations
- Antibiotic-resistant organisms (AROs) in ambulatory care
- Precautions for novel pathogens
- NICU Infection Control Measures
- PICU Infection Control Measures
- References

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Infection control practices in different pediatric clinical settings

Introduction

Transmission of infection in the pediatric office is an issue of increasing

concern. Prevention includes appropriate office design and administrative policies,
triage, routine practices for the care of all patients (e.g., hand hygiene; use of gloves,
masks, eye protection, and gowns for specific procedures; adequate cleaning,
disinfection, and sterilization of surfaces and equipment, including toys; and aseptic
technique for invasive procedures), and additional precautions for specific infections.
Personnel should be adequately immunized, and those infected should follow work-
restriction policies.

Young children readily acquire and transmit infections. They frequently harbor
infectious organisms and may shed pathogens, especially respiratory and
gastrointestinal viruses, even when asymptomatic. In places where young children
gather, close proximity of large numbers of infectious and susceptible hosts favors
transmission. Behavioral characteristics, such as incontinence or inadequate hygiene,
frequent mouthing of hands and toys or other objects, drooling and direct contact
among children during play, facilitate the spread of infection.

Infection control programs are designed to reduce the risk of transmission to an

acceptable level. The consequences of transmission in terms of infection severity and
outcome must be weighed against the consequences of preventive measures taken.
Practices must be tailored to the level of care being provided and the patient
population served.

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Infection control practices in different pediatric clinical settings

Terminology

Infection: The invasion and multiplication of microorganisms such as bacteria,

viruses, and parasites that is not normally present within the body. An infection may
cause no symptoms and be subclinical, or it may cause symptoms and be clinically
apparent.

Sepsis: is the body’s extreme response to an infection. It is a life-threatening medical

emergency. Sepsis happens when an infection you already have triggers a chain
reaction throughout your body. Infections that lead to sepsis most often start in the
lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can
rapidly lead to tissue damage, organ failure, and death.

Asepsis: is the state of being free from disease-causing micro-organisms (such

as pathogenic bacteria, viruses, pathogenic fungi, and parasites). There are two
categories of asepsis: medical and surgical. The goal of asepsis is to prevent
contamination, which can be ensured by the use of sterile devices, materials and
instruments and by creating an environment that is low in microbe volume.

Aseptic technique: means using practices and procedures to prevent contamination

from pathogens. It involves applying the strictest rules to minimize the risk of
infection. Healthcare workers use aseptic technique in surgery rooms, clinics,
outpatient care centers, and other health care settings.

Types of Aseptic Techniques: There are three main types of aseptic technique that
medical professionals use, depending on the situation. The three varieties are: ‌

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Infection control practices in different pediatric clinical settings
1. Sterile technique. The strictest form of aseptic technique, sterile technique is
intended to provide a space that has no germs whatsoever. Sterile technique is
used in surgeries and other large, invasive procedures where infection could be
the most dangerous. It requires a sterile room, gloves, gowns, caps tools, and
masks, along with hand washing and aseptic fields.
2. Surgical aseptic technique. This is a strict form of aseptic technique that can
be used outside the operating room. It uses everything that sterile technique
uses except for the sterile operating suite. Doctors use surgical aseptic
technique for procedures that are complicated, take a long time, or involve
many parts of the body.
3. Standard aseptic technique. The most common type of aseptic technique, this
is the sterilization process used for things like dialysis or IV insertions. Doctors
use hand washing, small aseptic fields, and masks and gloves to keep these
small areas free from germs.

Aseptic Technique vs. Clean Technique

 Not every medical procedure requires full aseptic technique. Minor procedures
like physical exams can be performed with clean technique, which is less strict.
 Clean technique involves hand washing and efforts to keep things clean, but
masks and sterile fields aren’t required.

Other differences include:

 ‌Sterile objects can touch non-sterile objects

 ‌Environments must be clean, but not necessarily aseptic
 ‌Supplies and materials are kept clean, dry, and uncontaminated, but full
sterility isn’t required

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Infection control practices in different pediatric clinical settings
 ‌Gloves must be clean but not necessarily sterile

Carrier: A person or animal that harbors a specific infectious agent without

discernible clinical disease and serves as a potential source of infection.

Infection control: is the discipline concerned with preventing healthcare-infections.

It refers to the policy and procedures implemented to control and minimize the
dissemination of infections in hospitals and other healthcare settings with the main
purpose of reducing infection rates.

Or: is a practical, evidence-based approach which prevents patients and health

workers from being harmed by avoidable infection and as a result of antimicrobial
resistance
BODY DEFENSE:

Body Defenses & Immunity

 Immunity = resistance to disease
 The immune system provides defense against all the microorganisms and
toxic cells to which we are exposed
 Our body has many ways to prevent or to slow infections
 Many factors affect an individual’s overall ability to resist infections:
1. Genetics: human diseases, zoonoses, etc
2. Age: mainly an immune response
3. Health: eg. Protein deficiency & less
phagocytic activity eg. stress & lower resistance
to disease
4. Hormones: eg. cortisone (a glucocorticoid) reduces inflammatory
response
 The body has three layers to its defense system:

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Infection control practices in different pediatric clinical settings
1. The first line of defense: (or outside defense system) includes physical and
chemical barriers that are always ready and prepared to defend the body
from infection. These include your skin, tears, mucus, cilia, stomach acid,
urine flow, 'friendly' bacteria and white blood cells called neutrophils.
2. The second line of defense: is nonspecific resistance that destroys invaders
in a generalized way without targeting specific individuals: Phagocytic cells
ingest and destroy all microbes that pass into body tissues. For example
macrophages are cells derived from monocytes (a type of white blood cell).
3. The third line of defense: Are immune cells that target specific antigens.
The immune cells that play a role in the third line of defense are B-cells and
T-cells, both are white blood cells. The B-cells produce antibodies. The T-
cells help identify pathogenic cells and destroy targeted cells

The Chain of Infection

The spread of an infection within a community is described as a “chain,”
several interconnected steps that describe how a pathogen moves about. Infection
control and contact tracing are meant to break the chain, preventing a pathogen from
spreading.
The spread of infection can be described as a chain with six links:

1. Infectious agent (pathogen)

2. Reservoir (the normal location of the pathogen)
3. Portal of exit from the reservoir
4. Mode of transmission
5. Portal of entry into a host
6. Susceptible host

 Infectious agent is the pathogen (germ) that causes disease

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Infection control practices in different pediatric clinical settings
 Reservoir includes places in the environment where the pathogen lives, such as
people, animals, and insects, medical equipment, and even soil or water
 Portal of exit is the way the infectious agent leaves the reservoir (through open
wounds, aerosols, or coughing, sneezing, and saliva)
 Means of transmission are the ways the infectious agent can be passed on (direct
contact, ingestion, or inhalation)
 Portal of entry is the way the infectious agent can enter a new host (through
broken skin, respiratory tract, mucous membranes or, for those in healthcare
settings, catheters and lines)
 The host is any carrier of an infection or someone at risk of infection.

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Infection control practices in different pediatric clinical settings

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Infection control practices in different pediatric clinical settings

Routes of Transmission of Infection

1. Contact transmission
- The most frequent route and includes both:
- Direct contact (physical contact between infected and susceptible
individuals)
- Indirect contact (via contaminated intermediate surfaces, such as hands,
equipment and toys).
- Appropriate routine patient care practices should prevent most transmission by
this route.
- Additional Contact Precautions (wearing gloves and gowns, and disinfection of
equipment and surfaces) are warranted for infectious agents of low infective
doses (e.g., rotavirus) and for situations in which extensive contamination of
the patient’s immediate environment is expected (e.g., watery diarrhea which

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Infection control practices in different pediatric clinical settings
cannot be contained in a diaper, or a young child with respiratory infection and
copious respiratory tract secretions).
2. Droplet transmission
- Refers to transmission by large droplets expelled from the respiratory tract
during coughing and sneezing, and inhaled by or deposited onto the respiratory
mucous membranes of individuals near to the infected child.
- Special ventilation is not required because large droplets do not stay suspended
in the air, but settle on surfaces close to the source patient.
- Wearing surgical or procedure masks was recommended for persons within 1
m of the patient until recently, when concern that large droplets may travel
further than 1 m led to extending this distance to 2 m, while recognizing that
1m is probably sufficient for young children and others whose cough is not
forceful.
- Some organisms transmitted by droplet transmission (e.g., Haemophilus
influenzae type b, Neisseria meningitidis, and Bordetella pertussis) are fragile
and do not survive on surfaces in the environment or on hands.

NOTE: Other organisms, such as RSV, influenza, Para influenza, rhinovirus,

adenovirus, and SARS coronavirus survive long enough on surfaces to be picked up
on the hands of patients or personnel. For these infections, droplet and contact
transmission occurs. Thus, respiratory viruses may be transmitted by inhalation, by
depositing large droplets onto mucous membranes or by inoculating nasal mucosa or
conjunctiva by contaminated hands.

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Infection control practices in different pediatric clinical settings
 Surgical or procedure masks can protect personnel from acquisition via
deposition of droplets on mucous membranes and may also help to keep
hands away from nose and mouth.
 Eye shields give added protection against infection via the conjunctiva.
 Face shields or goggles have been shown to prevent RSV infection in
health care personnel.
 RSV transmission to personnel was also reduced when they wore gloves
but used no masks or eye protection, probably because personnel are less
likely to touch their noses or eyes with gloved hands. This finding
suggests that for RSV, contact transmission may be more important than
droplet transmission.
3. Airborne transmission
- Occurs when infectious particles survive in aerosols of small, desiccated
droplets from the respiratory tract or aerosols from skin squames, which
remain suspended in the air and are dispersed over large distances by air
currents.
- Control requires a negative-pressure room with air exhausted outside the
building or passed through a high-efficiency particulate air (HEPA) filter
before recirculation.
- Special tight-fitting masks with built-in filters that remove particles
down to 1 micron in diameter at 95% efficacy (N95) are recommended
for susceptible persons who must enter the room.
- Airborne transmission is uncommon but important because varicella,
measles, tuberculosis, and smallpox are spread by this route. Although
evidence suggests that infections such as SARS coronavirus, Middle
Eastern Respiratory Syndrome (MERS) coronavirus, avian influenza and
viral hemorrhagic fevers are transmitted by large droplet and contact

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Infection control practices in different pediatric clinical settings
spread, it is thought that small particle aerosols generated during certain
procedures, such as intubation or bronchoscopy, may result in airborne
transmission over short distances.
- N95 masks are rarely needed in pediatricians’ offices. Personnel should
be immune to varicella and measles, and tuberculosis in children is
rarely contagious.
- In the event of an outbreak of a new pathogen for which route of
transmission is not yet known, N95 masks may be indicated.

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Infection control practices in different pediatric clinical settings

Stages of infection process

Infection occurs when an organism, such as a virus or bacterium, invades the

body. The infectious agent rapidly multiplies in the body’s tissues. Although not all
infections result in disease, some can trigger the immune system, causing symptoms
of illness.
There are five stages of infection:
1. Incubation: The incubation stage includes the time from exposure to an
infectious agent until the onset of symptoms.
2. Prodromal: the prodromal stage refers to the period after incubation and before
the characteristic symptoms of infection occurs. People can also transmit
infections during the prodromal stage. During this stage, the infectious agent
continues replicating, which triggers the body’s immune response and mild,
nonspecific symptoms.
3. Illness: The third stage of infection is an illness or clinical disease. This stage
includes the time when a person shows apparent symptoms of an infectious
disease.

4. Decline: During the decline stage, the immune system mounts a successful
defense against the pathogens, and the number of infectious particles decreases.
Symptoms will gradually improve. However, a person can develop secondary

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Infection control practices in different pediatric clinical settings
infections during this stage if the primary infection has weakened their immune
system. During this stage, the virus can still transmit to other people.
5. Convalescence: The final stage of infection is known as convalescence. During
this stage, symptoms resolve, and a person can return to their normal functions.

Transmission of infection in pediatric ambulatory care settings

 Most reported infections acquired in ambulatory care have been the result of
procedures performed there: abscesses after injection of contaminated vaccines
or medications, viral conjunctivitis from contaminated ophthalmic equipment,
transmission of blood-borne viruses from inadequately sterilized equipment,
infections complicating outpatient surgery, and infections related to inadequate
decontamination of endoscopes.
 Hepatitis B and C viruses have been transmitted by contamination of multidose
vials or by using the same physical space to prepare, dismantle, and dispose of
injection equipment.

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Infection control practices in different pediatric clinical settings
 Measles has been transmitted in pediatricians’ offices. Transmission by
contaminated air alone was documented in two pediatric office outbreaks.
There are reports of transmission of tuberculosis from physicians to patients in
pediatricians’ offices. Pertussis has been transmitted to health care workers in
pediatric ambulatory settings.
 Infections commonly seen in the community, such as viral respiratory and
gastrointestinal infections, may be transmitted in physicians’ offices if
precautions are not taken. However, in-office spread of these infections has not
been reported, possibly because it is difficult to distinguish between office and
community exposures.
 Young children have 4 to 10 respiratory infections and up to 4 episodes of
gastroenteritis per year. They can acquire infections in child care, at school, in
crowded shopping malls or recreational centers, or from siblings, parents, other
family contacts, friends, or caregivers.

Factors influencing risk of transmission

1. Young children and others who are unable to appropriately handle their
respiratory secretions, children with diarrhea who are in diapers or incontinent,
and those with infected open wounds or skin lesions, are likely sources of
infection.
2. Organisms that can survive on patient care equipment, environmental surfaces
or toys are more likely to transmit.
3. Heavy environmental contamination enhances transmission potential, as does a
low infective dose.
4. Respiratory viruses and rotavirus have low infective doses and persist for
prolonged periods on inanimate objects. Methicillin-resistant Staphylococcus
aureus (MRSA) and respiratory syncytial virus (RSV) survive on stethoscope

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Infection control practices in different pediatric clinical settings
diaphragms. Transmission of RSV from the inanimate environment has been
demonstrated.
5. Contaminated electronic thermometer bases and blood pressure cuffs have been
implicated in the transmission of Clostridium difficile and vancomycin-
resistant enterococcus (VRE).
6. Children who lack immunity to the infecting agent and those who are ill,
debilitated or immunocompromised are at increased risk for disease.

Note: The risk of transmission among patients may be less in an office setting than on
a hospital ward. In offices, the duration of contact between individuals is shorter,
patients are generally in better health and fewer invasive procedures are performed.
However, patients may remain in crowded common waiting areas for prolonged
periods of time. Also, it may not be immediately recognized that a patient has a
contagious illness, and the need for short turnaround time for examination rooms may
hamper cleaning. Some practices have chosen to eliminate waiting rooms and place
patients directly into examination rooms

Nosocomial Infection- Hospital acquired infection

Nosocomial infections, also called health-care-associated or hospital-acquired

infections, are a subset of infectious diseases acquired in a health-care facility. To
be considered nosocomial, the infection cannot be present at admission; rather, it
must develop at least 48 hours after admission.
HAI is the most common adverse event in health care that affects patient
safety. They contribute to significant morbidity, mortality, and financial burden on
patients, families, and healthcare systems.
HAI affects 3.2% of all hospitalized patients in the United States, 6.5% in the
European Union/European Economic Area, and worldwide prevalence is likely much
higher. Studies on HAIs show diverse results worldwide with a range of 3.5–12% in

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Infection control practices in different pediatric clinical settings
developed countries and 6–19% in developing countries, including Egypt, with the
highest incidence in ICUs, burn units, patients undergoing organ transplant, and
neonates
Types of Healthcare-Associated Infection (HAI)
Responsible pathogens originate from a variety of different sources and are
represented by different types of HAI. The Centers for Disease Control and
Prevention broadly categorizes the types of HAI as follows:
1. Central line-associated bloodstream infections (CLABSI)
2. Catheter-associated urinary tract infections (CAUTI)
3. Surgical site infections (SSI)
4. Ventilator-associated pneumonia (VAP)

The most common type of NIs in children is bloodstream infections, pneumonia

(ventilator-associated VAP), urinary tract infections (UTI), skin and surgical site
infections.

Symptoms of nosocomial infections

For a HAI, the infection must occur:
 up to 48 hours after hospital admission
 up to 3 days after discharge
 up to 30 days after an operation
 in a healthcare facility when someone was admitted for reasons other than the
infection
Symptoms of HAIs will vary by type. The most common types of HAIs are:
1. Urinary Tract Infections (Utis)
2. Surgical Site Infections
3. Gastroenteritis

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Infection control practices in different pediatric clinical settings
4. Meningitis
5. pneumonia
The symptoms for these infections may include:
 Discharge From A Wound
 Fever
 Cough, Shortness Of Breathing
 Burning With Urination Or Difficulty Urinating
 Headache
 Nausea, Vomiting, diarrhea
Causes of Nosocomial Infections
Bacteria, fungus, and viruses can cause HAIs. Bacteria alone cause about 90
percent of these cases. Many people have compromised immune systems during their
hospital stay, so they’re more likely to contract an infection. Some of the common
bacteria that are responsible for HAIs are:

Bacteria Infection type

Staphylococcus aureus (S. aureus) blood
Escherichia coli (E. coli) UTI
Enterococci blood, UTI, wound
Pseudomonas aeruginosa (P. kidney, UTI, respiratory
aeruginosa)

Note: Bacteria, fungi, and viruses spread mainly through person-to-person

contact. This includes unclean hands, and medical instruments such as catheters,
respiratory machines, and other hospital tools. HAI cases also increase when there’s

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Infection control practices in different pediatric clinical settings
excessive and improper use of antibiotics. This can lead to bacteria that are resistant
to multiple antibiotics.

Risk Group for Nosocomial Infections

 Increasing age
 Greater length of hospitalization
 Excessive or improper use of broad-spectrum antibiotics
 Higher number of invasive devices and procedures (for instance: central
venous catheters, urinary catheters, surgical procedures, and mechanical
ventilation)
 Comorbid conditions
o Diabetes
o Chronic lung disease
o Renal insufficiency
o Malnutrition
How can nosocomial infections be prevented?
 Implementation of infection control protocols to reduce exogenous and
endogenous transmission in health-care facilities.
1. Exogenous transmission occurs due to person-to-person interactions and
through environmental cross-contamination.
o Frequent hand hygiene is the most important preventative measure to
limit the spread of pathogens.
o Compliance with isolation precautions
o Proper use of personal protective equipment
o Avoidance of unnecessary use of indwelling devices, and remove them
as soon as advisable.

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Infection control practices in different pediatric clinical settings
o Practicing proper aseptic and/or sterile techniques during insertion and
maintenance of devices.
 Routine disinfection of surfaces, patient equipment, and medical
devices
 Appropriate waste management
2. Endogenous transmission
o From excessive and improper use of broad-spectrum antibiotics.
 Vancomycin affects the normal balance in the patient's own
endogenous bacterial flora, ultimately leading to an overgrowth of
some bacteria
 Appropriate antimicrobial use with the correct agent, dose, and
duration is needed to minimize the growth of antibiotic-resistant
pathogens
o Transfer from one part of the body to the other (as with urinary tract
infections)
o Depressed immune system from factors like malnourishment or
chemotherapy.

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Infection control practices in different pediatric clinical settings

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Infection control practices in different pediatric clinical settings
Infection control practices in different pediatric clinical settings

National Guidelines Infection Prevention &Control 2020

Impact of infection prevention &control

Establishing and enhancing effective delivery of IPC services is part of the

quality and safety of healthcare, which can contribute to the following
improvements in health outcomes:

1. Reduction in length of stay.

2. Reduction in cost.
3. Reduction in hospital attendance.
4. Effective utilization of beds.
5. Reduction in the spread of multi-drug resistant organisms
(MDROs).
6. Improved patient satisfaction, safety and quality of care.
7. Impact on individuals and families.

Key components of an IPC healthcare facility structure

Important components of the IPC programme are:

 Availability of basic infrastructure (hand washing facilities,

continuous water supply, soap, drying material and alcohol-based
hand (ABHR) product, hand hygiene at the point of care, etc.
 Availability of basic IPC supplies, gloves, personal protective
equipment, chemical disinfectant for environmental cleaning, etc.
 Implementation of basic measures for IPC, including triage,
isolation of patients with suspected/known communicable diseases

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Infection control practices in different pediatric clinical settings

and MDROs, and implementation of standard precautions for all

patients and additional precautions based on risk assessment.
 Education and training of healthcare workers.
 Availability and regular update of IPC and antimicrobial guidelines
with issuance and revision dates.
 Protection of healthcare workers, e.g. immunization and availability
of post-exposure prophylaxis (PEP).
 Identification of hazards and unsafe IPC practices and minimizing
the risks.
 Implementation of IPC practices essential to the provision of safe
patient care e.g. aseptic techniques, usage of single-use disposal
devices, adequate reprocessing of reusable instruments, items and
equipment, prompt management of blood and body fluid exposure in
HCWs, management of medical waste as per national and hospital
policy and support to implement antibiotic stewardship programme.
 Environmental management practices, including management of
support services e.g. catering, laundry, and pest control.
 Surveillance of healthcare associated infections, and outbreak
investigation.
 Regular audits and incident monitoring, and reporting to the
appropriate authorities.
 Education, practical training and research.

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Infection control practices in different pediatric clinical settings

Infection Prevention and Control Committee

The IPC committee plays a supervisory role and provides input, ensures
that the policies and procedures are implemented and supervise standardized
IPC professional healthcare. The committee must have adequate secretarial
support. The IPC committee includes wide representation from relevant
departments. The committee shall be led/chaired by the hospital administrator
or a suitable senior nominee, and must have adequate secretarial support for
day-to-day administrative needs.

The Composition of the IPC committee

1. Medical Superintendent/Administrator
2. Medical Microbiologist
3. Infectious Disease Physician
4. Hospital Epidemiologist
5. Senior member from key clinical specialties and allied departments
6. Senior member of Nursing/Matron’s office
7. Clinical pharmacist
8. Head of the Operating theater
9. Head of Sterile Supply Department
10. Head of the procurement of goods and services and stores department
11. Head of the catering department
12. Head of sanitary and housekeeping services
13. Biomedical Engineer
14. Civil engineer
15. Another co-opted member as and when required

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Infection control practices in different pediatric clinical settings

The role and responsibilities of the IPC Committee:

1. Elect a senior member of the committee as the chairperson who should

have direct access to the senior management and hospital administrator.
2. Ensure adequate resources and supplies are available to implement an
effective IPC programme.
3. Review and approve the IPC annual programme of activities for audits and
surveillance.
4. Provide timely feedback of data on audits and surveillance of HCAIs and
MDROs to the relevant department.
5. Develop and approve IPC policy and procedure manual with issues and
revised dates.
6. Review audit and surveillance data and identify areas for intervention to
facilitate prompt implementation of optimal IPC practices at all levels.
7. Ensure enhancement of staff capacities.
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Infection control practices in different pediatric clinical settings

8. Establish and supervene IPC Control team.

9. Direct resources to address any additional identified issue/problem.
[Link] communication among involved disciplines and different
departments.
[Link] regularly, monthly, but not less than three times a year. In an
emergency situation, such as an outbreak, the committee must be able to
meet promptly and more frequently.
[Link] as a multidisciplinary forum to facilitate input and cooperation of key
stakeholders and sharing of information to relevant departments.
[Link] IPC policies and procedures are based on current scientific
evidence and aligned with international recommendations.
[Link] revised and/or new policies and procedures and other information
are readily available to all HCWs.
[Link] for quality and cost effectiveness-based selection and
approval of chemical antiseptic & disinfectants, new items, other products,
and equipment which has IPC implications.
[Link] training and education of all relevant clinical and non- clinical staff
(clinical and non-clinical).
o The staff should receive education and practical aspect of hands
on training where appropriate.
o The training should be given to new staff upon induction,
introduction of new product or procedure on an ongoing basis for
updating the knowledge on new research and development.
[Link] in matters related to hospital construction and renovation.
[Link] and evaluate IPC performance through regular audits and
surveillance.

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Infection control practices in different pediatric clinical settings

[Link] newsletter publication on a regular basis for providing

information, and increase awareness on IPC related issues.
[Link] an activity report and statistical data to the federal committee every
six months.
Infection prevention and control team

For effective functioning and delivery of the IPC Programme, it is

essential that every acute healthcare facility (HCFs) should have dedicated
and trained IPC doctors and nurses. The IPC team comprises of an IPC
doctor/office and IPC nurse practitioner. It is essential that for effective
delivery of service, all IPC practitioners must meet the core competencies33
to ensure that they have both the knowledge and skill to execute their tasks
effectively.

The number of IPC practitioners required to run an effective

programme depends on various factors such as the number of beds, number of
HCFs, and the distance, types of acute HCFs with specialized units, tertiary
care center, etc.
Roles and responsibilities of the IPC Team

1. It should meet on a daily basis.

2. Serve as a specialist advisor and takes the leading role in the effective
functioning of the IPC team on a day to day basis.
3. Should be an active member of the hospital IPC committee and assists in
drawing up annual plans, policies & procedures, and long- term
programmes for the prevention of HCAIs and control of MDROs.
4. Provide advice on new products and emerging technologies.

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Infection control practices in different pediatric clinical settings

5. Ensure uninterrupted availability of IPC essential supplies and

infrastructure e.g. personal protective equipment, soap, hand drying
material, alcohol-based hand rub at all points of care.
6. Ensure compliance and adherence to the policy and procedures by
performing regular audits and surveillance.
7. Identify poor IPC practices and take remedial action by organizing
trainings.
8. Advise the staff on all aspects of IPC to maintain a safe environment for
patients, staff and visitors.
9. Monitor healthcare associated infections and report adverse incident.
[Link] outbreaks within the healthcare facility.
[Link] an annual training plan for healthcare workers and other relevant
staff.
[Link]-up necessary follow-up measures of needle stick injury (NSI) cases
after discharge, including periodic laboratory monitoring.
[Link] employee health programmes as per local policies.
[Link] in the preparation of tender documents for support services and
advises on IPC aspects.
[Link] should be involved in setting of quality standards, surveillance, and
monitoring of HCAIs and MDROs.
[Link] monthly reports on activities to the IPC.
Roles and responsibilities of the IPC Doctor

 Supervise the IPC nurse(s).

 Liaise with the director of IPC and microbiology laboratory.
 Serve as a specialist advisor and take a leading role in the effective
functioning of the IPC team.
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Infection control practices in different pediatric clinical settings

 Must be able to make day to day decisions on IPC within the guidelines of
the Infection Prevention and Control manual.
 Assist the hospital IPC committee in drawing up annual plans, policies and
long- term programs for the prevention of HCAIs.
 Advise the chief executive/hospital administrator directly on all aspects of
HCAIs and on the implementation of agreed policies.
 Participate in the preparation of tender documents for support services and
advises on IPC aspects.
 Should be involved in setting of quality standards, surveillance, and
monitoring of HCAIs. Participates in establishing policies on the use of
antimicrobial agents and provides advice on new products and emerging
technologies.
Infection Prevention and Control Nurse

An IPC nurse is a registered nurse with an additional academic

education and practical training in IPC to enable role and act as a specialist
advisor. It is essential that the IPC nurse has the expert knowledge of both
general and specialist nursing practice and must also have an understanding
not only of the functioning of clinical areas, but also operational areas and
services. The IPC nurse should be able to communicate effectively with all
grades of staff, negotiate, effect change and influence practice. A recognized
qualification in IPC is highly recommended to fulfill this job effectively.

Role and responsibilities of the IPC Nurse

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Infection control practices in different pediatric clinical settings

• Visit wards and clinics to detect and record HCAIs and communicable
diseases.
• Serve as a specialist advisor and take a leading day- to- day role in the
effective functioning of the IPC team.
• Should be an active member of the IPC committee.
• Provide specialist nursing input in surveillance, prevention, monitoring,
and control of HCAIs and MDROs.
• Identify and investigate unsafe IPC practices and procedures and take
timely action on hazardous practices.
• Advise the contracting departments and participate in the preparation of
documents relating to service specifications and quality standards.
• Ongoing contribution to the development and implementation of IPC
policies and procedures, participating in the audit, surveillance of HCAIs
and develop monitoring tools related to IPC, communicable diseases and
MDROs.
• Presentation of educational programmes and membership of relevant
committees where input from IPC is required.
• Perform audits of clinical practices related to prevention of infection, e.g.,
aseptic techniques, isolation of patients, disposal of healthcare wastes.
• Monitoring of food hygiene and health of food handling staff.
• Conduct education programmes on IPC for all new clinical staff (doctors,
nursing and paramedical staff) as a part of induction and ongoing training
in conjunction with medical and technical officers.
• Prepare IPC reports and statistics on HCAIs, MDROs, and communicable
disease for IPC committee, with the help and coordination of ICD
(Infection Control Doctor), medical microbiologist and clinical staff.

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Infection control practices in different pediatric clinical settings

Principles of Current Infection Control Guidelines (Infection control

practices)

Current guidelines for the prevention of transmission of infection are based on

the following principles:

1. Certain measures referred to as ‘Routine Practices’ are required for the

care of all patients, regardless of diagnoses, and are determined by the
task being performed. The goal is to prevent transmission from any
patient, whether symptomatic or not, assuming that blood, body fluids,
excretions, and secretions from any patient could contain pathogens.
2. Further measures called ‘Additional Precautions’ are required for
patients with specific infections based on clinical presentation, and are
determined by the methods of transmission of the micro-organisms
expected or known to be involved.
3. Screening for clinical manifestations of infection is essential to identify
patients for whom additional precautions are warranted.
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Infection control practices in different pediatric clinical settings

4. Concern about transmission of respiratory pathogens in ambulatory care

settings came to the forefront during the 2003 severe acute respiratory
syndrome (SARS) epidemic. Heightened awareness led to
recommendations for a new standard of patient behavior, ‘Respiratory
Etiquette’, in ambulatory care. Outpatient settings are being urged to
implement source containment measures to prevent transmission of
respiratory infections, beginning at the point of initial patient encounter
with the health care facility.

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Infection control practices in different pediatric clinical settings

Illnesses warranting ‘Additional Precautions’

Infection Precautions Duration of precautions
Antibiotic-resistant organisms (infection or Contact If patients assessed as at risk to transmit
colonization), including MRSA
Avian influenza† Droplet plus Contact To 14 days from onset
Enteroviral infection (diagnosed or suspected)‡ Contact For duration of illness
Gastroenteritis Contact For duration of symptoms or until an infectious cause is ruled
out
Hepatitis, viral (types A and E, diagnosed or suspected) Contact Until viral infection is ruled out; to 7 days after onset if
hepatitis A is diagnosed
Measles (diagnosed or suspected) Airborne To 4 days after onset of rash (and for duration of illness if
immunocompromised)
Meningitis (diagnosed or suspected) Droplet plus Contact Until 24 h of appropriate antibiotic received
Droplet For duration of illness
 Bacterial
Contact
 Viral
Mumps Droplet To 9 days after onset of swelling
Pertussis (diagnosed or suspected) Droplet Until 5 days of appropriate antibiotic received or pertussis
ruled out
Petechial or ecchymotic rash with fever (suspected Droplet Until 24 h of appropriate antibiotic received or
meningococcemia) meningococcus ruled out

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Infection control practices in different pediatric clinical settings

Rubella Droplet To 7 days after onset of rash

SARS† MERS-CoV† Droplet plus Contact To 10 days after resolution of fever
(plus N95 masks)
Scabies (diagnosed or suspected) Contact Until initial therapy applied
Skin infection (extensive lesions, abscess or infected Contact For duration of drainage or until exudative lesions are healed
wound if drainage or exudate not covered and
contained by dressing)
Streptococcus group A impetigo not covered by Contact Until 24 h of appropriate therapy received
dressing
Streptococcus group A invasive disease, pharyngitis, Droplet Until 24 h of appropriate antibiotic received
pneumonia, scarlet fever
Tuberculosis (diagnosed or suspected) infectious form§ Airborne Until assessed as not infectious
Varicella (diagnosed or suspected) Airborne plus Contact Until lesions crusted and dried or varicella is ruled out
Viral respiratory tract infection (diagnosed or Droplet plus For duration of illness or until viral infection is ruled out
suspected bronchiolitis, common cold, croup, Contact
pneumonia or pharyngitis)
Zoster (diagnosed or suspected)—rash not covered Airborne plus Contact Until lesions crusted and dried or zoster is ruled out

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Infection control practices in different pediatric clinical settings

Inanimate Environment and Infection

- Preventing acquisition of infection from the inanimate

environment involves appropriate disinfection and sterilization
of equipment and other items, cleaning surfaces, and standard
maintenance of ventilation and plumbing systems.
- For purposes of processing, medical equipment is classified into
three groups.
1. Items that are introduced into sterile body spaces
(critical) must be sterile.
2. Items in contact with mucous membranes or
nonintact skin or through which inspired air flows
(semicritical) require high-level disinfection
designed to inactivate all micro-organisms except
bacterial spores.
3. Items that are only in contact with intact skin
(noncritical) require low-level disinfection designed
to remove most micro-organisms and bring
contamination to an acceptable level.
 Most examination equipment in an office setting is in contact
with only the patient’s intact skin. Some experts have
suggested that cleaning with detergent and water is sufficient
for noncritical equipment.
 A disinfectant should be used when the equipment is
contaminated with blood or body fluid. Ideally, all such
equipment should be cleaned between patients.
 If this is not feasible, daily cleaning may suffice, but
equipment must be cleaned before reuse when it is

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Infection control practices in different pediatric clinical settings

contaminated with patient secretions or excretions or if visibly

soiled.
 Equipment that does not have direct patient contact should be
cleaned on a routine basis and when soiled.
 Environmental surfaces should be cleaned on a routine basis
with a low-level disinfectant or detergent.
 Frequently touched surfaces should be cleaned daily. Cleaning
with detergent and water may suffice, unless surfaces are
contaminated with blood or body fluids.

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Infection control practices in different pediatric clinical settings

Toys and transmission of infection

o Playing together and sharing of toys contribute to developing social skills.

Toys may be considered as part of the equipment of a pediatrician’s office,
but sharing of toys poses a potential health risk.
o Microbial contamination of toys has been documented in hospitals,
physician’s offices, and child care centers.
o Fecal coliforms and rotavirus have been found on toys in hospitals.
o The American Academy of Pediatrics recommended cleaning of toys in
offices. In response to these recommendations, some pediatricians
eliminated toys from their waiting rooms, finding the cleaning and
monitoring of toy use too arduous.
o Physicians must consider the needs of children when weighing the risks
and benefits of having toys in their offices.

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Infection control practices in different pediatric clinical settings

Hand hygiene

Hand hygiene is a crucial element in infection control. Traditionally,

hand hygiene has been performed with soap and water. Alcohol-based hand
rinses and gels have been shown to be more effective than soap and water
for removing micro-organisms from hands, and they also save time. Small
containers which can be carried in the pocket or clipped to clothing are
readily available for use when needed.

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Infection control practices in different pediatric clinical settings

Your five moments of Hand Hygiene

Patient placement

 The main aim of triage is to assess risk and segregate

suspected and/or confirmed infected patients with
transmissible infections and patients with multidrug-
resistant organisms in a single room, preferably with en
suite toilet facility.
 Implementation of the Triage system in the Accident &
Emergency (A&E) and out-patient department is essential
in all healthcare facilities to prevent cross-infection due to
overcrowding.
 Patients should be provided educational materials about
hand hygiene and respiratory hygiene/cough etiquette in
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Infection control practices in different pediatric clinical settings

emergency, receiving and waiting areas and all HCW must

apply standard precautions at all times for all patients.
 Based on the Triage and risk assessment, additional
precautions are necessary. Every effort should be made to
minimize contact of staff with transmissible infections and
effort should be made that only the staffs that are immune
should look after such patients, if possible.
 It is also critical that the A&E department must have
adequate isolation facilities to segregate these patients.

Types of Isolation Rooms

1. Source Isolation Room

 Infected patients are nursed in single rooms preferably with en suite
toilet and shower facilities and it is essential that an adequate number
of single rooms for source isolation are available for patients with
suspected and confirmed transmissible infection.
 Some patients with infectious diseases, which are spread by an
airborne route, e.g. patients with open tuberculosis (especially
multidrug- resistant- TB), measles, and chickenpox/varicella-zoster
require a negative pressure ventilation room, en suite toilet facilities,
and anteroom.
 A minimum of 6– 12 exchanges of air change (ACH) per hour (i.e.
an air volume equivalent to 6–12 times the volume of the rooms is
extracted each hour from the room) is recommended for the
protection of staff and visitors. However, in new buildings 12 air
changes/hour are recommended.

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Infection control practices in different pediatric clinical settings

 In addition, there should be adequate temperature and humidity

regulation, such that windows need not be opened, and doors can be
kept closed when the rooms are in use.
 The exhaust air from the isolation rooms should be vented to the
exterior and extracted air should terminate in a safe location away
from the fresh air supply inlet, ideally 3 metres above the highest part
of the building.
2. Protective Isolation
 The aim of protective isolation is the reverse of source isolation
precaution, i.e. to prevent transfer of infection from inanimate
environment and other personnel to immunosuppressed patients.
 It is important to note that immunosuppressed patients are also at
increased risk of endogenous infections where the source of infection
is their own microflora, e.g. immunosuppressed patients may get an
infection from microorganisms residing in his/ her gastrointestinal
tract which is damaged by chemotherapy.
 Most immunosuppressed patients can be nursed in single rooms with
en suite toilet facilities.
 Patients who are at greatest risk are individuals who are severely
neutropenic, patients undergoing any transplantation, and those who
have received intensive chemotherapy. It is essential that the rooms
do not have openable windows. This is because infection from
airborne contamination of fungal spores (especially Aspergillus spp.)
is a problem, especially in bone marrow transplant and profoundly
neutropenic patients.
 In addition to standard precautions, the following additional
precautions should be implemented when dealing with
immunosuppressed patients.
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Infection control practices in different pediatric clinical settings

In an outpatient waiting room, additional precautions for the

control of airborne transmission of disease may be required. These
patients should be seen ahead of others in the waiting room to
minimize the time they are exposed to other patients in the waiting
area. Where invasive medical or dental procedures are involved, it is
advisable to place immunosuppressed patients at the start of the
operating schedule, if possible.

Needle and syringes

 Do not give unnecessary injections to patients.

 Always use sterile needle and syringes— never reuse or
decontaminate needle or syringes as they are single-use items only.
 Do not administer medications from a syringe to multiple patients,
even if the needle or cannula on the syringe is changed, nor access a
medication or solution that might be used for a subsequent patient
through any vial with a used syringe or needle.
 If possible, utilize single-use disposable safety engineered ‘SMART’
syringes (auto-destructible) i.e. Re-Use Prevention (RUP) and Sharp
Injury Protection mechanisms (SIP).

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Infection control practices in different pediatric clinical settings

Skin disinfection

• Apply 60– 70% alcohol- based solution (isopropyl alcohol or

ethanol) on the skin for 30 seconds on a single use swab or cotton
ball and allow it to dry.
• Do not use cotton balls stored wet in a multi-use container. Do not
use methanol or methyl alcohol as these are not safe for human use.

Single-dose vials

• Use single-dose vials for IV medications whenever possible.

• Do not administer medications from single-dose vials or ampoules
to multiple patients or combine left over contents for later use.
• Do not use medications packaged as single- dose or single- use for
more than one patient.

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Infection control practices in different pediatric clinical settings

Multi-dose vials

• Avoid using multi-dose vials.

• Limit the use of multi-dose vials and dedicate them to a single
patient and always label with patient’s name.
• If multi-dose vials are used, they should be kept and accessed only
in a dedicated medication preparation area (Injection equipment and
area for preparation of injections). This is done to prevent
inadvertent contamination of the vial through direct or indirect
contact with potentially contaminated surfaces or equipment that
could then lead to infections in subsequent patients.
• Do not keep multi-dose vials in the immediate patient treatment
area, store in accordance with the manufacturer’s recommendations.
Discard if sterility is compromised or questionable.
• Never leave needles or cover with other objects (e.g. sticky tape) in
vial entry diaphragms between uses, as this could contaminate the
vial’s contents.
• Remember that once a multiple- dose vial is punctured, it should be
assigned a ‘beyond- use’ which starts when the vial is entered, or
open as multi-dose vials contain antimicrobial preservatives (to
prevent the growth of bacteria but have no activity against viruses)
— refer to the manufacturer’s recommendation regarding duration
of use.

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Infection control practices in different pediatric clinical settings

• Always use a new sterile needle and a new syringe to access a multi-
dose vial.

Avoid double- dipping

Using the same syringe to inject more than one patient from a multi-dose
vial is called ‘double- dipping’. Double-dipping is a dangerous and unsafe
practice.

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Infection control practices in different pediatric clinical settings

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Infection control practices in different pediatric clinical settings

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Infection control practices in different pediatric clinical settings

Injection Preparation Area

• Prepare all injections in a dedicated clean area.

• The injection preparation area or room must be a dedicated clean
area.
• It is essential that this area must not be
contaminated with blood and/or body fluids.
• Any contaminated items, including blood samples
must not be brought to this room or area.
• This clean area/room should be used to draw up
injections, but if the vial is used for the next
patient(s), even if new syringes and new needles are
used, infections can still be transmitted.
• Needles must be discarded into a robust, sharp container in a
dedicated dirty area (i.e. dirty utility).

Safe disposal of sharps

• Needles should not be re-capped, bent, broken or disassembled.

• Handle all sharp instruments or devices (needles, scalpels, etc.,)
carefully.
• Dispose all used needles and other sharp instruments in a
designated puncture-resistant sharp container.

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Infection control practices in different pediatric clinical settings

Disinfection and Sterilization

Cleaning: It is the first step required to physically remove contamination

by foreign materials, e.g. dust and soil. It also removes organic materials,
such as blood, secretions, excretions, and microorganisms, to prepare a
medical device for disinfection or sterilization.

Disinfection: It is the process of reducing the number of viable

microorganisms to a less harmful level. This process may not, however,
inactivate bacterial spores, prions, and some viruses.

Sterilization: It is a validated process used to render an object free from

viable microorganisms, including viruses and bacterial spores, but not
prions.
Environmental Cleaning
• The constant contamination of the environment with microorganisms
occurs from infected and/or colonized patients, staff, and visitors.
• Their survival in the environment depends on various factors, i.e.
moisture, temperature, humidity, and type of material.
• Therefore, regular and thorough cleaning of environmental surfaces,
items and equipment is essential to reduce bioburden, to minimize
transfer of pathogens directly via hands touching the contaminated
environmental surface or indirectly via contaminated hands, items, and
equipment.

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Infection control practices in different pediatric clinical settings

Types of housekeeping surfaces

Housekeeping surfaces can be divided into two groups:

1. Surfaces which come into frequent contact with hands or ‘high

frequency hand touch surfaces’, i.e. door handles, tabletops, work
surfaces.
2. Surfaces that have minimal contact with hands (low frequency
hand touch surfaces, i.e. floors, walls, ceilings and window sills.

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Infection control practices in different pediatric clinical settings

Cleaning methods

• Effective cleaning requires detergents, and the physical action of

scrubbing.
• Adding detergent aids cleaning as it mixes well with water and also with
organic matter.
• Cleaning is essential as it removes organic matter and visible soils— all
of which interfere with microbial inactivation if chemical disinfectants
are used.
• Warm water and detergent are sufficient for most purposes. In certain
situations, after thorough cleaning of the environment, the use of
disinfectants is also necessary as some pathogens especially C. difficile
spores, Acinetobacter spp., MRSA, and VRE can survive in the
environment for prolonged periods of time.

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Infection control practices in different pediatric clinical settings

The following points should be taken into consideration when cleaning is

undertaken

 All personnel should be educated and provided with practical training

so that they can perform their duties effectively.
 There should be guidelines and protocols as to who is responsible
(nursing personnel or housekeeping staff) for cleaning various
surfaces, items and equipment.
 Staffs who is performing cleaning should wear appropriate PPE and
follow local procedures and protocol.
 To prevent cross contamination, cleaning must always be carried out
from the cleanest area first and finish in the dirtiest area last, and
always clean from the top first and bottom last.
 Colour- coded cleaning equipment should be used for each area, i.e.
clinical, non- clinical, kitchen, and sanitary area, according to the
local policy.
 Special emphasis must be placed on cleaning and disinfecting high
frequency hand touch surfaces and these areas should be cleaned
more frequently.
 Damp dusting (using pre-moistened cleaning cloths with water and
deter- gent) of horizontal surfaces should be done daily as they gather
dust more easily, and more frequently than vertical surfaces.
 The frequency of cleaning must be increased in an outbreak situation.
 Walls, blinds, and window curtains should be regularly cleaned to
ensure that they are free from dirt, stains, splatters, or fungi.

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Infection control practices in different pediatric clinical settings

Management of Healthcare Waste

The waste generated by any healthcare facility (esp. hospital) is a
specialized type of waste. This may pose a threat not only to healthcare
workers, patients and visitors, but also to the general public and the
environment. Healthcare waste not only contains pathogenic
microorganisms, but also sharp items and appropriate treatment of these
items must be made mandatory. Therefore, it is essential that the
management of clinical and related wastes must conform to the appropriate
national and international guidelines.

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Infection control practices in different pediatric clinical settings

Education and Training

 It is essential that all employees who are required to handle and move
clinical waste should be adequately trained in safe procedures.
 They must be provided with appropriate personal protective
equipment (PPE), i.e. water-repellent clothing, heavy- duty gloves,
and protective footwear), and be trained in how to use the PPE.
 Spillages and other incidents must be dealt with according to written
protocols.
 All accidents and incidents involving clinical waste, particularly
those resulting in injury to, or contamination of handlers, must be
dealt with according to the local policy.

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Infection control practices in different pediatric clinical settings

Categories of Waste

The majority of healthcare waste (i.e. between 75 to 90%) poses no risk and
can be disposed of like domestic waste- this is non-hazardous/non-
infectious waste.

WASTE CATEGORY EXAMPLE

Waste suspected to contain pathogens e.g.
Infectious waste laboratory cultures, waste from surgeries,
autopsies and originating from patient care units
etc.
Pathological waste Human tissues, body parts, foetuses, blood and
body fluids, etc.
Sharps Sharp waste e.g. needles, scalpels, knives, blades,
broken glass, etc.
Waste containing pharmaceuticals, e.g.
Pharmaceutical Waste pharmaceuticals that are expired or no longer
needed, items contaminated by or containing
pharmaceuticals (bottles, boxes, tubes, vials).
Waste containing substances with genotoxic
properties e.g. waste containing cytotoxic drugs
Genotoxic waste (often used in cancer therapy) including
syringes/vials used in preparation. Urine, faeces
and vomit from patients treated with cytotoxic
drugs/chemicals.
Contains chemical substances, e.g. laboratory
Chemical waste reagents, film developer, and chemical
disinfectants that are expired or no longer needed
etc.
Wastes with high content Batteries; broken thermometers, blood-pressure
of heavy metals
gauges, etc.
Pressurized containers Gas cylinders; gas cartridges; aerosol cans.
Contaminated with radionucleotides e.g. unused
liquids from radiotherapy or laboratory research,
Radioactive contaminated glassware, packages, or absorbent
paper, urine and excreta from patients treated or
tested with unsealed radionuclide, sealed sources
etc.

Waste minimization
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Infection control practices in different pediatric clinical settings

 This can be achieved by selecting items generating less waste,

especially hazardous ones, maintaining good stock management,
reducing the tendency to recycle, and appropriate waste segregation
training at the point of generation.
 Minimization of healthcare waste is essential as the cost of disposal
is very high.

Waste segregation

To make separate collection possible, hospital personnel at all levels,

especially the nurses, support staff, and cleaners, should be trained to sort
the waste they produce. The waste disposal points should be clearly marked
for each ward/unit. Segregation should:
1. Always is the responsibility of the waste producer.
2. Take place on the site of generation or as close as possible to
where the waste is generated.
3. Be maintained in safe storage areas after transportation.
4. Guided by behavioural clues posters at the waste disposal point.
5. Be sorted into colour-coded plastic bags or containers as outlined
in local guidelines.
6. Ensure that general healthcare waste join the stream of
community waste.
7. Ensure that highly infectious waste should, whenever possible, be
sterilized immediately by autoclaving. Be packaged in bags that
are compatible with the proposed treatment process: red bags,
suitable for autoclaving, are recommended.
8. Collect low-level radioactive infectious waste (e.g. swabs,
syringes for diagnostic or therapeutic use) in yellow bags or

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Infection control practices in different pediatric clinical settings

containers for infectious waste, if these are destined for

incineration.
9. Collect Cytotoxic waste, most of which are produced in a major
hospital or research facilities, in strong, leak-proof containers
clearly labelled as ‘cytotoxic waste’.
10. Collect small amounts of chemical or pharmaceutical waste
together with infectious waste.
11. Return large quantities of obsolete or expired pharmaceuticals
stored in hospital wards or departments to the pharmacy for
disposal. Other pharmaceutical wastes generated at this level, such
as spilled or contaminated drugs or packaging containing drug
residues should not be returned because of the risk of
contaminating the pharmacy. Such wastes should be deposited in
the correct container at the point of production.
12. Pack large quantities of chemical waste in chemical resistant
containers and send to specialized treatment facilities (if
available).
13. The identity of the chemicals, the name should be clearly marked
on the containers. Hazardous chemical wastes of different types
should never be mixed.
14. Collect waste with a high content of heavy metals (e.g. cadmium
or mercury) separately.

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Infection control practices in different pediatric clinical settings

Types of healthcare waste and colour coding.

Types of Waste Colour Coding

Infectious Yellow/Red/Orange
Non-infectious Blue/green/white/black
Sharps Sharp box yellow/red and then secured in an
infectious waste bag if being outsourced

Waste Collection
Certain recommendations should be followed by the workers in charge of
waste collection:
o Waste should be collected daily (or as frequently as required)
and transported to the designated central storage site. A
timetable should be provided to the waste originator.
o Nursing and other clinical staff should ensure that waste bags
are tightly closed or sealed and in no case more than ¾ full.
o No bags should be removed unless labeled with their point of
production, date, weight and contents-this information should
be written on the bag or on the printed label securely attached.
o The bags or containers should be replaced immediately in
separate bins/ drums with new ones of the same type.
o Ensure cleaning of the bin/container before a new bag is fitted.
o Staff who regularly have to handle, transfer, transport, or
incinerate clinical waste containers must be provided with
appropriate PPE, i.e. heavy-duty gloves, appropriate footwear,
industrial apron or leg shields, waterproof clothing, face visors
and respiratory equipment as required.
o Spillages of waste should be treated according to the local
policy.
o All accidents and incidents involving clinical waste,

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Infection control practices in different pediatric clinical settings

particularly those resulting in an injury or of contamination of

handlers, must be reported without delay to the line manager.

Storage of the waste

Recommendations of storage facilities for healthcare waste:
• A storage location should be designated inside the facility and
sized according to the need.
• Should have an impermeable, hard-standing floor with good
drainage and be easy to clean and disinfect.
• Should have a water supply for cleaning purposes.
• Should afford easy access for the staff in charge of handling the
waste.
• Should be possible to lock the store to prevent access by
unauthorized persons.
• Easy access for waste-collection vehicles is essential.
• They should be protected from the sun.
• The storage area should be inaccessible to animals, insects, and
mbirds.
• There should be good lighting and at least passive ventilation.
• Should not be situated in proximity of fresh food stores or food
preparation areas.
• Storage time should not exceed 24-48 hours.
Waste transport
On-site transport of healthcare waste should be by means of wheeled
trolleys, containers, or carts that are not used for any other purpose and
meet the following specifications:
• Must follow specific routes to the central storage area.
• Easy to load and unload.
• No sharp edges that could damage waste bags or containers during
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Infection control practices in different pediatric clinical settings

loading and unloading.

• Easy to clean and wash.
• Marked with corresponding colour coding.

Treatment and disposal of the waste

Each healthcare facility should identify a method for the treatment and
disposal of hazardous waste, according to the national and local guidelines.
Infectious waste

• Incineration in double-chamber incinerators should be the method of

choice in establishments that apply minimal waste management
programmes.
• Highly infectious waste (esp. Hazard Group 3 and 4 pathogens),
microbiological cultures and stocks of infectious agents from
laboratory work, must be sterilized by autoclaving in the laboratory
at the earliest stage not allowing accumulation for more than 24
hours.
• Clinical waste harbouring or suspicious of harbouring Hazard group
3 and 4 pathogens should be sterilized by autoclaving before
transportation from the laboratory and healthcare facility to the
incinerator.
• In the case of an autoclave malfunction, it should be packaged in
accordance with the approved requirements for carriage, and
transferred to an incinerator as soon as possible. For other infectious
healthcare wastes, disinfection to reduce the microbial concentration
is sufficient as per the local policy.

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Wastes requiring incineration include:

1. Anatomical parts and animal carcasses.
2. Cytotoxic drugs (residues or outdated).
3. Toxic laboratory chemicals other than mercury.
Wastes that may be incinerated include:
1. Patient-contaminated non-plastics.
2. Non-chlorinated plastics.
Wastes that should not be incinerated include:
1. Chlorinated plastics.
2. Volatile toxic wastes such as mercury.
3. Plastics, non-plastics contaminated with blood and body fluids,
secretions and excretions, and infectious laboratory wastes.

Such wastes should be treated by steam sterilization in an autoclavable

container/bags or by microwave treatment. Shredding may follow both of
these methods. If neither method is available, a chemical disinfectant can be
used as per the local policy based on international recommendations.
However, excessive use of chemical disinfectants should be avoided, as it
may be a health and environmental hazard.
Sharps disposal

• Sharps are collected in puncture-proof and leak-proof containers,

such as high-density polyethylene boxes, metallic drums, or barrels.
• Sharps should undergo incineration whenever possible.

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• When a container is three-quarters full, a material such as cement

mortar, bituminous sand, plastic foam, or clay is poured until the
container is filled.
• After the medium has dried, the containers are sealed and disposed of
in landfill sites.
• After incineration or other disinfection, the residues can be disposed
of in a pit. Such a pit can be dug and lined with brick, masonry or
concrete rings. The pit should be covered with a heavy concrete slab,
which is penetrated by a galvanized steel pipe.
• Burial should be 2 to 3 meters deep and at least 1.5 meters above the
groundwater level. When the pit is full, it can be sealed completely
but before that another pit must have been prepared.
• Another easy method for safe disposal of sharps is encapsulation.

Protection of Healthcare Workers

Protection of staff is an integral part of health and safety. It is the

responsibility of all healthcare facilities (HCFs) to ensure that all their
employees are appropriately trained and proficient in the procedures
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Infection control practices in different pediatric clinical settings

necessary for working safely. All healthcare workers (HCWs) must be

given adequate education and practical training on all issues relating to
Infection Prevention and Control (IPC) as part of their induction/orientation
programme and this training should be made mandatory.
1. All HCWs should be immunized against vaccine- preventable
diseases (tetanus, diphtheria, polio, measles, mumps, and rubella etc.)
and should have up to date record of their routine immunizations.
This is important in the context of the ability of staff to transmit
infections to vulnerable groups but also for their own protection.
2. Personnel should undergo pre-employment tuberculin testing and,
if negative, repeat testing after any significant exposure. In some
jurisdictions, pre-employment testing may be required only for
clinics where tuberculosis patients are frequently seen.
3. Policies should be developed and implemented outlining work
restrictions for personnel with communicable infections and
measures to be taken to prevent transmission while working with an
infection.
 Colds and other minor RTIs are not criteria for exclusion
from work. However, personnel should not have direct
contact with high-risk patients, should contain coughs and
respiratory secretions using surgical or procedure masks
and tissues, and perform meticulous hand hygiene after
each contact with nasal or other respiratory tract secretions
and before every contact with patient or patient care
equipment.
 Personnel with blood-borne viral infections (e.g., hepatitis
B, hepatitis C, and HIV) should not perform procedures
with a high risk for transmission of blood from the health

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Infection control practices in different pediatric clinical settings

care worker to a patient. Such procedures are mainly

surgical and are extremely unlikely to be performed in the
routine office settings.
RECOMMENDATIONS

In the absence of data from pediatric office settings, the following

recommendations are based on expert opinion and extrapolations from other
health care settings, with a level of evidence rating of B-III.

1. Administrative policies
 Policies and procedures for infection control and prevention
should be developed and implemented.
 Policies should be reviewed at least every 2 years.
 Ongoing education should be provided for all office personnel and
should include how infections are transmitted, infection control
measures, recognition of symptom complexes, prevention and
management of potential exposures to blood-borne viruses, and
cleaning and disinfection of equipment, toys, and surfaces.
 A system of communication with local public health authorities
should be established and maintained to facilitate systematic
reporting of notifiable diseases and exchange of information about
suspected outbreaks.
2. Office design
 Infection control needs should be considered in office planning
(e.g., layout, sinks and materials used).
 Hand washing sinks with adjacent soap and disposable towel
dispensers, as well as waterless hand hygiene products, should be
available in all patient care areas.

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Infection control practices in different pediatric clinical settings

 Plans should include specific spaces to display signs and place

materials for Respiratory Etiquette.
 Carpeting should be avoided in examination and waiting rooms.
 Ventilation for new or renovated medical offices should provide a
minimum of six air exchanges per hour.
3. Triage
 Triage should be performed by telephone at the time an
appointment is made or as soon as possible after arrival.
 Immunocompromised children need protection from exposure to
patients with transmissible infections, especially respiratory viral
infections. They should not be left in a waiting room but placed in
an examination room upon arrival.
 Children with transmissible infections:
o Parents should be advised to inform the receptionist
immediately upon arrival if they suspect their child has a
contagious illness.
o Signs should be posted in appropriate locations reminding
parents and patients to do this.
o Children with symptomatic infections should be segregated
from well children as quickly as possible. Ideally, those
with any contagious illness should not stay in a waiting
room but be shown into an examination room immediately.
At a minimum, children with suspected or diagnosed
airborne infections (e.g., varicella and measles) should be
quickly removed from a common waiting area.
4. Waiting rooms
 Patient visits should be scheduled to minimize crowding and
shorten wait times.

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Infection control practices in different pediatric clinical settings

 Information and instructions for parents and patients regarding

infection control (e.g., posters, handouts, videos) should be
available in the waiting room.
 Hand hygiene equipment (e.g., waterless hand hygiene products
or sinks with soap and disposable towels) should be available in
the waiting room.
 Contact between children with contagious illnesses and other
children should be minimized.
 Visits for suspected infections should be scheduled for a different
time of the day than routine appointments, or a regular, separate
time period reserved for drop-in visits.
 Infants and young children with vomiting, diarrhea, fever, cough
or open skin lesions should be in the waiting room for as short a
time as possible, placed in an examination room as soon as
possible, and not be allowed in common play areas or to handle
toys or other shared items.
 Signs explaining this policy should be posted.

5. Toys

Sharing of toys by infants and young children should be minimized.

Options include:

 Removing toys from waiting rooms, unless their use can be

supervised and appropriate cleaning is feasible.
 Asking parents to bring a couple of the child’s own toys from
home, designed for individual play, and to avoid sharing these
with other children.

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 Providing toys for infants and young children that can be cleaned
easily and frequently.
 Choose toys with smooth, solid surfaces and avoid toys with small
pieces or creviced surfaces, stuffed toys and toys made of fabric
or plush.
 Ask parents to supervise their child’s use of office toys and to
place them in a designated used toy container when finished. Used
toys should be removed from circulation until cleaned.
 Providing small books, booklets or toys that are designed for
individual play and can be given to the child to take home or
disposed of after use.
 Older children who are mature enough to practice hand hygiene
and handle respiratory secretions appropriately may share toys,
books, puzzles, and computer games.

6. ‘Routine Practices’ for care of all patients

1. Hand hygiene
 All health care personnel should perform hand hygiene using alcohol-
based waterless hand rinses or soap and water:
o Immediately before and after contact with each patient.
o Before moving to a clean-body site from a contaminated-body site
during care of the same patient.
o After contact with blood, body fluids, secretions, excretions, or
objects contaminated with any of these.
o After direct hand contact (e.g., a spill or splash) with a live
vaccine, such as rotavirus or live attenuated influenza vaccine.
o After contact with an environmental surface or item likely to be
contaminated.
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Infection control practices in different pediatric clinical settings

o Before invasive procedures (use an antiseptic soap or antiseptic

hand rinse).
o Before preparing or handling sterile medications or other sterile
products.
o After removing gloves.
 Alcohol-based hand rinses should contain 60% to 90% isopropyl or
ethyl alcohol.
 Soap and water should be used if hands are visibly soiled.
 Parents and children should be instructed about the need for hand
hygiene.
 Alcohol-based hand rinses for patient use should be placed out of reach
of children, and parents should be advised to supervise their children to
avoid accidental ingestion or contact with eyes.

2. Personal protective equipment

 Gloves should be worn:
 If anticipating direct hand contact with blood, body fluids,
secretions or excretions, or with items contaminated by any
of these substances.
 For direct hand contact with mucous membranes or
nonintact skin.
 For direct hand contact with a patient when the health care
provider has an open lesion on the hand.
 Gloves are not needed for routine child care, such as wiping a
nose or changing a diaper, provided that these actions can be
performed without direct hand contamination.
 Gloves are not routinely required for administering vaccines.

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 A surgical mask or procedure mask and eye protection (e.g.,

goggles or face shield or mask with visor attached) should be
worn during procedures with risk of splashing blood, body fluids,
respiratory secretions, or other secretions or excretions into the
face (e.g., suctioning).
 A mask should be used only once and changed when wet or
soiled.
 A gown should be worn to protect clothing during procedures
likely to generate splashes of blood, body fluids, secretions, or
excretions.
3. Policies regarding blood-borne pathogens
 Needles and other sharp instruments should be handled with care
during use and disposal.
 Puncture-proof, impermeable, approved sharps disposal
containers should be available at the point-of-use where injections
or venipunctures are performed.
 These containers should be kept out of the reach of young
children and should not be overfilled.
 Spills of blood or bloody body fluids should be contained
promptly and cleaned with detergent followed by bleach (a 1:10 to
1:100 dilution of household bleach, using the higher concentration
for larger spills).
 Gloves should be worn for cleaning blood spills.
 Mouthpieces, resuscitation bags or other ventilation devices
should be readily available in areas where the need to resuscitate
may be required.

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Infection control practices in different pediatric clinical settings

 Policies and protocols for managing injuries with used needles or

other sharp objects, and for other potential exposures to blood-
borne viruses, should be available and implemented.
4. Disinfection and sterilization
 Written policies and protocols for disinfection and, sterilization
should be in place and implemented.
 Disinfectants approved for health care should be used.
 Level of disinfection required for medical equipment:
 Items entering sterile body spaces (e.g., needles) should be
disposable or sterilized before reuse.
 Items in contact with mucous membranes or nonintact skin
(e.g., thermometers, suture cutters, vaginal speculums)
should be disposable or undergo high-level disinfection or
sterilization before reuse.
 Items in contact with intact skin only (e.g., stethoscopes,
otoscopes, blood pressure cuffs, infant scales, electronic
devices) should undergo low-level disinfection or cleaning
with detergent and water.
 Items contaminated with blood or body fluids should
undergo low-level disinfection.
o Optimally, these should be cleaned after each use. If
this is not feasible, clean daily, and immediately
when soiled.
o Clean the bell and diaphragm of stethoscopes, the
handle and body of otoscopes and ophthalmoscopes,
and reusable ear curettes, with alcohol or disinfectant
wipes or with soap and water. Disinfect when
contaminated with blood.
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o Items designed for single-patient use (e.g.,

glucometers) should not be used for more than one
patient.
 Clean equipment should be stored where it will not become
contaminated.
 Measures should be taken to avoid contaminating the bases of
electronic thermometers, pulse oxymetry and tympanometry
equipment, and other frequently handled devices, with body
fluids, excretions, or secretions. These should be cleaned daily
and when soiled.
 Frequently touched office items that are difficult to clean (e.g.,
pens, charts, computer keyboard and mouse, personal digital
assistant devices, and pagers) should always be considered
contaminated. Hand hygiene should always be performed
immediately before patient contact, because it is common to have
contact with these items right before examining a patient.
Computer mice and keyboards should be cleaned daily . Using
transparent covers on computer keyboards may facilitate cleaning.
5. Cleaning of surfaces
 Written policies and protocols for cleaning should be in place and
implemented.
 A low-level detergent-disinfectant approved for health care
settings or detergent should be used.
 The examining table should be covered with disposable paper or a
washable cloth that is changed between patients. Clean the table
between patients, if soiled. If soiled with body fluids or stool, clean
and disinfect with a 1:100 bleach solution.

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 Examination tables, treatment chairs, sinks and other frequently

touched surfaces (e.g., light switches, door knobs, and telephones)
should be cleaned daily.
 Washrooms should be cleaned daily and when soiled. Provide a
diaper-changing area with disposable paper covers, and a receptacle
for used diapers.
 Surfaces such as countertops, chairs, and floors are usually not an
infection risk and should be cleaned weekly or on a routine basis and
when soiled.
6. Cleaning of toys
 Optimally, toys used by infants and young children should be
cleaned between uses by different patients. If this is not possible,
they should be cleaned at the end of every day. Toys that come in
contact with body fluids (e.g., are mouthed) should be removed
from the area of use until they have been cleaned.
 Disinfect with 1:100 bleach solution, wash with soap and water,
and air dry. Alternatively, toys can be cleaned in a dishwasher
designed to sanitize dishes.
 Toys, puzzles, and computer games that are used by older children
should be cleaned or discarded when soiled. Frequently touched
surfaces (e.g., knobs, buttons, handles, and joy-sticks) should be
cleaned daily.
 Large toys that are built-in or considered part of the office
furniture and touched frequently should be cleaned daily and if
soiled.

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Infection control practices in different pediatric clinical settings

7. Aseptic technique and injection safety

 Aseptic technique should be maintained for immunization,
venipuncture, suturing, incision, or other invasive procedures and
for accessing or manipulation of intravascular catheters.
 Skin should be prepared with an antiseptic. The preferred agent
for venipuncture or immunization is 70% alcohol. For insertion of
intravascular catheters and other invasive procedures, and for
obtaining blood cultures, 2% chlorhexidine, chlorhexidine in 70%
alcohol, 10% povidone-iodine or an alcoholic tincture of iodine
should be used. Povidone-iodine should be left to dry for 2
minutes.
 Because antiseptics can be contaminated during use, single-use
products are preferable. When multiple-use containers are used,
label them with the date and discard after 28 days of use.
 Avoid multidose medication vials whenever possible, but if used:
1. Handle and store them with care to maintain sterility of
contents and comply with expiry dates.
2. Restrict their use to a centralized medication area.
 Reserve separate surfaces for assembling clean equipment (e.g.,
syringes, needles) or preparing medications, and for handling used
equipment.
 Equipment contaminated with blood or body fluids should be
handled with care to prevent transfer of organisms to patients and
surfaces.
 Physical barriers (e.g., disposable paper or plastic pads) should be
used to protect surfaces from blood contamination during blood
sampling.

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8. Respiratory Etiquette

Respiratory Etiquette refers to measures designed to minimize

transmission of respiratory pathogens via the droplet route in health care
settings. These measures include:

 Early identification of all persons (patients, parents, and others)

with febrile respiratory illness in outpatient areas.
 Posting signs at facility entrances and at the reception or
registration desks with instructions for patients and those
accompanying them to:
1. Inform the receptionist promptly if they have symptoms of
a respiratory infection.
2. Cover the mouth and nose with tissues while coughing or
sneezing or, if necessary, sneeze or cough into the elbow
rather than the hands.
3. Promptly dispose of used tissues in a no-touch receptacle.
4. Perform hand hygiene after contact with respiratory
secretions.
5. Use a surgical or procedure mask, if tolerated and if the
patient is old enough to wear one.
 Instructing family members with a febrile respiratory illness not to
accompany patients to the office unless it is unavoidable, in which
case they should take these same measures.
 Providing tissues, no-touch waste receptacles, masks and hand
hygiene products.
 Ensuring that supplies of soap and towels are available at every
sink.

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Infection control practices in different pediatric clinical settings

 Placing patients with a cough and those accompanying them at

least 1 m to 2 m away from others in common waiting areas, when
space permits.

Antibiotic-resistant organisms (AROs) in ambulatory care

1. Systems should be developed and implemented to readily identify

patients known to be colonized with AROs.
2. Routine Practices, especially hand hygiene, suffice to manage
most asymptomatic patients colonized with AROs.
3. The need for Contact Precautions should be assessed on a case-
by-case basis, considering the nature of the encounter (e.g.,
procedures to be performed) and the risk for environmental
contamination (e.g., active infection versus colonization,
uncontrolled respiratory secretions, stool incontinence, or
colonized ostomy sites).
4. Antibiotics should be used judiciously, to prevent or delay
emergence of antimicrobial resistance.

Precautions for novel pathogens

Newly identified pathogens, also called emerging pathogens, may have the
potential to impact public health significantly.

For SARS or MERS coronavirus, avian influenza or any new pandemic

influenza strain:

 Droplet Precautions (including eye protection) and Contact

Precautions are sufficient for routine care.
 Airborne Precautions are recommended when performing
aerosol-generating procedures (e.g., endotracheal suctioning,
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intubation, manual ventilation, high-flow oxygen or nebulizer

therapy, bronchoscopy). Such procedures are unlikely to be
performed in an office [Link] Ebola virus :
 Contact public health authorities immediately.
 Droplet Precautions (including eye protection) and Contact
Precautions are sufficient for low-risk patients (those with
early-stage disease or in convalescence, with no bleeding,
diarrhea, or vomiting).
1. For patients with more advanced disease (bleeding,
vomiting, or incontinence), more extensive protective
apparel must be used to cover all exposed skin.
Airborne Precautions are recommended when
performing aerosol-generating procedures. Patients
with suspected Ebola virus infections should not be
managed in an office setting.
2. Local, provincial/territorial or federal authorities
should be consulted. Recommendations may be
revised as more information becomes available.

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Infection control practices in different pediatric clinical settings

NICU Infection Control Measures

 The NICU is the Neonatal Intensive Care Unit

 Patients in the NICU are premature and their immune systems are
weak, requiring extra precautions
 NICU patients can get infections during the birth process but also
from the hospital itself
 Involves Neonatal - Perinatal Medicine, Infectious Diseases,
Neonatal Transport Program
Why is there a high risk of infection in the NICU?

 There are several reasons why babies in the neonatal intensive care
unit are at risk for infection. Many NICU newborns are premature
and, as a result, their immune systems are immature and weak. Those
babies are also typically in the hospital for prolonged periods of time.
As with any sustained hospitalization, necessary medical
interventions may carry a risk of infection.
Infections occur most often in the NICU
Bacterial infections are the most common NICU infections. They fall in
two main categories:
1. Infections that are acquired during the labor and birth process
2. Hospital-acquired infections that babies contract while they are
patients in the NICU.

How are infections treated in the NICU?

 While these infections are treated with antibiotics, the antibiotics

used can be different than they are for adults, due to the risk of
potential side effects with certain drugs when administered to
newborns.
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 Initial treatment courses are geared toward the bacteria that most
commonly cause infection in newborn babies, such as Group B
streptococcus (GBS), which are sometimes different from the types
of bacteria that cause infection in adults.
 Treatments can sometimes last for weeks, depending on the nature of
the infection and the severity of illness in the newborn.

NOTE: Once a newborn acquires an infection, there's a significant

risk of developing a lot of health problems, some of them serious and even
potentially fatal. Babies that survive infection also face an increased risk of
having problems when they get older, such as developmental and growth
delays and impairments.

INFECTION CONTROL MEASURES IN NICU

1. Gloves should be worn whenever coming into contact with any bodily
fluids (e.g. stool, urine or blood).
2. Handle soiled diapers as little as possible and discard these into the
trash receptacle as soon as possible.
3. If a soiled diaper is placed on top of the isolette, a barrier such as a
clean diaper, cloth or paper towel should be placed between the diaper
and the isolette to decrease environmental contamination.
4. If placed inside the isolette, the soiled diaper should be kept at the foot
of the bed, away from respiratory support equipment and umbilical or
intravenous access lines.
5. After discarding a soiled diaper, remove gloves and disinfect hands
with an alcohol-based waterless hand gel.
6. Re strain hair in a manner that prevents its coming in contact with the
infant.
7. Keep jewelry to a minimum when caring for an infant (e.g. remove
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Infection control practices in different pediatric clinical settings

watches and rings)

8. Do not eat, drink, or store food or drink within patient care areas in the
NICU or well newborn nurseries.
9. Provide a dedicated stethoscope f or each infant in the NICU and well
newborn nurseries on infection control precautions.
[Link] these dedicated stethoscopes at the start of each shift and after
patient discharge with germicidal or alcohol wipes. After contact with
infants in the well newborn nurseries who are not on isolation
precautions, disinfect stethoscopes with germicidal or alcohol wipes
between each patient examined.
[Link] of sharps and needles according to hospital policy after use.
12. Do not reuse sharps and needles.
[Link] of single use items according to hospital policy after use. Do
not reuse.
[Link] medical waste, including items contaminated with blood or bodily
fluids, in appropriate containers (refer to the BWH Exposure Control
Planand BWH Safe Work Practices).
15. Place used linen in plastic linen bags and process according to hospital
policy.
[Link] instructions for cleaning and changing of respiratory
equipment can be found in Neonatal Respiratory manual for policies
and procedures (Newborn Respiratory Care Policy and Procedure
Manual).

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Infection control practices in different pediatric clinical settings

ENVIRONMENT
1. Environmental Services clean all sinks and floors with an
approved hospital disinfectant on a daily basis.
2. Counters and other surfaces are cleaned daily and on an as
needed basis.
3. Clean small blood/body fluid spills using the approved
hospital disinfectant.
4. Prior to discharge, clean beds every two weeks and clean
isolettes weekly unless this negatively impacts the infant’s
medical condition.
5. Clean infant isolettes and cribs upon discharge.
6. Clean scales with hospital approved disinfectant wipes after
each use and cover for storage.
7. Change and disinfect Humidity chambers that are in use
weekly with germicidal wipes and dry these in the drying
cabinet.
8. Clean all unit-based equipment (e.g. bedside tables, bilirubin
blankets, and monitors) between each patient use prior to the
start of a shift or as needed with an approved hospital
disinfectant.

PERSONNEL

1. Employees will abide by established Occupational Health Services

Guidelines:
a) Prior to employment, employees must be immune to measles,
mumps and rubella.

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Infection control practices in different pediatric clinical settings

b) At time of employment, employees are screened for varicella

zoster and TB.
c) Employees who are not immune to varicella zoster are offered
the varicella vaccine at no cost.
d) The Influenza vaccine is offered annually.
e) TB skin testing is performed annually through Occupational
Health or by unit based peer to peer TB resource nurses.
f) Employees who have been exposed to a communicable
disease (e.g., whooping cough, chickenpox) should be cleared
by OHS before reporting to work.
g) Employees with symptoms consistent with a potentially
transmissible infection, (e.g. gastrointestinal illness or upper
respiratory symptoms with fever (100.4 or greater)) should
stay home and contact OHS for guidance on when they may
return to work.

2. Occupational exposures to blood or other bodily fluids via puncture or

splash to mucous membranes or non-intact skin must be immediately
washed.
3. Employees, who are not seropositive for Hepatitis B antibody are
strongly encouraged to receive the Hepatitis B vaccine which is offered
to employees at no cost.
4. All staff caring for newborns at BWH are encouraged to receive
anannual influenza vaccine and Tdap vaccine/booster if needed.
5. New nursing personnel must receive an in-service to the Newborn
Infection Prevention and Control guidelines at the time of employment.
6. Employees must complete required Infection Control training on Health
stream. Additional in-services are provided as needed.

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PICU Infection Control Measures

General principles on PICU.

1. Each bed space is denoted by its own floor lines and has
coloured plastic aprons (varying colour to next bed space).
2. Each bed space has its own sink for hand washing and personal
protective equipment available at that space.
3. No equipment should be borrowed from another bed space
without the usual cleaning requirement being adhered to.
4. Hand gel is provided at both sides of each bedspace for ease of
hand decontamination in most circumstances.
5. On entering the area around each bed space this should be
considered a room and therefore aprons and other personal
protective equipment (PPE) eg gloves, goggles, removed and hands
decontaminated before leaving the area. The ONLY exception to
this rule is when transferring bodily fluids or waste water to the
sluice, when all PPE is removed in the sluice and hands
decontaminated before leaving the sluice.
6. Any MDT “multidisciplinary team” staff attending patients must
be “bare below the elbow” adhering to dress code including
jewellery, hair, decontaminate hands according to Trust policy and
wear aprons before approaching the patient. All other PPE (gloves
masks goggles) must be worn according to trust policy. This
includes the use of goggles for any aerosol inducing procedures eg
suctioning, accessing arterial lines, central and peripheral lines,
removal of lines etc.
7. Visitors to bed spaces should be restricted to 2 at any one time

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Infection control practices in different pediatric clinical settings

(unless special circumstances which should be discussed with

Nurse in charge/ Sisters/ Charge Nurse/ Matron /PICU
Consultant on for day).
8. Patients with larger extended family should be asked to
streamline visiting to support this and ask for single point of
contact for telephone enquiries within their extended family
outside of the hospital.
9. Parents and visitors should be asked to wear aprons and
decontaminate their hands before when entering and leaving the bed
areas. They should wear aprons if carrying out cares. Parents and
relatives of other patients on the ward should be discouraged from
visiting at other patients’ bed areas.
[Link], visitors and staff attending any patient presenting with
diarrhea must use soap and water for hand hygiene as the gel is
less effective for some of the diarrheal infections (see hand
hygiene policy).

Blood gases and PPE

1. After removing PPE and carrying out hand decontamination at the
bedside, the sample (syringe or capillary tube) should be carried
on a cardboard tray to the blood gas room.
2. New gloves should be worn whilst processing sample and
removed once procedure complete.
3. Hand hygiene should be carried out as per trust policy before and
after procedures.

Single Rooms
1. Whenever possible, patients with infections should be moved to

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Infection control practices in different pediatric clinical settings

either a side-room or cohorted in an adjoining area.

2. If patients have to remain on an open ward area this decision
should be made in discussion with the Infection Control Team
where possible. There is a microbiology consultant on call for
support if required.
3. If no single rooms are available discuss new referrals to PICU
requiring isolation with the PICU Consultant for the day.
Medication considerations
1. Drawing up drugs at bed spaces.
2. Trollies must be sprayed with hard surface spray (70% alcohol
spray) and wiped in an even motion from one side to the other to
prepare clean surface.
3. This should also be carried out with blue/ white trays before
preparing drugs. Blue/ white trays should be used to carry drugs to
the patients’ bedside for administration. NB. A patient’s drugs
must not be prepared outside the bed area they are occupying.

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References
American Academy of Pediatrics. Recommendations for care of children
in special circumstances: Infection control and prevention in
ambulatory settings. In: Kimberlin DW, Brady MT, Jackson MA,
Long SS, eds. Red Book: 2018 Report of the Committee on
Infectious Diseases, 31st edn. Itasca, IL: American Academy of
Pediatrics;2018:163–165.

American Academy of Pediatrics. Tuberculosis. In: Kimberlin DW,

Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of
the Committee on Infectious Diseases, 31st edn. Itasca, IL:
American Academy of Pediatrics;2018:829–851.

Canadian Paediatric Society. Caring for Kids. Avoiding Infection: What

to do at the Doctor’s Office.
[Link]/handouts/avoiding_infection_at_the_
doctors_office(Accessed Marsh 17, 2022).

Centers for Disease Control and Prevention. Cover Your Cough.

[Link] gov/flu/protect/[Link] (Accessed Marsh
17, 2022).

Centers for Disease Control and Prevention. Interim Guidance for

Infection Control within Healthcare Settings When Caring for
Confirmed Cases, Probable Cases, and Cases Under Investigation
for Infection with Novel Influenza A Viruses Associated with
Severe Disease. Last updated January 26, 2016:
[Link]
(Accessed Marsh 17, 2022).

Houghton, C., Meskell, P., Delaney, H., Smalle, M., Glenton, C., Booth,
A., ... & Biesty, L. M. (2020). Barriers and facilitators to
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healthcare workers’ adherence with infection prevention and

control (IPC) guidelines for respiratory infectious diseases: a rapid
qualitative evidence synthesis. Cochrane Database of Systematic
Reviews, (4).

Munoz-Price, L. S., Bowdle, A., Johnston, B. L., Bearman, G., Camins,

B. C., Dellinger, E. P., ... & Birnbach, D. J. (2019). Infection
prevention in the operating room anesthesia work area. Infection
Control & Hospital Epidemiology, 40(1), 1-17.

Public Health Agency of Canada. Annex F. Prevention and Control of

Influenza During a Pandemic for All Healthcare Settings. 2011:1–
108.
[Link]
aspc/cpip-pclcpi/assets/pdf/[Link] (Accessed Marsh 17,
2022).

Public Health Agency of Canada. Chapter 15: Canadian Tuberculosis

Standards, 7th Edition: 2014 – Prevention and Control of
Tuberculosis Transmission in Health Care and Other Settings. 1–
47. [Link]
diseases/canadian-tuberculosis-standards-7th-edition/edition-
[Link] (Accessed Marsh 17, 2022).

Public Health Agency of Canada. Hand Hygiene Practices in Healthcare

Settings. 2012.
[Link]
(Accessed Marsh 17, 2022).

Public Health Agency of Canada. Infection control guidelines: Prevention

and control of occupational infections in health care. Canada
Communicable Disease Report 2002;28 (S1):1–264.
88
Infection control practices in different pediatric clinical settings

[Link]
(Accessed Marsh 17, 2022).

Public Health Ontario. Provincial Infectious Diseases Advisory

Committee (PIDAC). Infection Prevention and Control for
Clinical Office Practice, revised April 2015.
[Link]
Office_Practice_2013.pdf (Accessed May Marsh 17, 2022).

Rathore MH, Jackson MA; AAP Committee on Infectious Diseases.

Infection prevention and control in pediatric ambulatory settings.
Pediatrics 2017;140(5):e20172857.

Schwierzeck, V., König, J. C., Kühn, J., Mellmann, A., Correa-

Martínez, C. L., Omran, H., ... & Kampmeier, S. (2021). First
reported nosocomial outbreak of severe acute respiratory syndrome
coronavirus 2 in a pediatric dialysis unit. Clinical Infectious
Diseases, 72(2), 265-270.

Sehulster LM, Chinn RY, Arduino MJ, et al. Guidelines for

Environmental Infection Control in Health-Care Facilities.
Recommendations from CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC). 2004 (last updated
February 15, 2017).
[Link]
-[Link] (Accessed Marsh 17, 2022).

Seigel JD, Rhinehart E, Jackson M, Chiarello L; the Healthcare

Infection Control Practices Advisory Committee. Guideline for
Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. [Link]

89
Infection control practices in different pediatric clinical settings

infectioncontrol/pdf/guidelines/[Link] (Accessed
Marsh 17, 2022).

90
Infection control practices in different pediatric clinical settings

36