Review
Infection control in paediatrics

https://doi.org/10.1016/S1473-3099(07)70310-9Get rights and content

Summary

Infection control has a particularly important role in paediatric hospitals and must take into account the specificity of the needs and environment of the paediatric patient. Children are susceptible to infections that are prevented in older patients by vaccination or previous natural exposure. Consequently, the nosocomial pathogens and most common health-care-associated infection sites in children differ from those observed among adults. The immunological naivety of young children, especially neonates, translates into an enhanced susceptibility to many infections with important health consequences as well as higher rates and longer duration of microorganism shedding. In particular, respiratory virus infections, rotavirus, varicella zoster virus, and pertussis represent persistent challenges in children's hospitals. Specific factors such as the use of breastmilk, toys, or therapy animals are associated with an increased risk for health-care-associated infections. We review the emergence of antimicrobial-resistant organisms and strategies to prevent health-care-associated infections in the paediatric setting.

Introduction

The history of infection control is closely linked to the paediatric population. Ignácz Semmelweis not only made the association between hand hygiene and puerperal fever in women, but also noted its relation with perinatal infection rates.1 In response to the high incidence of infectious diseases on paediatric wards over the past century, several infection control measures have been implemented and tested in child-care settings before application to adult environments.2 In both adults and children, certain patients are particularly at risk of health-care-associated infections (HAI); among these are neutropenic patients and those in intensive care with indwelling devices. Other risk factors for HAI, such as close physical contact with health-care workers or stay in environments where antibiotic-resistant organisms are endemic, are common to adult and paediatric patients. Because of young age and the immaturity of their immune systems (figure 1), children are susceptible to infections that are prevented in older patients through vaccination or a more robust, innate immune response. Therefore, the nosocomial pathogens and most common HAI sites in children differ from those reported among adults. Children have fewer chronic or degenerative organ system disorders than adults,3 but present more often with congenital or acquired immune deficiencies as well as congenital syndromes. Close physical contact between children in communal rooms or play areas, between children and visitors such as parents and siblings, and uncontrolled fluids and bodily secretions also provide ample opportunities for infection spread.

Specific aspects of children's hospitals, such as shared rooms in general paediatric intensive care units (PICUs) instead of separate medical and surgical ICUs as for adults, toy-sharing, pet-visiting, and partial ambulatory care, also contribute to nosocomial infection risk.4 Infection control has a particularly important role in paediatric hospitals and is not a simple transposition of adult recommendations; it must take into account the specificity of the paediatric patients' needs and environment. This Review addresses issues that characterise infection control in paediatrics with a particular focus on some important differences with adults.

Section snippets

Epidemiology

Surveillance for HAI in paediatric populations usually depends on institutional or public-health requirements and commitment, and the available resources. Several studies have shown the benefit of surveillance through early detection and intervention during outbreaks, and also identification of centre-specific risk factors for HAI. Most paediatric institutions in developed countries use the US Centers for Disease Control and Prevention (CDC) definitions for nosocomial infections.5 These are

Different pathogens, different infections

HAIs among children differ from those seen among adults in several respects. Site and pathogen distribution vary according to age-group and setting (figure 2 and figure 3). Of note, the type of predominant pathogen in the neonatal setting has changed over time. Gram-negative organisms are major contributors to HAI in developing countries (figure 4).24, 35, 41, 48 By contrast, particularly in neonates,3, 49 the proportion of infections caused by coagulase-negative staphylococci has increased

Risk factors for infection

Paediatric and adult patients share common risk factors for HAIs, including exposure to intravascular devices, hyperalimentation, mechanical ventilation, and comorbidities, such as immune-compromising conditions. There are, however, additional risk factors inherent to children. When children, especially the young, encounter common pathogens such as respiratory syncytial virus (RSV) and rotavirus, it is often their first encounter. This immunological naivety not only affects the likelihood of

Effect of infection on length of stay, morbidity, and mortality

As in adult medicine, the cost and impact of paediatric HAI depends largely on the type of infection and the patient's underlying condition. In general, bloodstream infection carries the highest morbidity and mortality and neonates are the age-group at highest risk for poor outcome (table 2). For example, whereas bloodstream infection has an estimated attributable mortality of 3% in paediatric patients,17 the estimate is 11% among neonates with very low birthweight: crude mortality was 18% in

Special microorganisms

Certain organisms have a special role in paediatric infection control, either because they induce more pronounced disease in children or because of issues around acquisition and transmission. For example, children are often admitted to hospital with infections causing community epidemics such as respiratory and gastrointestinal viral infections.70 As a result, the hospitalised child serves as a potential source for the nosocomial transmission of typically community-associated pathogens in the

Specific subpopulations

Several issues related mainly to maturation of the immune system and normal child development are very relevant to paediatric infection control. The immunological naivety of children translates into an enhanced susceptibility to many infections with important health consequences as well as higher rates and longer duration of microorganism shedding. Child development requires close contact with care-givers, including parents and health-care workers, as well as other family members, particularly

Environment

As previously discussed, the developmental status of the paediatric patient has a crucial role in HAI acquisition risk. As part of normal development, children interact closely with their environment and this poses unique risks for infection. For instance, chewing can present a risk when practised by the babies on dialysis catheters.99 Some specific paediatric environmental concerns are addressed below.

Antimicrobial drug resistance in paediatrics

The emergence and dissemination of antimicrobial-resistant organisms is a crucial concern in paediatrics and is closely related to the use of antimicrobial agents, as in the adult setting.114, 115 The Intensive Care Antimicrobial Resistance Epidemiology project and the NNIS data that report on the use of these agents in participating adult and paediatric ICUs in the USA have shown that third-generation cephalosporins are by far the most commonly used antimicrobials, followed by parenteral

Hand hygiene

Hand hygiene is considered the simplest and most effective measure to prevent cross-transmission of microorganisms and HAI.46, 137 Many reports have documented the transmission of viruses or bacteria in paediatric hospitals by health-care workers.138 Unfortunately, professionals appear to have difficulties in performing hand hygiene procedures and compliance below 50% has been repeatedly reported.139 Non-compliance with hand hygiene practices and the effect of promotional programmes have often

Conclusion

Infection control has a particularly important role in paediatric hospitals and there is a pressing need to develop guidelines and preventive measures targeted specifically at the paediatric setting. Paradoxically, the challenges for the future are linked to the evolution of modern medicine. Over the past decade, the development of sophisticated life-support technology has resulted in a substantial increase of extremely low birthweight premature infants at high risk for nosocomial infection and

Search strategy and selection criteria

Data for this Review were identified by searches of PubMed, Medline, the authors' own databases, and references from relevant articles using the search terms “infection control”, “p(a)ediatric”, “cross infection”, or “nosocomial infection”, and the following: “neonate”, “children”, “drug resistance”, “drug therapy”, “varicella zoster virus”, “tuberculosis”, “pertussis”, “influenza virus”, “respiratory syncytial virus”, “parainfluenza”, “adenovirus”, “rotavirus”, “hand hygiene”,

References (165)

  • BH Stover et al.

    Nosocomial infection rates in US children's hospitals' neonatal and pediatric intensive care units

    Am J Infect Control

    (2001)
  • JM Lopes et al.

    Prospective surveillance applying the national nosocomial infection surveillance methods in a Brazilian pediatric public hospital

    Am J Infect Control

    (2002)
  • DO Duerink et al.

    Surveillance of healthcare-associated infections in Indonesian hospitals

    J Hosp Infect

    (2006)
  • TF Leung et al.

    Infection control for SARS in a tertiary paediatric centre in Hong Kong

    J Hosp Infect

    (2004)
  • M Giles et al.

    What is the best screening method to detect Serratia marcescens colonization during an outbreak in a neonatal intensive care nursery?

    J Hosp Infect

    (2006)
  • P Gianino et al.

    Incidence of nosocomial rotavirus infections, symptomatic and asymptomatic, in breast-fed and non-breast-fed infants

    J Hosp Infect

    (2002)
  • AK Zaidi et al.

    Hospital-acquired neonatal infections in developing countries

    Lancet

    (2005)
  • P Travis et al.

    Overcoming health-systems constraints to achieve the Millennium Development Goals

    Lancet

    (2004)
  • D Pittet et al.

    Clean Care is Safer Care: a worldwide priority

    Lancet

    (2005)
  • F Barchiesi et al.

    Outbreak of fungemia due to Candida parapsilosis in a pediatric oncology unit

    Diagn Microbiol Infect Dis

    (2004)
  • G Kovacicova et al.

    Nosocomial fungemia due to amphotericin B-resistant Candida spp in three pediatric patients after previous neurosurgery for brain tumors

    J Infect Chemother

    (2001)
  • DB Lewis et al.

    Developmental immunology and role of host defenses in fetal and neonatal susceptibility to infection

  • LM Mahieu et al.

    Additional hospital stay and charges due to hospital-acquired infections in a neonatal intensive care unit

    J Hosp Infect

    (2001)
  • LA Grohskopf et al.

    A national point-prevalence survey of pediatric intensive care unit-acquired infections in the United States

    J Pediatr

    (2002)
  • A Onen et al.

    Epidemiology and control of nosocomial infections in paediatric surgery

    J Hosp Infect

    (2002)
  • P Le Roux et al.

    Nosocomial viral infections in a pediatric service: example of rotaviral gastroenteritis and respiratory syncytial viral bronchiolitis

    Arch Pediatr

    (2004)
  • HC Maltezou et al.

    Nosocomial influenza in children

    J Hosp Infect

    (2003)
  • H Faden et al.

    Outbreak of adenovirus type 30 in a neonatal intensive care unit

    J Pediatr

    (2005)
  • M Lanari et al.

    High risk of nosocomial-acquired RSV infection in children with congenital heart disease

    J Pediatr

    (2004)
  • GL Barnes et al.

    Excretion of serotype G1 rotavirus strains by asymptomatic staff: a possible source of nosocomial infection

    J Pediatr

    (2003)
  • E Piednoir et al.

    Economic impact of healthcare-associated rotavirus infection in a paediatric hospital

    J Hosp Infect

    (2003)
  • JM Langley et al.

    Variation in risk for nosocomial chickenpox after inadvertent exposure

    J Hosp Infect

    (2000)
  • AH Sohn et al.

    Prevalence of nosocomial infections in neonatal intensive care unit patients: results from the first national point-prevalence survey

    J Pediatr

    (2001)
  • CC Carlos et al.

    Nosocomial Staphylococcus epidermidis septicaemia among very low birth weight neonates in an intensive care unit

    J Hosp Infect

    (1991)
  • MP Venkatesh et al.

    Coagulase-negative staphylococcal infections in the neonate and child: an update

    Semin Pediatr Infect Dis

    (2006)
  • I Semmelweis

    The etiology, concept and prophylaxis of childbed fever

    (1983)
  • MJ Richards et al.

    Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System

    Crit Care Med

    (1999)
  • DH Winterberg et al.

    A boy with nosocomial malaria tropica contracted in a Dutch hospital

    Pediatr Infect Dis J

    (2005)
  • JS Garner

    Guideline for isolation precautions in hospitals. Part I. Evolution of isolation practices, Hospital Infection Control Practices Advisory Committee

    Am J Infect Control

    (1996)
  • TC Horan et al.

    Surveillance of nosocomial infections

  • TG Emori et al.

    Accuracy of reporting nosocomial infections in intensive-care-unit patients to the National Nosocomial Infections Surveillance System: a pilot study

    Infect Control Hosp Epidemiol

    (1998)
  • GJ Parry et al.

    Relationship between probable nosocomial bacteraemia and organisational and structural factors in UK neonatal intensive care units

    Qual Saf Health Care

    (2005)
  • P Gastmeier et al.

    Surveillance of nosocomial infections in intensive care units. Current data and interpretations

    Wien Klin Wochenschr

    (2003)
  • JW Gray

    A 7-year study of bloodstream infections in an English children's hospital

    Eur J Pediatr

    (2004)
  • K Muhlemann et al.

    Prevalence of nosocomial infections in Swiss children's hospitals

    Infect Control Hosp Epidemiol

    (2004)
  • M Urrea et al.

    Incidence study of nosocomial infection in pediatric trauma patients

    J Pediatr Orthop B

    (2005)
  • M Urrea et al.

    Prospective incidence study of nosocomial infections in a pediatric intensive care unit

    Pediatr Infect Dis J

    (2003)
  • A Simon et al.

    Surveillance for nosocomial and central line-related infections among pediatric hematology-oncology patients

    Infect Control Hosp Epidemiol

    (2000)
  • M Almuneef et al.

    Ventilator-associated pneumonia in a pediatric intensive care unit in Saudi Arabia: a 30-month prospective surveillance

    Infect Control Hosp Epidemiol

    (2004)
  • M Frank et al.

    Nosocomial bloodstream infections in children and adolescents in southern Israel: a 10-year prospective study (1992–2001)

    Scand J Infect Dis

    (2005)
  • Cited by (83)

    • Surface sampling within a pediatric ward—how multiple factors affect cleaning efficacy

      2020, American Journal of Infection Control
      Citation Excerpt :

      A wide diversity of contaminants have been isolated from public areas in other studies within the clinical environment.21-23 Within the pediatric environment, patient interaction is more likely to occur within communal areas due to the nature of the patient subset and unique surface interactions, such as sitting and playing on the floor and interacting with toys and other sensory objects.16 Our data indicate that surfaces having the greatest interaction with patients and their parents or guardians were the most contaminated following cleaning (Fig 1c).

    • Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European Centre for Disease Prevention and Control point-prevalence survey

      2017, The Lancet Infectious Diseases
      Citation Excerpt :

      Our results show that the burden of health-care-associated infections in childhood is highest in the first year of life and demonstrate the importance of bloodstream infections as the most common type of infections in children. Lower respiratory tract infections and surgical-site infections were more frequent in older age groups and the distribution of infections in children aged 5 years or older was close to the distribution of health-care-associated infections in adults.1,3,9,10 These findings suggest that age-adapted strategies are needed for infection prevention and control in paediatric settings, with focus on the prevention of bloodstream infections.

    • Probiotics Use in Infectious Disease (Respiratory, Diarrhea, and Antibiotic-Associated Diarrhea)

      2017, The Microbiota in Gastrointestinal Pathophysiology: Implications for Human Health, Prebiotics, Probiotics, and Dysbiosis
    View all citing articles on Scopus
    View full text