Special Populations

Learning objectives

1. Identify special populations and their specific features

2. Describe specific risk factors of each special population that make it vulnerable to healthcare-associated infections

3. For any special population, outline additional methods for the prevention of healthcare-associated infections

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Time involved

• 60 minutes

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Special populations

• Geriatrics• Paediatrics• Burns• Behavioural health• Ambulatory/Community care• Immunocompromised populations• Endoscopy

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Basic Infection Prevention and Control (IP&C) Strategies

• Hand hygiene• Standard precautions/routine

practices• Isolation/precautions• Staff education• Aseptic techniques• Vaccination

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Geriatrics - 1

• Susceptibility of the elderly to infection is a result of • underlying illness• multiple medications• alterations in immune function

• Residents of nursing homes or long-term care facilities are particularly at risk

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Geriatrics - 2• Most frequent problems

• Respiratory tract infections• Urinary tract infections• Gastrointestinal infections• Skin and soft tissue infections

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Geriatrics – Respiratory Risk Factors• Swallowing disorders or poor gag reflex

with aspiration• Impaired mucociliary clearance• Increased esophageal reflux• Immobility• Dehydration

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Geriatrics – Skin Risk Factors

• Chronic oedema• Venous insufficiency• Unrecognised trauma• Diabetes mellitus• Dry skin

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Geriatrics – Diarrhoea Risk Factors• A significant cause of morbidity,

particularly in institutionalised older persons.

• Pathogens may be spread by ingestion of microorganisms or toxins from 1. an infected person2. contaminated food or water3. contaminated objects in the

environment, or 4. infected animals

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Preventing infectionsInfection Prevention

Urinary tract infection Adequate hydrationGood personal hygieneMobilisationAvoid bladder catheters

Bronchitis and pneumonia Vaccination Cohorting patients with respiratory illnessLimiting group activities and communal dining during influenza outbreaksMobilisationAdequate hydration

Pressure ulcers Mobilisation Keeping the patient dry Providing nutritional support Using antipressure devices

Diarrhoeal illnesses Early implementation of cohorting or room closure Reinforcement of environmental disinfection Hand hygieneIsolation precautions

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Paediatrics

• Youth and immature immune systems make children more susceptible to infections

• Close contact with patients, siblings and family, uncontrolled body fluids, and play areas create unique opportunities for the spread of infection

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Paediatrics - Risks

• Children at higher risk for infections• those in intensive care• patients with cancer• solid organ transplant and haematopoietic cell

transplantation recipients• neonates

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Paediatrics – PreventionInfection/Risks Prevention

Communicable diseases Vaccinate according to national guidelines

Breast milk and infant formula Mothers should be instructed on hygienic methods

Proper cleaning and disinfection of breast pumps

Toys Frequent cleaning of toys and environment

Avoid high-risk toys, such as soft/stuffed toys, that are difficult to clean and dry

Viral respiratory and gastrointestinal illnesses

Patients should be screened; isolation/precautions initiated

while awaiting a diagnosis.

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Burns

• Have a major impact on cellular and humeral immune systems; predispose patients to infection

• Burn causes mechanical disruption of the skin; allows skin and environmental microbes to invade deeper tissues

• As burn size increases, the risk of infection increases

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Burns – Prevention- 1

• Strict aseptic technique• Use of sterile gloves and dressing materials• Wearing masks for dressing changes• Spatial separation of patients, either using

single rooms or cubicles

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Burns – Prevention - 2

• Hand hygiene before and after patient contact• Standard precautions/routine practices• Protective apparel (aprons, gowns) before each

patient contact• Changing gloves when soiled and before

continuing with care at another site on the same patient

• Cleaning and disinfection of reusable equipment before use on another patient

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Burns – Prevention - 3

• Restrict plants and flowers at the bedside• Restrict non-washable toys (stuffed animals,

cloth objects) for paediatric burn patients• Place catheters through unburned skin or

frequent change of the catheter to decrease risk of infection

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Burns – Prevention - 4

• Isolate patients colonised with multiply resistant microorganisms in single rooms or cubicles

• Hydrotherapy • used routinely in some facilities; has

been associated with outbreaks• Some prefer to use local wound care

with sterile saline solution instead • If hydrotherapy used, shower tables are

less risky than immersion• Rinse the tanks or equipment with

sodium hypochlorite after each use

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Behavioural Health

• Behavioural health care provides prevention, intervention and treatment services in these areas• Mental health, • Substance abuse • Development disabilities • Sexualities

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Behavioural Health - Prevention - 1• Practice standard precautions/routine

practices• Staff working with children vaccinated for

typical childhood illnesses• Inpatient influenza and pneumococcal

immunisation program for adults; children up-to-date on immunisations

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Behavioural Health - Prevention - 2• Prevent mixing of patient clothing; special

consideration for clothing of patients with incontinence, wound infections, or lesions, and suspected or confirmed cases of scabies or lice

• Provide patients with a caddy or basket to keep personal toiletry items if they share a bathroom

• Disposable paper mats for individual shower use; protect from transmission of athlete’s foot (Tinea pedis)

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Behavioural Health - Prevention - 3Lice and scabies procedures

• Identification of illness• Monitoring for transmission• Treatment (includes staff monitoring of the application

of treatment) and follow-up• Housekeeping procedures

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Behavioural Health - Prevention - 4• Provide disposable razors for shaving;

discard after use in an appropriate sharps container• If electric shavers provided, have a protocol for

cleaning and disinfecting the shaver after use

• For electroconvulsive therapy• Hand hygiene• Use of gloves• Cleaning and disinfection of equipment• Bite blocks and laryngoscope blades require

high-level disinfection

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Ambulatory/Community Care

• Provision of health care to patients who do not remain overnight• Physician’s surgeries• Clinics • Dental surgeries• Diagnostic treatment centres• Physical and occupational therapy centres

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Ambulatory/Community Care

• Overall risk of HAIs lower in ambulatory/community settings than in hospitals

• Visits are brief, environmental contamination lower, less invasive procedures performed, and population healthier

• Risks: waiting areas, procedures

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Ambulatory/Community Care Infection/Risks Prevention

Respiratory illness Respiratory hygiene / respiratory etiquette

Communicable diseases (tuberculosis, chickenpox, measles, mumps, rubella, bacterial meningitis)

Wear a surgical mask and place in a separate room with the door closed

Toys Limit sharingEasily cleanable

Instruments Clean, disinfect/sterilise properly; use of safer devices to reduce the risk of needle-stick injuries

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Immunocompromised Populations - 1Severe neutropenia of treatment regimens and certain underlying diseases, and invasive devices and procedures, result in a high frequency of infection in these patients

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Immunocompromised Populations - 2

Four broad categories of risk factors: 1. Neutropenia (granulocytopenia)2. Immune system defects3. Destruction of protective barriers, e.g., skin

and mucous membranes4. Environmental contamination/alteration of

microbial flora

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Immunocompromised Populations - Risks

• Ventilation• Construction/renovation• Equipment• Plants• Play areas and toys• Health-care workers• Visitors• Skin and oral care

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Immunocompromised Populations – Prevention - 1 Patient-focused

• Good oral and dental hygiene important• oral cavity a reservoir for microorganisms • severe mucositis predisposes the spread of

microorganisms into the bloodstream

• Patients and family members, as well as healthcare workers, should be taught the importance of hand hygiene

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Immunocompromised Populations – Prevention - 2Staff-visitor-focused

• Screening programs for communicable infections, especially during the appropriate “seasons” for certain illnesses

• Restrict from direct patient care activities all healthcare workers with communicable infections

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Immunocompromised Populations – Prevention - 3• Environment-focused

• Isolation/precautions techniques are debateable; there are insufficient data to recommend the use of additional protective precautions

• Prevent dust accumulation with daily cleaning of frequently touched horizontal surfaces

• Avoid cleaning methods that generate dust

• Close doors to patient rooms while any vacuuming takes place nearby

• Exclude plants and flowers • Clean toys regularly and when visibly soiled or mouthed

• Avoid toys that cannot be washed or disinfected after use

• Immunocompromised patients should avoid construction or renovation areas

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Endoscopy

• Risks due to the complexity of the instruments

• Microorganisms contaminating the equipment might be introduced into the patient, or patient’s own microorganisms may be spread by the endoscope (rare)

• Outbreaks have been caused by • inadequate cleaning/disinfection of endoscopes or

accessories between patients• contaminated water rinses or contaminated

automatic endoscope reprocessors

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Endoscopes• Internal channels for air, water, aspiration,

and accessories exposed to body fluids and other contaminants

• Cleaning is critical • Six steps for re-processing:

• Cleaning• Rinsing• Disinfection• Rinsing• Drying• Storage

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Endoscopy Protocols - 1• Set-up

• Endoscopic procedure room designated as clean areas• Separate contaminated areas where accessories and

specimens are handled from clean counter areas

• Cleaning• Manual cleaning important; include brushing, using a medical

grade, low-foaming, and neutral pH detergent • Use automatic disinfection, rinsing, and drying of all exposed

surfaces of the endoscope, when available. Water for automatic endoscope reprocessors should be free from particles and microorganisms.

• Isopropyl alcohol for flushing endoscope channels as part of the drying process

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Endoscopy Protocols - 2

• Use single-use accessories when possible • Discard rubber valves covering the working

channel after procedures involving the passage of biopsy forceps, guidewires, and/or other accessories

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Key Points

• Basic infection prevention strategies apply, regardless of patient type or setting

• Additional strategies may be required for special populations

• Strategies designed for hospitals may need adapting for other health care settings

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Additional Reading - 11. Geriatrics: SHEA/APIC Guideline: Infection prevention

and control in the long-term care facility, 2008. http://www.apic.org/Content/NavigationMenu/PracticeGuidance/APIC-SHEA_Guideline.pdf

2. Endoscopes: Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011. http://www.asge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/Multisociety%20guideline%20on%20reprocessing%20flexible%20gastrointestinal.pdf and WGO-OMGE and OMED Practice Guideline: Endoscope Disinfection, 2005. http://www.omed.org/downloads/pdf/guidelines/wgo_omed_endoscope_disinfection.pdf

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Additional Reading - 2

1. Burns: European Practice Guidelines for Burn Care, 2002. http://www.euroburn.org/e107_files/downloads/guidelinesburncare.pdf

2. Ambulatory care: Infection Control Manual for Ambulatory Care Clinics, Texas Department of State Health Services, 2009. http://www.dshs.state.tx.us/idcu/health/infection_control/manual/InfectionControlManual.pdf

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Additional Reading - 3

1. Immunocompromised: Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective. Biol Blood Marrow Transplant 15: 1143-1238 (2009). http://www.shea-online.org/Assets/files/guidelines/2009_HSCT_Guideline.pdf

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Quiz1. Mobilisation of older patient is important measure in

prevention of urinary tract and respiratory tract infections and pressure ulcers. T/F

2. Specific measures for prevention of burn wound infections include:

a) Hand hygiene before and after patient contactb) Frequent change of vascular catheters in some circumstancesc) Disinfection of hydrotherapy tanks with sodium hypochlorite

solutiond) All of the above

3. Destruction of protective skin barriers is a risk factor for highly immunocompromised patients. T/F

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International Federation of Infection Control• IFIC’s mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .

• The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.

• For more information go to http://theific.org/

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