|Year : 2018 | Volume
| Issue : 6 | Page : 60-63
PICU quiz -HAI
Chief, Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra, India
|Date of Submission||21-Nov-2018|
|Date of Acceptance||08-Dec-2018|
|Date of Web Publication||31-Dec-2018|
Chief, Advanced Pediatric Critical Care Centre & Head, Dept of Pediatrics, Wanless Hospital, Miraj, 416101, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Patki V. PICU quiz -HAI. J Pediatr Crit Care 2018;5:60-3
Q.1 The institution of policies to reduce hospital-acquired infection has been least effective in preventing which of the following in children?
- Catheter-associated urinary tract infection (CA-UTI)
- Central line–associated bloodstream infection (CLA-BSI)
- Ventilator-associated pneumonia (VAP)
- Ventriculostomy-related infections
Q.2 Wearing a mask is extremely important in the prevention of which of the following diseases?
- Clostridium difficile-associated diarrhea
- Methicillin-resistant Staphylococcus aureus
- Neisseria More Details meningitides after 24 hours of antibiotics
- Respiratory syncytial virus
Q.3 A 4-year-old child requires placement of a short-term central venous catheter (CVC). To assist with prevention of a central line–associated bloodstream infection (CLA- BSI), the person inserting the catheter should do which of the following?
- Always use an antibiotic-coated central line.
- Follow maximal barrier precautions, including head-to-toe draping of the patient and donning of a cap, mask, sterile gown, and sterile gloves.
- Institute prophylactic antibiotics.
- Prepare the skin with an antiseptic agent followed by a saline solution rinse of the prepared site prior to insertion.
Q.4 A 2-month-old infant is admitted to the pediatric intensive care unit (PICU) with a history of fever and irritability leading to a decreased level of consciousness, a raised red rash, and increasing respiratory distress. To decrease the spread of infectious agents within the PICU and hospital, what is the most important priority for this patient upon admission?
- Acquisition of blood for culture and sensitivity
- Acquisition of cerebrospinal fluid for culture and sensitivity
- Broad-spectrum antibiotic prophylaxis of exposed health care workers
- Isolation with negative pressure
Q.5: What is the most prevalent contagion in central line–associated bloodstream infection (CLA-BSI) in critically ill children with a central venous catheter?
- Candida species
- Coagulase-negative Staphylococcus
- Pseudomonas species
Q.6: A key principle for the elimination of ventilator-associated pneumonia (VAP) includes which of the following?
- Institution of prophylactic antibiotics
- Minimization of aspiration of secretions and colonization of the aerodigestive tract
- Placement of the patient in the prone position
- Regularly scheduled instillation and suctioning of the endotracheal tube
Q.7: Which of the following is the most important action staff can take to prevent a urinary tract infection (UTI) in patients in the PICU?
- Catheterize all children with continuous morphine infusions.
- Limit the use of urinary tract instrumentation.
- Maintain adequate hand hygiene
- Insert urinary catheters using an aseptic technique.
Q.8: Standard precautions of infection control include hand hygiene, safe injection practices, use of personal protective equipment where appropriate, and appropriate respiratory hygiene and cough etiquette. Hand hygiene has been identified as a simple yet effective step in drastically reducing health care–associated infections. What is true regarding hand hygiene?
- It is not necessary if donning surgical gloves.
- It is limited to patient contact only.
- It is most effective when using soap and water.
- It is recommended before touching a patient, before performing clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching a patient’s surroundings.
Q.9: Which of the following should receive prophylaxis for a patient who presents with suspected meningococcal disease?
- The physician who took over care 2 days after presentation
- The unit clerk
- The initial emergency room doctor who intubated the patient
- The nurse in emergency room triage who saw the patient through a window
Q.10: If herpes simplex virus (HSV) encephalitis or neonatal disease is suspected, the most important initial step is to do which of the following?
- Determine the source of the exposure.
- Initiate empiric treatment with intravenous acyclovir.
- Initiate appropriate infection control precautions.
- Obtain diagnostic specimens including cerebrospinal fluid for HSV polymerase chain reaction.
Q.1 : A
There have been fairly dramatic declines in the incidence of VAP and CLA-BSI with the introduction of bundles of care that have been shown in large studies to be effective at their prevention. Ventriculostomy-related infections are not common. Hospital-acquired sinusitis is a challenging diagnosis to make without consensus criteria.
The incidence of CA-UTI remains significant, as the only evidence-proved intervention is reducing indwelling catheter days. In some situations urinary catheters must remain in situ, as reflected by the persistent incidence of CAUTI. New techniques such as coated catheters or antibiotic instillation have yet to prove effective.
Masks to prevent acquisition of disease via the airborne or droplet route are useful primarily for respiratory viruses such as RSV or influenza, as well as diseases that are potentially aerosolized such as measles, tuberculosis, and chickenpox. Diseases that require direct contact for transmission, such as MRSA, clostridium difficile–associated diarrhea, and norovirus infection do not formally need a mask for prevention if all other precautions are maintained. However, many infection control programs will insist that practitioners wear masks in these conditions to avoid inadvertently touching their face with gloved, contaminated hands while providing care. Neisseria meningitides does not need droplet precautions after appropriate antibiotic therapy has been administered.
Successful programs to reduce the incidence of CLA-BSI have been reported; all use multimodal team-based systematic approaches in which combinations of effective preventive interventions are introduced into a care setting. The central line bundle is a compilation of eight components broken into two separate bundles for insertion and maintenance. The insertion bundle components include hand hygiene, maximal barrier precautions, and skin antisepsis. Maximal barrier precautions for the person inserting the catheter entail strict compliance with hand hygiene and wearing a cap that covers all hair, a mask that covers the mouth and nose securely, a sterile gown, and sterile gloves. The patient is covered from head to toe with a sterile drape except for a small opening for the insertion site and to maintain the airway. Chlorhexidine skin antisepsis is recommended over other antiseptic agents. With regard to the optimal site for a line, practitioners are urged to consider what is best for the patient based on current and future needs, anatomic features, and the inserter’s technical competence.
Other components of success include empowering nurses to enforce the use of a central line checklist that incorporates inclusion of all components of the insertion bundle and constraining practice by creating central line insertion kits or carts that include the required equipment needed to maintain asepsis (eg, offering only one antiseptic-chlorhexidine).
Antibiotic-impregnated CVCs are not recommended for routine use unless concerted efforts to implement a strategy fail to reduce a local institution’s infection rates below benchmark levels. Antibiotic-impregnated CVCs may be considered in specific patient populations such as immunosuppressed patients requiring long-term CVC use, although their superiority over standard CVCs in this population has never been proved.
In addition to hand hygiene, the maintenance bundle to prevent CLA-BSI incorporates multimodal education and training programs, accessing the lumens aseptically (ie, scrubbing the hub), checking the entry site for inflammation regularly (at a minimum, with each dressing change), daily review of line necessity with removal if it is deemed unnecessary, and a dedicated total parenteral nutrition line.
Q. 4: D
Isolating a patient in a negative-pressure room is the first step in preventing the spread and potential cross-contamination of unknown contaminants.
Q. 5: B
The most common infecting organism in persons with CLA-BSI is the gram-positive bacteria coagulase-negative Staphylococcus, a group of about 20 species, including Staphylococcus epidermidis, which are normal flora of human skin. gram-negative bacteria, including Enterobacteriaceae, and nonfermenting gramnegative bacteria, such as Pseudomonas species, Acinetobacter species, and Stenotrophomonas species, account for about 25% of infections. Increasingly, Candida species infections are recognized.
Strategies of prevention are directed against the three mechanisms by which VAP is thought to occur: aspiration of secretions, colonization of the aerodigestive tract, and use of contaminated equipment. General recommended measures are to conduct active surveillance for VAP, minimize the duration of ventilation and use noninvasive ventilation whenever possible, perform daily assessments of the patient’s readiness to be weaned from ventilation, and educate health care workers who care for ventilated patients about VAP.
Specific precautions of the pediatric VAP bundle are practicing hand hygiene before and after circuit manipulation, elevating the head of the bed (the angle varies depending on positioning limitations of the child based on his or her age), positioning the oral or nasal gastric tube properly, eliminating the routine use of instillation prior to suctioning of the endotracheal tube, changing in-line suctioning catheters only when they are visibly soiled or malfunctioning, providing regular oral care for all children, and maintaining the ventilator tubing in a dependent position.
Guidelines for the prevention of catheter-associated urinary tract infection (CA-UTI) in acute care hospitals focus on certain key strategies, all related to urinary catheter use:
(1) recommendations regarding which patients should receive indwelling urinary catheters; (2) recommendations for catheter insertion; (3) recommendations for catheter maintenance; and (4) quality improvement programs to achieve appropriate placement, care, and removal of catheters. The most important action that PICU staff can take to prevent UTIs is to limit the use of urinary tract instrumentation, particularly indwelling urinary catheters. Systemic morphine infusions are not a contraindication to the removal of the urinary catheter.
Proper technique for catheter insertion includes hand hygiene before and after any manipulation of the device, use of aseptic technique, use of the smallest bore catheter needed, and proper securement of the catheter after insertion to prevent movement. The catheter should be maintained as a closed drainage system with unobstructed urine flow. The catheter and collecting system should be replaced if the system is disconnected or if leaks occur. Standard precautions should be used for any manipulation of the catheter or collecting system (eg, use of gloves and gowns as appropriate). Systemic antimicrobials, bladder irrigation with antimicrobial agents, and complex drainage systems with antiseptic agents are not recommended to prevent CA-UTI. Special catheter materials (eg, antimicrobial-impregnated catheters) are only recommended if a comprehensive strategy to reduce CA-UTI rates is unsuccessful.
The World Health Organization Patient Safety initiative on hand hygiene emphasizes five moments for hand hygiene: before touching a patient, before performing clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching a patient’s surroundings.
Meningococcal disease can rapidly cause shock and multiorgan failure. Hence, prevention is the most important component in managing this severe illness. Only close contacts that were potentially exposed to nasopharyngeal secretions early in the treatment course are recommended to receive antibiotic prophylaxis.
Aggressive therapy for meningococcal disease has been shown to significantly improve outcomes. Early antibiotics, appropriate hemodynamic support, and referral to higher levels of care are all fundamental components of the management of invasive meningococcal infections.
When it is untreated, HSV encephalitis carries a death rate in excess of 70%, and even when it is treated, death and complications for those who survive remain on the order of 15% and 20%, respectively. Similarly, despite treatment, neonatal HSV central nervous system disease carries a significant risk of death and morbidity, ranging from 0% to 15% and 43% to 68%, respectively. Early identification of patients and rapid initiation of acyclovir have been associated with a better outcome. Unless an alternative cause is clear, high-dose acyclovir should be initiated in all children with encephalitis until HSV can be ruled out.