Review Article: Infection Control in Pediatric Extended Care Facilities • Author(s): Jo‐Ann S. Harris , MDSource: Infection Control and Hospital Epidemiology, Vol. 27, No. 6 (June 2006), pp. 598-603Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/504937 .

Accessed: 15/05/2014 15:09

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp

.JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact support@jstor.org.

.

The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaboratingwith JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology.

http://www.jstor.org

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

infection control and hospital epidemiology june 2006, vol. 27, no. 6

r e v i e w a r t i c l e

Infection Control in Pediatric Extended Care Facilities

Jo-Ann S. Harris, MD

Pediatric extended care facilities provide for the biopsychosocial needs of patients younger than 21 years of age who have sustained self-care deficits. These facilities include long-term and residential care facilities, chronic disease and specialty hospitals, and residential schools.Infection control policies and procedures developed for adult long-term care facilities, primarily nursing homes for elderly people, are notapplicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilitiesand their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profilesfound in pediatric extended care facilities.

Infect Control Hosp Epidemiol 2006; 27:598-603

From the Section of Pediatric Infectious Diseases, Boston Medical Center, Department of Pediatrics, Boston University School of Medicine, and FranciscanChildren’s Hospital, Boston, Massachusetts. (Present affiliation: Pediatric Infectious Diseases, University of Kansas Medical Center, Kansas City.)

Received June 9, 2004; accepted June 8, 2005; electronically published May 24, 2006.� 2006 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2006/2706-0011$15.00.

The delivery of health care has undergone major changesduring the past two decades, with more services being offeredin non–acute care hospital settings, such as long-term carefacilities. This change is due to multiple factors, includingeconomic forces that result in earlier discharge of patients,advances in medical technology, and patient or parent desireto receive care outside the hospital.1,2 In the past, hospitalinfection prevention and control programs used by these fa-cilities were based on infection control programs establishedfor acute care hospitals. It was not until the 1980s that in-fections acquired in long-term care facilities (primarily nurs-ing homes) were characterized and infection control policiesand procedures were developed specifically for that setting.3

A considerable body of knowledge has accumulated aboutthe rates and types of infections in nursing homes and theefficacy of interventional strategies for prevention. More than1.5 million individuals reside in nursing homes, and 90% ofthem are elderly.1,3 Information about other types of extendedcare facilities that may serve younger patients, such as pe-diatric long-term care and residential care facilities, as wellas rehabilitation and specialty hospitals, is lacking.

Current strategies for prevention and control of nosoco-mial infections in pediatric acute care facilities have primarilybeen developed for acute care hospitals that address the needsof adult patient populations. Although some of these strat-egies apply to infants and children, pediatric patients andpediatric units are unique and require child-specific preven-tion and control plans. It has been established that nosoco-mial infections among pediatric patients in acute care hos-pitals differ from those among adults.4,5 Children have fewercases of wound infection, nosocomial pneumonia (ventilator-associated), and urinary tract infection (UTI) than adults do.

Children have more cases of viral respiratory tract and viralgastrointestinal tract infection, bacteremia, and cutaneous in-fection.4 Multiple factors contribute to the differences in thenosocomial infections that occur in infants and young chil-dren and those that occur in adults, including host factors,sources of infection, routes of transmission, and distributionof pathogens.4,5 Similarly, infections that occur among elderlypatients in long-term care facilities reflect the aging process,such as decreased mobility, waning immunity, and underlyingand chronic diseases6; therefore, infection control policies andprocedures developed for adult long-term care facilities arenot applicable to pediatric extended care (PEC) facilities. Thisarticle reviews characteristics of PEC facilities and their res-idents, and the epidemic and endemic nosocomial infections,infection control programs, and antimicrobial resistance pro-files found in PEC facilities.

characteristics of pec facilitiesand their residents

No standardized definition exists for a PEC facility. Suchfacilities provide for the biopsychosocial needs of patientsyounger than 21 years who have sustained self-care deficits.7

These facilities include long-term and residential care facil-ities, rehabilitation facilities, chronic disease and specialtyhospitals, and schools. They provide a variety of services toa diverse patient population. The number of pediatric patientsserved by these facilities is not well known. Combined datafrom the National Association of Children’s Hospitals andRelated Institutions and the American Hospital Associationindicate that there are 41 freestanding institutions with 2172beds that consider themselves PEC facilities.7 This number isbased on volunteered information and does not include pe-

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

infection control in pediatric extended care facilities 599

table 1. Relative Prevalences of Nosocomial Infection at 4 Types of Long-Term Care Facility

Percentage of nosocomial infections,by type and location of institution

Site or type of infection

Pediatriclong-term care

(Toronto, Ontario)18

Pediatricacute care

(Toronto, Ontario)19

Pediatricrehabilitation

(Boston, MA)20

Geriatriclong-term care

(France)21

Respiratory tractOverall 42 16 58 20Upper 37 10 42 …Lower 5 6 16 …

Urinary tract 31 6 24 40Skin and soft tissue 16 5 9 20Gastrointestinal 4 35 6 2.4Bloodstream Not reported 21 2 2.4

diatric beds in adult facilities, and therefore it gives a grossunderestimation of the pediatric population that requiressome form of extended care.

A survey performed by the Pediatric Prevention Networkof the Centers for Disease Control and Prevention (CDC)and the National Association of Children’s Hospitals and Re-lated Institutions in 2001 reported on the characteristics of17 PEC facilities from multiple geographic areas.8 This samplerepresented 1200 beds and 15,000 admissions during 1 year(2000). Ten of the 17 PEC facilities were affiliated with theShriners Children’s Hospital System. Most patients were re-ceiving care for neurologic deficit or injury, central nervoussystem injury, orthopedic disorders, birth defects or geneticdefects, burns, and pulmonary infection. One third of thePEC facilities had beds for both acute-care and subacute-carepatients, and 6% of facilities had beds for patients requiringhospice, respite, or mental-health care. Medical device usewas frequent in the facilities: most practitioners had patientswho required a central venous line, tracheostomy tube, per-cutaneous feeding tube, and/or intermittent urinary cathe-terization. Central nervous system shunts were used in halfof the PEC facilities surveyed. The median number of bedsvaried from 30 to 130, and the average length of stay perPEC facility was 27 days, with a range of 1 day to more than350 days.

epidemic and endemic infections

The most common types of nosocomial infections in nursinghomes are UTIs; lower respiratory tract infections, predom-inantly pneumonia; and skin and soft-tissue infections, pri-marily cellulitis and infected pressure sores. The pathogensresponsible vary widely and reflect not only community-acquired infections but also those acquired in the acute carehospital.2,9 The epidemiology of infections in PEC facilitieshas been characterized primarily in terms of small epidemicsthat have been reported in the literature. Outbreaks of Hae-mophilus influenzae type b meningitis,10 coxsackievirus B4infection,11 influenza,12 respiratory syncytial virus infection,13

hepatitis virus A infection,14 adenovirus infection,15 varicella

infection,16 and methicillin-resistant Staphylococcus aureus(MRSA) infection17 have all been reported in PEC facilities.Few studies have examined endemic nosocomial infectionsin PEC facilities or pediatric specialty hospitals, such as thosefor burn patients. Table 1 compares data on the relative prev-alences of nosocomial infections at 4 facilities of various types,including a pediatric long-term care facility in Toronto, On-tario,18 a pediatric acute care facility in Toronto,19 a pediatricrehabilitation hospital in Boston, Massachusetts,20 and 248geriatric units in France.21 In the pediatric long-term carefacility in Toronto, the most common types of infection wererespiratory tract (42% of cases), urinary tract (31%), and skin(16%) infections, whereas at the affiliated pediatric acute carefacility in Toronto, the common types of infection were gas-trointestinal (35%), bloodstream (21%), and respiratory(16%). The pathogens identified in the 2 facilities also dif-fered. In the long-term care facility, the most common caus-ative organisms were Escherichia coli (23% of infections) andenterococci (15%) and staphylococcal species (15%); at theacute care facility, the most common pathogens were staph-ylococcal species (42% of infections) and streptococcal species(8%). The pediatric rehabilitation hospital in Boston had adistribution of types of infection similar to that at the long-term care facility in Toronto but different from that at thegeriatric facilities in France. There were more respiratory tractinfections and fewer urinary tract and skin and soft-tissueinfections at the pediatric facilities.

Increasing numbers of children are being discharged fromthe hospital with medical devices still in use, which previouslyrequired prolonged admission in an acute care facility. It isnot unusual for patients to be discharged directly from in-tensive care units to extended care facilities with multipledevices still in use, including mechanical ventilators. Littleinformation has been reported on rates of infection associatedwith medical device use in the non–acute care setting. Onestudy monitored nosocomial infection rates in a pediatricrehabilitation hospital during a 2-year period, using defini-tions of nosocomial infections based on the standards de-veloped for acute care hospitals.20 The patient population

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

600 infection control and hospital epidemiology june 2006, vol. 27, no. 6

table 2. Device-Associated Nosocomial Infection Rates at 3 Types of Pediatric Care Facilities

Site or type of infection Device

No. of infections, by type of facility and date

Rehabilitation hospital(Jan 1993–Dec 1994)20

NNIS PICU(2002)22

PPN PICU(2001)23

Burn unit(Jan 1990–Dec 1991)24

Lower respiratory tract Mechanical ventilator 2.4a 2.2 3.7 11.4Urinary tract Urinary catheter 13.0b 4.8 5.4 13.2Bloodstream Central venous line 5.0 7.4 8.5 4.9Burn infection NA NA NA NA 5.6c

note. The denominator is 1,000 device-days, unless otherwise indicated. NA, not applicable; NNIS, National Nosocomial Infections SurveillanceSystem; PICU, pediatric intensive care unit; PPN, Pediatric Prevention Network of Centers for Disease Control and Prevention and NationalAssociation of Children’s Hospitals and Related Institutions.a All patients who underwent mechanical ventilation had tracheostomy tubes.b All patients were following intermittent catheterization regimens.c The denominator is 1,000 patient-days.

consisted of children with birth defects, cancer, neuromus-cular disorders, spinal cord injuries, head trauma, and con-ditions related to prematurity. There was a high rate of deviceuse, including use of central venous lines, tracheostomy tubes,mechanical ventilators, percutaneous feeding tubes, and in-termittent use of urinary catheters. The highest rates of in-fection were found in the youngest patients with the largestnumber of devices. Table 2 compares the device-associatedinfection rates at the rehabilitation facility and at pediatricintensive care units (PICUs), where the rate of device use isalso high.20,22-24 The rehabilitation facility had a higher rateof UTI, compared with the PICUs, but a lower rate of blood-stream infection and similar rate of respiratory tract infection.Definitions of nosocomial infection and methods of surveil-lance differed among these studies, and the rates may not becomparable.

The data on rates of nosocomial infection in pediatric spe-cialty hospitals are also limited. Weber et al.24 monitored allpatients with acute burns admitted to a pediatric burn centerduring a 2-year period. The rate of infection also differedfrom the rates in the PICUs, with higher rates of lower re-spiratory tract infection and UTI. More lower respiratorytract infections occurred in the burn unit, but rates of UTIand bloodstream infection were similar to those in the pe-diatric rehabilitation hospital (Table 2). Weber et al.24 foundthat the incidence of nosocomial urinary tract infection andsecondary bloodstream infection increased with increasingburn size. Gastmeier et al.25 performed a prospective cohortstudy in a pediatric burn unit in Germany. They followed up41 children for a period of 2 years. They based their criteriafor burn wound infections on the criteria established by We-ber et al.24 They found overall higher rates of device-associatedinfection and burn wound infection than did Weber et al.24

The rates of device-associated nosocomial infection were 55.2cases per 1,000 device-days for pneumonia, 8.9 cases per 1,000device-days for bloodstream infection, and 41.7 cases per1,000 device-days for UTI. The incidence density of burnwound infections was 18.5 cases per 1,000 patient-days, 3times the rate found by Weber et al.24 Gastmeier et al.25 found

that although the total burn surface area (expressed as a per-centage of total skin area) was a risk factor for burn woundinfection, it was not a risk for device-associated infection.The durations of urinary catheter use and mechanical ven-tilation use were identified as risk factors for the correspond-ing device-associated infections. Appropriate definitions andeffective surveillance strategies to detect nosocomial infec-tions in burn centers are needed to establish effective infectioncontrol and prevention interventions for that unique pediatricsetting.

infection control programs

Considerable progress has been made during the past decadein the implementation and practice of infection control innon–acute care settings. Evidence-based guidelines with rec-ommendations on the structure and components of an in-fection control program in long-term care facilities have beenpublished by the Society for Hospital Epidemiology of Amer-ica and the American Practitioners of Infection Control,26

consensus definitions have been published for the surveillanceof infection in extended care facilities,27 and a consensus panelrepresenting several national organizations (the CDC, theAmerican Practitioners of Infection Control, the Society forHospital Epidemiology of America, the Joint Commission onAccreditation of Healthcare Organizations, and the PediatricInfectious Diseases Society) published a report on the re-quirements for the infrastructure and essential activities ofinfection control in out-of-hospital settings.1 The structureand process of infection control include the fundamentalcomponents of surveillance, policy development, and em-ployee health and education appropriate for extended carefacilities. Once again, these guidelines have been establishedprimarily for nursing home patients (therefore, for elderlypatients) and may not be relevant for the pediatric populationin extended care. Surveys of the structure and process ofinfection control programs during the past decade have foundinfection control in adult long-term care facilities to be lessthan adequate.28 A study of 259 skilled nursing long-term

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

infection control in pediatric extended care facilities 601

care facilities by Goldrick28 found that 98% of respondentsreported their facility had an infection control practitionerwho was responsible for infection control programs, 85%were registered nurses, and most had other responsibilitiesand spent an average of 8 hours per week on surveillanceand control activities. Also, only 52% of the infection controlpractitioners had received formal training in infection con-trol. In addition, Goldrick found that only 25% of facilitiessurveyed had a physician with a special interest in infectioncontrol as part of the infection control program staff. Gold-rick28 concluded that surveillance activities, definitions of nos-ocomial infections, and calculation of rates were not stan-dardized but varied among institutions. Infection controlpolicies and procedures were variable, as well, and were oftennot based on published recommendations and guidelines.28

In the Pediatric Prevention Network survey of 17 PECfacilities, infection control structures and processes were eval-uated.8 This study found that 76% of the facilities had in-fection control practitioners, with an average of 0.72 full-timeequivalent staff per facility, 53% of whom were certified ininfection control. Only 35% of the facilities had physiciansin the program, and 35% had physicians available with in-fectious diseases training. Infection surveillance was facility-wide in 82% of facilities, and 18% performed surgical siteinfection surveillance only. The National Nosocomial Infec-tion Surveillance definitions developed by the CDC or themodified National Nosocomial Infection Surveillance defi-nitions were used in 71% of the facilities. Rate calculationsfor analyzing nosocomial infections varied widely, and 6% offacilities did not calculate rates at all. Clinical practices werenot standardized either; for example, only 65% of the facilitiesused sterile or maximum barrier precautions for central ve-nous line placement, and 59% changed ventilator tubing ev-ery 7 days. There was an infection control committee at 70%of the facilities, and 82% had an employee health program.Influenza vaccination was offered at 82% of the facilities, butonly 30% of facilities had more than 50% of the employeesvaccinated. All of the facilities had infection control educationas part of new-employee orientation. As with adult long-termcare facilities, considerable variation exists among PEC fa-cilities with regard to the structure and processes of infectioncontrol programs.

Information is lacking on whether infection control pro-grams or specific interventions are effective in reducing therates of nosocomial infection in long-term care facilities. Fewstudies of adult extended care facilities have reported ratesof nosocomial infection achieved after infection control in-terventions have been put in place. Limited evidence existsto show that infection control programs reduce the incidenceof endemic infections, as has been shown in acute care fa-cilities by studies such as the landmark Study on the Efficacyof Nosocomial Infection Control.9,26,29 Makris et al.30 evalu-ated an interventional program in nursing homes that con-sisted of hand washing and infection control education andenvironmental cleaning. The intervention did not decrease

the endemic infection rates in the nursing homes, comparedwith rates in the nursing homes used as controls. Ostrwoskyet al.31 studied 32 healthcare facilities, 26 of which were adultlong-term care facilities, in one geographical region for theprevalence of vancomycin-resistant enterococci (VRE). Thelong-term care facilities followed CDC or modified CDC rec-ommendations for preventing the spread of vancomycin re-sistance. They found that performance of surveillance culturesand isolation of infected or colonized patients reduced or elim-inated transmission of VRE. Other studies have also found thatinfection control interventions can reduce the transmission ofresistant organisms such as VRE in adult long-term care fa-cilities.9,32-34 Information is limited on the outcomes of infectioncontrol interventions in PEC facilities. Weber et al.35 examinedthe use of laminar air-flow patient isolation units for 66 crit-ically ill pediatric burn patients during a 5-year period to de-termine the effect on the rate of cross-colonization with resis-tant organisms and found the rate to be low (3.2 cases per1,000 patient-days). Camilleri et al.36 evaluated the possibilityof cross-contamination between children on a combined burnand plastic surgery unit. They performed prospective screeningswab cultures for 226 consecutively admitted patients. Inter-ventions included use of topical antimicrobials and good asep-tic techniques for wound handling. Their overall rate of in-fection was low, they did not identify any “undesirable”organisms, and burn wounds became colonized from the pa-tient’s own flora rather than from the flora of other patients.They concluded that use of screening cultures could be valuableto identify patients colonized or infected with “undesirable”organisms, and mixing plastic-surgery and burn patients didnot appear to be a risk for cross-contamination. No rigorouslycontrolled studies exist on the efficacy of infection controlinterventions in PEC facilities.

antimicrobial resistance

The problem of antimicrobial resistance in adult long-termcare facilities is well recognized. High rates of colonizationwith antimicrobial-resistant organisms have been reported inmany nursing homes. Both MRSA and VRE have been eval-uated the most thoroughly, whereas resistant gram-negativerods and penicillin-resistant pneumococci (PRSP) have beenreported but not as well studied.9 Factors associated with theemergence of resistant pathogens in adult long-term care fa-cilities include transfer of patients from acute care facilitieswho are colonized or infected with multidrug-resistant path-ogens, excess use of broad-spectrum antibiotics that selectfor resistance, presence of patients with risk factors associatedwith the recovery of resistant strains (use of a percutaneousfeeding tube, malnutrition, pressure sores, immunosuppres-sion, prior antibiotic use), and the cycle of institutionalizationand hospitalization.37 How these factors apply to PEC facilitieshas not been extensively studied. Toltzis et al.38 evaluated thefactors that predicted preexisting colonization with antibiotic-resistant, gram-negative bacilli (resistant to ceftazidime or

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

602 infection control and hospital epidemiology june 2006, vol. 27, no. 6

tobramycin) among patients admitted to a PICU. They foundthat residence in a long-term care facility was strongly as-sociated with colonization. Patients from long-term care fa-cilities comprised one third of all PICU patients colonizedwith an antibiotic-resistant gram-negative bacillus. Coloni-zation was also associated with the number of past PICUadmissions and administration of intravenous antibiotics inthe past 12 months.38 Mannheimer et al.39 analyzed the riskfactors for the acquisition of PRSP at a university hospital inNew York City and found that residence in a pediatric long-term care facility was significantly associated with penicillinresistance. An investigation at one long-term care facilityfound that 33% of the children had PRSP colonization.39

Resistant pathogens that have been recovered in adult long-term care facilities include extended-spectrum b-lactamase–producing gram-negative bacilli, quinolone-resistant gram-positive and gram-negative bacteria, aminoglycoside-resistantenteric bacilli, MRSA, PRSP, and multidrug-resistant enter-ococci (VRE and aminoglycoside-resistant strains). In a studyof antibiotic-resistant gram-negative organisms in 2 PEC fa-cilities with a total of 186 beds, the most common resistantorganisms were Stenotrophomonas (26% of isolates), Pseu-domonas (25%), and Klebsiella species (17%). The agents towhich the most isolates were resistant were gentamicin (74%of isolates), ceftazidime (64%), piperacillin-tazobactam (52%),and meropenem (39%).40 In the Pediatric Prevention Net-work survey of PEC facilities, routine admission screeningfor antimicrobial-resistant pathogens was performed in 18%of the facilities; 47% of facilities monitored for gentamicin-resistant gram-negative rods, 59% for PRSP, 88% for MRSA,and 88% for VRE. Gentamicin-resistant gram-negative rodswere identified in 6% of the PEC facilities, PRSP in 12%,MRSA in 59%, and VRE in 29%.

Once resistant organisms are introduced into a long-termcare facility, they become endemic and are difficult to erad-icate.28 Many studies have found that there is intensive useof antimicrobials in adult long-term care facilities, most ofwhich is inappropriate.9,41 Efforts to control antimicrobialuse—and, therefore, antimicrobial resistance—in these facil-ities have been hampered by the complexity of the patientpopulation, the lack of availability of diagnostic tests, and thelack of controlled clinical trials.9 Evaluation of the intensityor appropriate use of antimicrobials in PEC facilities has notbeen performed. Because of the increase in the endemicityof antimicrobial-resistant organisms and the inappropriateuse of antimicrobials in adult long-term care facilities, rec-ommendations have been made to include an antimicrobial-use program as part of the infection control program.26,28,40,

41 Smith et al.42 found that 52% of 25 adult nursing homessurveyed had an antimicrobial-use review program in place.In the Pediatric Prevention Network survey of PEC facilities,47% of the facilities had antibiotic control programs, of which57% had written policies. Guidelines have been publishedthat recommend approaches to antimicrobial therapy for

common infections in adult long-term care patients,41 butthese are not relevant for children in extended care.

future directions

The goals for infection prevention among residents of PECfacilities are similar to those for adults in long-term carefacilities.43 These goals include decreasing the morbidity andmortality attributable to infections, preventing and control-ling outbreaks, preventing acquisition of infection by health-care workers, and limiting the inappropriate use of antimi-crobials and decreasing rates of antimicrobial resistance, allwhile maintaining resident functional status in an optimalsocial environment. How these goals are achieved will bedifferent for pediatric settings. Children are not little adults,and policies and procedures developed for adult long-termcare facilities are not necessarily applicable. Policies and pro-cedures used in pediatric acute care cannot be assumed tobe appropriate for PEC facilities. In PEC facilities, policiesand procedures will have to account for the different devel-opmental stages of the patients being treated, including suchfactors as the intensive interactions of healthcare workers withchildren (ie, cuddling and consoling of infants) that do notoccur with adults. Specialized areas, such as age-appropriateplayrooms and schoolrooms, are necessary to accommodatediffering educational and social needs of children. In thesespecialized areas, there are close interactions among pediatricpatients that cause infection control problems not found inadult extended care facilities. More information is needed todevelop evidence-based guidelines for the prevention andcontrol of nosocomial infections and for the appropriate useof antibiotics in these unique, non–acute care pediatric set-tings. Appropriate definitions of nosocomial infection needto be developed, and surveillance systems standardized, forinfection rates to be meaningful. Only then can the effec-tiveness of infection control interventions be evaluated. Anetwork of PEC facilities needs to be established and resourcesallocated to conduct studies for this to be accomplished. Asmore intense medical care is shifted to non–acute care set-tings, we must be prepared to prevent and control associatedinfections by developing appropriate policies and proceduresfor children in extended care.

Address reprint requests to Jo-Ann S. Harris, MD, Pediatric InfectiousDiseases, University of Kansas Medical Center, MS 4004, 3901 Rainbow Blvd,Kansas City, KS 66160 (jharris7@kumc.edu).

references

1. Friedman C, Barnette M, Buck AS, et al. Requirements for infrastructureand essential activities of infection control and epidemiology in out-of-hospital settings: a consensus panel report. Am J Infect Control 1999; 27:418-430.

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions

infection control in pediatric extended care facilities 603

2. Stausbaugh LJ, Joseph CL. Epidemiology and prevention of infectionsin residents of long term care facilities. In: Mayhall CG, ed. HospitalEpidemiology and Infection Control. 2nd ed. Philadelphia, PA: LippincottWilliams & Wilkins; 1999:1461-1482.

3. Smith PW. Nursing home infection control: a status report. Infect ControlHosp Epidemiol 1998; 19:366-369.

4. Harris JS. Pediatric nosocomial infections: children are not little adults.Infect Control Hosp Epidemiol 1997; 18:739-742.

5. Donowitz L. Hospital-acquired infections in children. N Engl J Med 1990;323:1836-1837.

6. Nicolle LE, Garibaldi RA. Infection control in long term care facilities.In: Herwaldt LA, Decker MD, eds. A Practical Handbook for HospitalEpidemiology. Thorofare, NJ: Slack; 1998:349-356.

7. Hsu K, Harris JS. Control of infections in nonacute care pediatric settings.Semin Pediatr Infect Dis 2001; 12:92-99.

8. Harris JS. Infection control programs in pediatric extended care facilities.In: Abstracts of the 12th Annual Meeting of the Society for HealthcareEpidemiology of America; Salt Lake City, UT; April 6-9, 2002. Abstract 22.

9. Nicolle LE. Preventing infections in non-hospital settings: long term care.Emerg Infect Dis 2001; 7:205-207.

10. Glode MP, Schiffer MS, Robbins JB, et al. An outbreak of Haemophilusinfluenzae type b meningitis in an enclosed hospital population. J Pediatr1976; 88:36-40.

11. Johnson I, Hammon GW, Verma MR. Nosocomial coxsackie B4 virusinfections in two chronic care pediatric neurological wards. J Infect Dis1985; 151:1153-1156.

12. Atkinson WL, Arden NH, Patriarca PA, et al. Amantadine prophylaxisduring an institutional outbreak of type A (H1N1) influenza. Arch InternMed 1986; 146:1751-1756.

13. Finger R, Anderson LJ, Dicker RC, et al. Epidemic infections caused byrespiratory syncytial virus in institutionalized young adults. J Infect Dis1987; 155:1335-1339.

14. Tassopoulos NC, Roumeliotou-Karayannis A, Sakka M, et al. An epi-demic of hepatitis A in an institution for young children. Am J Epidemiol1987; 125:302-307.

15. Gerber SL, Erdman DD, Pur SL, et al. Outbreak of adenovirus genometype 7d2 infection in a pediatric chronic-care facility and tertiary-carehospital. Clin Infect Dis 2001; 32:694-700.

16. Sheridan RL, Weber JM, Pasternak MM, et al. A 15-year experience withvaricella infections in a pediatric burn unit. Burns 1999; 25:353-356.

17. Stover BH, Duff A, Adams G, et al. Emergence and control of methicillin-resistant Staphylococcus aureus in a children’s hospital and pediatric longterm care. Am J Epidemiol 1987; 125:302-305.

18. Vermaat JH, Rosebrugh E, Ford-Jones EL, et al. An epidemiologic studyof nosocomial infections in a pediatric long-term care facility. Am J InfectControl 1993; 21:183-188.

19. Ford-Jones EL, Mindorff M, Langley JM, et al. Epidemiologic study of4684 hospital-acquired infections in pediatric patients. Pediatr Infect DisJ 1989; 8:668-675.

20. Harris J, Hogan M, Kagel S. Nosocomial infections in a pediatric re-habilitation hospital. In: Abstracts of the Fifth Annual Meeting of theSociety for Healthcare Epidemiology of America; San Diego, CA; April2-4, 1995. Abstract S29.

21. Golliot F, Astagneau P, Cassou B, et al. Nosocomial infections in geriatriclong-term care and rehabilitation facilities: exploration in the develop-ment of a risk index for epidemiologic surveillance. Infect Control HospEpidemiol 2001; 22:746-753.

22. National Nosocomial Infections Surveillance (NNIS) system report, data

summary from January 1992–June 2002, issued August 2002. Am J InfectControl 2002; 30:458-475.

23. Stover BH, Shulman ST, Bratcher DF, et al. Nosocomial infection ratesin US children’s hospitals’ neonatal and pediatric intensive care units.Am J Infect Control 2001; 29:152-157.

24. Weber JM, Sheridan RL, Pasternack MS, et al. Nosocomial infections inpediatric patients with burns. Am J Infect Control 1997; 25:195-201.

25. Gastmeier P, Weigt O, Sohr D, et al. Comparison of hospital-acquiredinfection rates in pediatric burn patients. J Hosp Infect 2002; 52:161-165.

26. Smith PW, Rusnak PG. Infection prevention and control in the long-term-care facility. Infect Control Hosp Epidemiol 1997; 18:831-849.

27. McGreer A, Campbell B, Eckert DG, et al. Definitions for surveillanceof infections in residents of long-term care facilities. Am J Infect Control1991; 19:1-7.

28. Goldrick BA. Infection control programs in long-term-care facilities:structure and process. Infect Control Hosp Epidemiol 1999; 20:764-769.

29. Haley RW, Culver DH, White JW, et al. The efficacy of infection sur-veillance and control programs in preventing nosocomial infections inUS hospitals. Am J Epidemiol 1985; 121:182-205.

30. Makris AT, Morgan L, Gaber DJ, et al. Effect of a comprehensive infectioncontrol program on the incidence of infections in long-term care facil-ities. Am J Infect Control 2000; 28:3-7.

31. Ostrowsky BE, Trick WE, Sohn AH, et al. Control of vancomycin-resistant enterococcus in health care facilities in a region. N Engl J Med2001; 344:1427-1433.

32. Greenaway CA, Miller MA. Lack of transmission of vancomycin-resistantenterococci in three long-term-care facilities. Infect Control Hosp Epi-demiol 1999; 20:341-343.

33. Armstrong-Evans M, Litt M, McArthur MA, et al. Control of transmis-sion of vancomycin-resistant Enterococcus faecium in a long-term-carefacility. Infect Control Hosp Epidemiol 1999; 20:312-317.

34. Bradley SF. Issues in the management of resistant bacteria in long-term-care facilities. Infect Control Hosp Epidemiol 1999; 20:362-366.

35. Weber JM, Sheridan RL, Schultz JT, et al. Effectiveness of bacteria-con-trolled nursing units in preventing cross-colonization with resistant bac-teria in severely burned children. Infect Control Hosp Epidemiol 2002;23:549-551.

36. Camilleri IG, Pedler SJ, Murphy O, et al. Cross infection on a combinedpediatric plastic surgery and burns unit: a clinical and microbiologicaudit. Burns 1999; 25:655-658.

37. Bonomo RA. Multiple antibiotic resistant bacteria in long-term-care fa-cilities: an emerging problem in the practice of infectious diseases. ClinInfect Dis 2000; 31:1414-1422.

38. Toltzis P, Hoyen C, Spinner-Block S, et al. Factors that predict preexistingcolonization with antibiotic-resistant gram-negative bacilli in patientsadmitted to a pediatric intensive care unit. Pediatrics 1999; 103:719-723.

39. Mannheimer SB, Riley LW, Roberts RB. Association of penicillin-resistantpneumococci with residence in a pediatric chronic care facility. J InfectDis 1996; 174:513-519.

40. Lidsky K, Hoyen C, Salvator A, et al. Antibiotic-resistant gram-negativeorganisms in pediatric chronic-care facilities. Clin Infect Dis 2002; 34:760-766.

41. Nicolle LE, Bentley DW, Garibaldi R, et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidemiol 2000; 21:537-545.

42. Smith PW, Seip CW, Schaefer SC, et al. Microbiologic survey of long-term care facilities. Am J Infect Control 2000; 28:8-13.

43. Nicolle LE. Infection control in long-term care facilities. Clin Infect Dis2000; 31:752-756.

This content downloaded from 194.29.185.103 on Thu, 15 May 2014 15:09:23 PMAll use subject to JSTOR Terms and Conditions