Infection control in paediatrics

Invasive fungal infections in critically ill children: epidemiology, risk factors and antifungal drugs

Background

Invasive fungal infections (IFIs) are important infectious complications amongst critically ill children. The most common fungal infections are due to Candida species. Aspergillus, Zygomycetes and Fusarium are also emerging because of the empirical use of antifungal drugs. This updated review discusses the epidemiology of IFIs as well as antifungal drugs, dosing and potential adverse effects in critically ill children.

Methods

A PubMed search was conducted with Clinical Queries using the key terms "antifungal", "children", "critical care" AND "paediatric intensive care unit" OR "PICU". The search strategy included clinical trials, randomized controlled trials, meta-analyses, observational studies and reviews and was limited to the English literature in paediatrics.

Results

Candida and Aspergillus spp. are the most prevalent fungi in paediatric IFIs, causing invasive candidiasis infections (ICIs) and invasive aspergillosis infections (IAIs), respectively. These IFIs are associated with high morbidity, mortality and healthcare costs. Candida albicans is the principal Candida spp. associated with paediatric ICIs. The risks and epidemiology for IFIs vary if considering previously healthy children treated in the paediatric intensive care unit or children with leukaemia, malignancy or a severe haematological disease. The mortality rate for IAIs in children is 2.5-3.5-fold higher than for ICIs. Four major classes of antifungals for critically ill children are azoles, polyenes, antifungal antimetabolites and echinocandins.

Conclusions

Antifungal agents are highly efficacious. For successful treatment outcomes, it is crucial to determine the optimal dosage, monitor pharmacokinetics parameters and adverse effects, and individualized therapeutic monitoring. Despite potent antifungal medications, ICIs and IAIs continue to be serious infections with high mortality rates. Pre-emptive therapy has been used for IAIs. Most guidelines recommend voriconazole as initial therapy of invasive aspergillosis in most patients, with consideration of combination therapy with voriconazole plus an echinocandin in selected patients with severe disease. The challenge is to identify critically ill patients at high risks of ICIs for targeted prophylaxis. Intravenous/per os fluconazole is first-line pre-emptive treatment for Candida spp. whereas intravenous micafungin or intravenous liposomal amphotericin B is alternative pre-emptive treatment.This article is part of the Challenges and strategies in the management of invasive fungal infections Special Issue: https://www.drugsincontext.com/special_issues/challenges-and-strategies-in-the-management-of-invasive-fungal-infections.

Epidemiological and genetic characteristics of vancomycin-resistant Enterococcus faecium isolates in a University Children's Hospital in Germany: 2019 to 2020

Background

Vancomycin-resistant Enterococcus faecium (VREfm) strains are one of the most important pathogens causing nosocomial infections in Germany. Due to limited treatment options and an increased risk for acquisition in immunocompromised children, surveillance to monitor occurrence of VREfm in paediatric clinical facilities is of critical importance. Following an unusual accumulation of VREfm positive patients between April 2019 and August 2020 at Dr. von Hauner Children’s Hospital in Munich, Germany, our study aimed to identify dynamics and routes of transmission, and analyse the affected population in view of previously described host risk factors for VREfm colonisation or infection.

Methods

The hospital database was used to collect epidemiological and clinical data of VREfm cases. Descriptive statistical analyses were conducted to outline patient characteristics and depict possible differences between VREfm-colonised and -infected children. An outbreak investigation determining genetic relatedness among VREfm isolates was performed by core genome multilocus sequence typing (cgMLST). To examine potential transmission pathways, results of genome analysis were compared with epidemiological and clinical data of VREfm positive patients.

Results

VREfm acquisition was documented in a total of 33 children (< 18 years). Seven VREfm-colonised patients (21.2%), especially those with a haemato-oncological disease (4/7; p = 0.011), showed signs of clinical infection. cgMLST analysis revealed seven distinct clusters, demonstrating a possible connection within each clonal lineage. Additional eight singletons were identified. Comparison with epidemiological and clinical data provided strong evidence for a link between several VREfm positive patients within the hospital.

Conclusions

A nosocomial spread—at least in part—was the most likely reason for the unusual accumulation of VREfm cases. The study highlights that there is a constant need to increase efforts in hygiene measures, infection control and antibiotic stewardship to combat VREfm transmission events within German paediatric hospitals. Continuous monitoring of adherence to respective policies might reduce the occurrence of clustered cases and prevent future outbreaks.

Use of Limosilactobacillus reuteri DSM 17938 in paediatric gastrointestinal disorders: an updated review

Strains of lactobacilli are the most widely used probiotics and can be found in a large variety of food products and food supplements throughout the world. In this study, the evidence on Limosilactobacillus reuteri DSM 17938 (LR DSM 17938) has been reviewed. This species secretes reuterin and other substances singularly or in microvesicles, inhibiting pathogen growth and interacting with the intestinal microbiota and mucosa, restoring homeostasis. The use of LR DSM 17938 has been exploited in several pathological conditions. Preclinical research has shown that this probiotic can ameliorate dysbiosis and, by interacting with intestinal mucosal cells, can raise the pain threshold and promote gastrointestinal motility. These aspects are amongst the significant components in functional gastrointestinal disorders, such as colic and regurgitation in infants, functional abdominal pain and functional constipation in children and adolescents. This strain can decrease the duration of acute diarrhoea and hospitalization for acute gastroenteritis but does not seem to prevent nosocomial diarrhoea and antibiotic-associated diarrhoea. Because of its ability to survive in the gastric environment, it has been tested in Helicobacter pylori infection, showing a significant decrease of antibiotic-associated side effects and a tendency to increase the eradication rate. Finally, all these studies have shown the excellent safety of LR DSM 17938 even at higher dosages. In conclusion data from various clinical trials here reviewed can guide the clinician to find the correct dose, frequency of administration, and therapy duration.

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan

BACKGROUND

Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children.

MATERIALS AND METHODS

Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients.

FINDINGS

Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%).

CONCLUSIONS

A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.

Comparing Dynamics and Determinants of Severe Acute Respiratory Syndrome Coronavirus 2 Transmissions Among Healthcare Workers of Adult and Pediatric Settings in Central Paris

Background

Health-care workers (HCW) have paid a heavy toll to the coronavirus disease-19 (COVID-19) outbreak. Routes of transmission remain to be fully understood.

Methods

This prospective study compared a 1,500-bed adult and a 600-bed pediatric setting of a tertiary-care university hospital located in central Paris. From February 24^th until April 10^th, 2020, all symptomatic HCW were screened for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on a nasopharyngeal swab. HCW screened positive were questioned on their profession, symptoms, occupational and non-occupational exposures to SARS-CoV-2.

Results

Among 1344 HCW tested, 373 were positive (28%) and 336 (90%) corresponding questionnaires were completed. Three hospitalizations and no death were reported. Most HCW (70%) had patient-facing occupational activities (22% in COVID-19 dedicated units). The total number of HCW cases peaked on March 23^rd, then decreased slowly, concomitantly with a continuous increase of compliance to preventive measures (including universal medical masking and personal protective equipment (PPE) for direct care to COVID-19 patients). Attack rates were of 3.2% and 2.3% in the adult and pediatric setting, respectively (p=0.0022). In the adult setting, HCW more frequently reported exposure to COVID-19 patients without PPE (25% versus 15%, p=0.046). Report of contacts with children attending out-of-home care facilities dramatically decreased over the study period.

Conclusion

Universal masking, reinforcement of hand hygiene, and PPE with medical masks for patients’ care allowed protection of HCW and containment of the outbreak. Residual transmissions were related to persistent exposures with undiagnosed patients or colleagues and not to contacts with children attending out-of-home care facilities.

Short-term exposure to air pollution and hospital admission for pneumonia: a systematic review and meta-analysis

BACKGROUND

Air pollution is a major issue that poses a health threat worldwide. Although several studies investigated the adverse effects of air pollution on various diseases, few have directly demonstrated the effects on pneumonia. Therefore, we performed a systematic review and meta-analysis on the associations between short-term exposure of air pollutants and hospital admission or emergency room (ER) visit for pneumonia.

METHODS

A literature search was performed using PubMed, Embase, and Web of Science up to April 10, 2020. Pooled estimates were calculated as % increase with 95% confidence intervals using a random-effects model. A sensitivity analysis using the leave-one-out method and subgroup analysis by region were performed.

RESULTS

A total of 21 studies were included in the analysis. Every 10 μg/m3 increment in PM2.5 and PM10 resulted in a 1.0% (95% CI: 0.5-1.5) and 0.4% (95% CI: 0.2-0.6) increase in hospital admission or ER visit for pneumonia, respectively. Every 1 ppm increase of CO and 10 ppb increase of NO2, SO2, and O3 was associated with 4.2% (95% CI: 0.6-7.9), 3.2% (95% CI: 1.3-5.1), 2.4% (95% CI: - 2.0-7.1), and 0.4% (95% CI: 0-0.8) increase in pneumonia-specific hospital admission or ER visit, respectively. Except for CO, the sensitivity analyses yielded similar results, demonstrating the robustness of the results. In a subgroup analysis by region, PM2.5 increased hospital admission or ER visit for pneumonia in East Asia but not in North America.

CONCLUSION

By combining the inconsistent findings of several studies, this study revealed the associations between short-term exposure of air pollutants and pneumonia-specific hospital admission or ER visit, especially for PM and NO2. Based on the results, stricter intervention policies regarding air pollution and programs for protecting human respiratory health should be implemented.

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

BACKGROUND

The objectives of this study were to assess the number of organisms present on different surfaces within a clinical environment before and after cleaning took place, and to identify the impact of cleaning. The study involved extensive 2-week microbiological environmental monitoring of an entire ward before and after cleaning; the ward was located within a pediatric hematology-oncology ward comprised of a day unit and outpatient ward.

METHODS

Tryptone soya agar contact plates were used to take a total of 1,160 surface samples before and after cleaning from 55 predetermined sites. Samples were taken from representative surfaces throughout the ward representing a variety of materials, surface heights, functions, and distances from patients, as well as both high-touch and infrequently touched surfaces.

RESULTS

After surface cleaning was undertaken within the ward, there was a significant difference between the amount of colony-forming units (CFUs) recovered before and after cleaning (P < .0001). Cleaning produced an average CFU reduction of 68% throughout the ward environment. The corridor was the most contaminated area within the ward. There were differences in the CFUs among the various areas within the ward, which were cleaned with varying efficiency. The surface material, who interacted with the surface, levels of initial contamination, perceived risk, and perceived cleanability were all found to have a varying impact on the cleaning effectiveness.

CONCLUSIONS

To the authors' current knowledge, this is the only study to assess cleaning within a pediatric ward by taking samples directly before and after cleaning. The standard of cleaning undertaken within the ward is open for discussion, and these data highlight the need for an improved cleaning intervention and can provide insight into the multitude of factors that must be considered when designing an effective training protocol.

Pediatric Blood Cultures and Antibiotic Resistance: An Overview

Bloodstream infections (BSI) due to multidrug-resistant organisms, especially from pediatric intensive care units (PICU), are being increasingly reported across the world. Since BSI is associated with high mortality, it is essential to treat these infections early with appropriate antibiotics. Surveillance of etiology and emerging antimicrobial resistance (AMR) is considered an important step in the formulation of antibiotic policy for early treatment and judicious use of antibiotics. In this review on etiology and its antibiogram in community acquired BSI, S. typhi followed by S. paratyphi A were the major bacterial isolates. Quinolone resistance of more than 90% in Salmonella is now reported from all over India. Ceftriaxone remains the drug of choice for enteric fever due to its 100% susceptibility. In PICU there is an emergence of candidemia due to non-albicans candida which are now predominant isolates at few centers. BSI due to gram-negative bacteria, mostly by Klebseilla pneumoniae and gram-positive cocci (S. aureus) are the other major pathogens commonly observed in BSI from PICU. There is a high prevalence of antimicrobial resistance to commonly used antibiotics like ampicillin (94.9%-90.7%), cefotaxime (92.4%-71.4%), piperacillin-tazobactum (31.2%-27.5%) and levofloxacin (42.4%-39.8%). Resistance to carbapenems, primarily due to bla_NDM is seen in all the centers and the rate varies between 1%- 79% with K. pneumoniae and A. baumannii showing the maximum resistance. This review highlights the magnitude of the AMR in the pediatric population and calls for the urgent implementation of antimicrobial stewardship programs to save the remaining antimicrobials.

Incidence of Healthcare-Associated Influenza-Like Illness After a Primary Care Encounter Among Young Children

BACKGROUND

Despite potential respiratory virus transmission in pediatric clinics, little is known about the risk of healthcare-associated viral infections attributable to outpatient encounters. We evaluated whether exposure to a pediatric clinic visit was associated with subsequent influenza-like illness (ILI).

METHODS

Using electronic health record data, we conducted a retrospective cohort study of all children aged <6 years who presented to a provider in a 29-clinic pediatric primary care network for a non-ILI-related encounter over 2 respiratory virus seasons (September 1, 2012, to April 30, 2014). We defined a risk period for potential healthcare-associated (HA) ILI of 1 to 8 days after a non-ILI clinic visit and identified all cases of ILI to compare the incidences of ILI visits 1 to 8 days after a non-ILI encounter and those of visits >8 days after a non-ILI encounter.

RESULTS

Among 149987 children <6 years of age (mean age, 2.5 years) with ≥1 non-ILI visit during the study period, 531928 total encounters and 13951 (2.9%) ILI encounters were identified; 1941 (13.9%) occurred within the HA-ILI risk window. The incidence rate ratios (IRRs) for ILI 1 to 8 days after compared with ILI >8 days after a non-ILI visit during season 1 were 1.36 (95% confidence interval, 1.22-1.52) among children ≥2 years of age and 1.01 (95% confidence interval, 0.93-1.09) among children <2 years of age. Estimates remained consistent during season 2 and with a risk window of 3, 4, or 9 days.

CONCLUSIONS

Pediatric clinic visits during a respiratory virus season were significantly associated with an increased incidence of subsequent ILI among children aged 2 to 6 years but not among those aged <2 years. These findings support the hypothesis that respiratory virus transmission in a pediatric clinic can result in HA ILI in young children.

Acute Infectious Diarrhea

Acute infectious diarrhea (AID) is one of the most common diseases in pediatric age with relevant burden both in high- and in low-income countries.Thanks to their direct action on enterocyte functions and indirect actions on mucosal and systemic immune system and intestinal microenvironment, probiotics are an ideal intervention to manage AID in childhood. However, their efficacy is strictly related to strains and indications, and practitioners should take this information into account in clinical practice.This chapter summarizes the main mechanisms of action of probiotics in AID, with a focus on proof of efficacy supporting their use in prevention and treatment of infant AID.The use of selected strains in appropriate doses is strongly recommended by guidelines of AID, based on large and consistent proofs of efficacy and safety. At present, therapy with probiotics of AID is arguably the strongest indication for probiotics in medicine. Future research should investigate probiotic efficacy in at-risk populations and settings where the evidence is missing.Their role in prevention of AID is however questionable in healthy population, whereas it should be considered in at-risk population. Evidence for prevention of diarrhea in day-care centers and communities is lacking, but consistent evidence supports efficacy in prevention of hospital acquired diarrhea.Overall, AID is the most convincing area for probiotic use in children, and effective strains should be used early after onset of symptoms.

Use of Probiotics in the Prevention of Nosocomial Infections

Nosocomial, hospital-acquired or health care-associated infections occur worldwide, affecting both developed and developing countries. This results in a prolonged hospital stay, increased antimicrobial resistance, increased mortality rate, and significant financial burden on the health care system. Routine preventive measures have led to the decrease in infection spreading; however, it cannot successfully prevent all of them, making a place for the development of new strategies, including probiotics. The aim of this review was to summarize available evidence of the role of probiotics in the prevention of nosocomial infections in children. Currently there is enough evidence showing that Lactobacillus rhamnosus GG administrated in a dose of at least 10 colony-forming units per day during the hospital stay can significantly reduce a risk for nosocomial diarrhea at regular pediatric ward. For other indications including the risk of respiratory tract infections at regular pediatric ward or risk of nosocomial infections at intensive care units we do not have enough evidence to give a recommendation. Therefore, additional research is needed to increase our knowledge and possibly further improve clinical practice.

Guidance on the use of probiotics in clinical practice in children with selected clinical conditions and in specific vulnerable groups

AIM

The use of probiotics has been covered by many guidelines, position papers and evidence-based recommendations, but few have referred to specific patient groups or clinical indications. This review summarises recommendations and scientifically credited guidelines on the use of probiotics for children with selected clinical conditions and provides practice points.

METHODS

An expert panel was convened by the European Paediatric Association in June 2017 to define the relevant clinical questions for using probiotics in paediatric health care and review and summarise the guidelines, recommendations, position papers and high-quality evidence.

RESULTS

The panel found that specific probiotic strains were effective in preventing antibiotic-associated and nosocomial diarrhoea, treating acute gastroenteritis and treating infantile colic in breastfed infants. However, special caution is indicated for premature infants, immunocompromised and critically ill patients and those with central venous catheters, cardiac valvular disease and short-gut syndrome. This review discusses the safety of using probiotics in selected groups of paediatric patients and the quality of the available products providing practice points based on proved findings.

CONCLUSION

Efficacy of probiotics is strain specific. Their benefits are currently scientifically proven for their use in selected clinical conditions in children and not recommended for certain patient groups.

Outpatient Infection Prevention: A Practical Primer

As more patients seek care in the outpatient setting, the opportunities for health care-acquired infections and associated outbreaks will increase. Without uptake of core infection prevention and control strategies through formal initiation of infection prevention programs, outbreaks and patient safety issues will surface. This review provides a step-wise approach for implementing an outpatient infection control program, highlighting some of the common pitfalls and high-priority areas.

Probiotics for the Prevention of Nosocomial Diarrhea in Children

This document provides recommendations developed by the ESPGHAN Working Group on Probiotics and Prebiotics on the role of probiotics in the prevention of nosocomial diarrhea in children based on a systematic review of previously completed systematic reviews and of subsequently published randomized controlled trials. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation guidelines. Recommendations were given only if at least 2 randomized controlled trials examined the same probiotic strain. Based on currently available evidence the Working Group recommends using Lactobacillus rhamnosus GG if the use of probiotics for preventing nosocomial diarrhea in children is considered.

Probiotics in Children: What Is the Evidence?

The number of papers discussing probiotics increases tremendously that limits the possibility for primary care physicians and clinicians to stay updated. Therefore, the aim of this paper will be to summarize available evidence of probiotic use in well-defined clinical indications of importance for pediatricians. Based on currently available evidence certain probiotic strains (Lactobacillus rhamnosus GG [LGG] and Saccharomyces boulardii) have proven effect in the treatment of acute gastroenteritis and prevention of antibiotic associated diarrhea. Furthermore, LGG was proven to be effective in prevention of nosocomial diarrhea and respiratory tract infection in day care centers. In conclusion, not all probiotic strains have same efficacy for all clinical indications, therefore, only strains with proven efficacy and safety should be recommended.

Prospective surveillance of healthcare associated infections in a Cambodian pediatric hospital

Background

Healthcare associated infections (HAI) are the most common preventable adverse events following admission to healthcare facilities. Data from low-income countries are scarce. We sought to prospectively define HAI incidence at Angkor Hospital for Children (AHC), a Cambodian pediatric referral hospital.

Methods

Prospective HAI surveillance was introduced for medical admissions to AHC. Cases were identified on daily ward rounds and confirmed using locally adapted Centers for Disease Control and Prevention (CDC) definitions. During the surveillance period, established infection prevention and control (IPC) activities continued, including hand hygiene surveillance. In addition, antimicrobial stewardship practices such as the creation of an antimicrobial guideline smartphone app were introduced.

Results

Between 1st January and 31st December 2015 there were 3,263 medical admissions and 102 HAI cases. The incidence of HAI was 4.6/1,000 patient-days (95% confidence interval 3.8–5.6) and rates were highest amongst neonates. Median length of stay was significantly longer in HAI cases: 25 days versus 5 days for non-HAI cases (p < 0.0001). All-cause in-hospital mortality increased from 2.0 to 16.1% with HAI (p < 0.0001). Respiratory infections were the most common HAI (54/102; 52.9%). Amongst culture positive infections, Gram-negative organisms predominated (13/16; 81.3%). Resistance to third generation cephalosporins was common, supporting the use of more expensive carbapenem drugs empirically in HAI cases. The total cost of treatment for all 102 HCAI cases combined, based on additional inpatient days, was estimated to be $299,608.

Conclusions

Prospective HAI surveillance can form part of routine practice in low-income healthcare settings. HAI incidence at AHC was relatively low, but human and financial costs remained high due to increased carbapenem use, prolonged admissions and higher mortality rates.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-017-0172-5) contains supplementary material, which is available to authorized users.

Essentials of infection prevention in the pediatric population

Application of infection prevention and control (IP&C) measures is synonymous with safety, quality, resource saving, and the rights of all patients, staff and visitors. An extensive literature review was undertaken to identify key IP&C measures that address pediatric-specific requirements, taking into account age-related factors, diseases that occur most frequently among pediatric populations, and the important role of the caregiver in prevention and disease transmission. IP&C initiatives that target and incorporate both human (intrinsic) and environmental (extrinsic) sources of infection are population specific and guide practices and provide safe caring environments when used appropriately.

Categories of care specifically geared to the pediatric age-group (0–14 years) are divided into two categories: within-the-healthcare system and outside-of-the-healthcare setting. By taking into account the child's developmental age; physiological, psycho-social and immunological development; differing impacts on the body's natural defense mechanisms, including procedural, device type and length of utilization; and availability of specific technologies and disciplines, the caregiver IP&C strategies can be developed and tailored to address specific needs. Within-the-healthcare setting strategies focus on surveillance, standard and transmission-based precautions, the immune system, age-related factors, institutional regulations, the family and visitation. Outside the healthcare setting preventative and protective measures are vital for providing maximum and comprehensive care. Care provided within and outside the healthcare setting can either be independent of each other or work together to maximize the health and safety of the child.

This review article highlights the importance of IP&C knowledge, need for strict adherence to approved standards, and need for auditing compliance to achieve the ultimate goal of providing safe, quality care as well as an infection-free environment.

Randomised clinical trial: a Lactobacillus GG and micronutrient-containing mixture is effective in reducing nosocomial infections in children, vs. placebo

BACKGROUND

Nosocomial infections are a major public health issue and preventative strategies using probiotics and micronutrients are being evaluated.

AIM

To investigate the efficacy of a mixture of Lactobacillus GG and micronutrients in preventing nosocomial infections in children.

METHODS

A randomised, double-blind, placebo-controlled trial was conducted in hospitalised children. Children (6 months to 5 years of age) received Lactobacillus GG (6 × 10(9) CFU/day) together with vitamins B and C and zinc or placebo, for 15 days, starting on the first day of hospitalisation. The incidence of gastrointestinal and respiratory nosocomial infections after discharge was determined by follow-up telephone call at 7 days. After 3 months, another telephone call estimated the incidence of further infections during follow-up.

RESULTS

Ninety children completed the follow-up. Of 19/90 children with a nosocomial infection (20%), 4/45 children (9%) were in the treatment group and 15/45 (33%) in the placebo group (P = 0.016). Specifically, 2/45 (4%) children in the treatment group vs. 11/45 (24%) children in the placebo group (P = 0.007) presented with diarrhoea. The duration of hospitalisation was significantly shorter in the treatment group (3.9 days ± 1.7 vs. 4.9 ± 1.2; P = 0.003). At the follow-up, a total of 11/45 (24.4%) children in the treatment group had at least one episode of infection compared to 22/45 (48.9%) in the placebo group (P = 0.016).

CONCLUSION

A mixture containing Lactobacillus GG and micronutrients may reduce the incidence of nosocomial infections, supporting the hypothesis that this may represent a valid strategy to prevent nosocomial infections.

The design and testing of interactive hospital spaces to meet the needs of waiting children

OBJECTIVE

To design an innovative interactive media display in a pediatric hospital clinic waiting space that addresses the growing demand for accessible, contact-surface-free options for play.

BACKGROUND

In healthcare settings, waiting can be anxiety provoking for children and their accompanying family members. Opportunities for positive distraction have been shown to reduce waiting anxiety, leading to positive health outcomes.

METHODS

An interactive media display, ScreenPlay, was created and evaluated using a participatory design approach and a combination of techniques including quality function deployment and mixed data elicitation methods (questionnaires, focus groups, and observations). The user and organizational design requirements were established and used to review contemporary strategies for positive distraction in healthcare waiting spaces and to conceptualize and test ScreenPlay. Ten staff members, 11 children/youths, and 6 parents participated in the design and evaluation of ScreenPlay.

RESULTS

ScreenPlay provided a positive, engaging experience without the use of contact surfaces through which infections can be spread. It was accessible to children, youth, and adults of all motor abilities. All participants strongly agreed that the interactive media display would improve the healthcare waiting experience.

CONCLUSIONS

ScreenPlay is an interactive display that is the result of a successful model for the design of healthcare waiting spaces that is collaborative, interdisciplinary, and responsive to the needs of its community.

KEYWORDS

Design process, healing environments, hospital, interdisciplinary, pediatric.

What are the indications for using probiotics in children?

The health benefits of probiotics have been the subject of extensive research. Still, some questions are being repeatedly asked: should one use or not use probiotics? If yes, how and when should probiotics be used? The purpose of this review is to summarise current evidence on specific probiotics' efficacy and safety to help healthcare professionals make evidence-based decisions on the indications for using specific probiotic strains or combinations in children. To identify relevant data, searches of MEDLINE and the Cochrane Library databases were performed in July 2015 to locate randomised controlled trials or their meta-analyses published in the last five years. The MEDLINE database also was searched for evidence-based clinical practice guidelines, developed by scientific societies. Considering that probiotics have strain-specific effects, the main focus was on data on individual probiotic strains, not on probiotics in general.

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing bacterial complications in children aged two months to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 7), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August week 1, 2015) and EMBASE (1974 to August 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing antibiotic prescriptions with placebo or no treatment in children aged two months to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated, so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.We found no studies assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Effectiveness of Lactobacillus reuteri DSM 17938 for the Prevention of Nosocomial Diarrhea in Children: A Randomized, Double-blind, Placebo-controlled Trial

BACKGROUND

Multiple studies of probiotics used to prevent nosocomial diarrhea have provided conflicting results. The effects likely depend on the probiotic strain and/or dosage. The aim of this study was to assess the effectiveness of Lactobacillus reuteri DSM 17938 (L. reuteri; daily dose of 1 × 10 colony forming units) for preventing nosocomial diarrhea in children.

METHODS

We conducted a multicenter, randomized, double-blind, placebo-controlled trial in 184 children, 1-48 months of age, admitted to the hospital for reasons other than diarrhea. A computer-generated randomization scheme was used to allocate participants to receive either L. reuteri (n = 91) at a daily dose of 1 × 10 colony forming units, for the duration of hospitalization, or an identical appearing placebo (n = 93). Patients, study personnel and data analysts were blinded to assignment. The primary outcome was the occurrence of nosocomial diarrhea (≥3 loose or watery stools in 24 hours that occurred >72 hours after admission). Analysis was by intention-to-treat.

RESULTS

Baseline characteristics were similar in the 2 groups. Nosocomial diarrhea occurred in 13 (7.1%) children. No difference was found between the L. reuteri and the placebo groups (7/91 vs 6/93, respectively; relative risk: 1.19; 95% confidence interval: 0.43-3.27). There was also no difference between the L. reuteri and placebo groups for any of the secondary outcomes, including adverse effects. Rotavirus vaccination status had no effect on the results.

CONCLUSION

L. reuteri in the dosage regimen used was not effective in preventing nosocomial diarrhea in children.

Imaging fungal infections in children

Fungal infections in children rarely occur, but continue to have a high morbidity and mortality despite the development of newer antifungal agents. It is essential for these infections to be diagnosed at the earliest possible stage so appropriate treatment can be initiated promptly. The addition of high-resolution computer tomography (HR CT) has helped in early diagnosis making; however, it lacks both sensitivity and specificity. Metabolic changes precede anatomical changes and hybrid imaging with positron emission tomography (PET) integrated with imaging modalities with high anatomical resolution such as CT or magnetic resonance imaging (MRI) is likely to detect these infections at an earlier stage with higher diagnostic accuracy rates. Several authors presented papers highlighting the advantages of PET/CT in imaging fungal infections. These papers, however, usually involve a limited number of patients and mostly adults. Fungal infections behave different in children than in adults, since there are differences in epidemiology, imaging findings, and response to treatment with antifungal drugs. This paper reviews the literature and explores the use of hybrid imaging for diagnosis and therapy decision making in children with fungal infections.

Health care-associated infection surveillance in a tertiary neonatal intensive care unit: A prospective clinical study after moving to a new building

BACKGROUND

There are very few prospective clinical studies on neonatal health care-associated infection (HAI) surveillance. HAI surveillance helps reduce not only mortality, but also morbidity, length of hospital stay, and health care costs.

METHODS

This prospective clinical study covered a period of 12 months in a tertiary neonatal intensive care unit (NICU). HAI rates were calculated using different denominators: number of patients hospitalized in the NICU, number of patient-days, and number of specific device-days.

RESULTS

The HAI rate was 18%, and the incidence density was 17/1,000 patient-days. The most common HAI was bloodstream infection (n = 34; 50%). The most common pathogen was coagulase-negative staphylococci (CoNS; 54.9%) in gram-positive bacteria and in general. Methicillin resistance was 96.4% for CoNS. Klebsiella spp (13.7%) was the most common gram-negative bacteria. Extended-spectrum β-lactamase positivity was 14.3% for Klebsiella spp and 25% for Escherichia coli. HAI-related mortality was 0.3%.

CONCLUSIONS

NICUs should perform their own HAI surveillance with prospective clinical design. Attention paid to handwashing, disinfection and sanitizing, complying with the terms of asepsis, extending in-service training, increasing the number of medical staff, preventing frequent changes in health care staff positions, and improving physical environmental conditions in NICUs might eventually decrease HAI rates.

Probiotics for Prevention and Treatment of Diarrhea

Probiotics are increasingly used for prevention and treatment of diarrhea more in children than in adults. Given the broad spectrum of diarrhea, this review focuses on the main etiologies: acute gastroenteritis, antibiotic-associated diarrhea (AAD), and necrotizing enterocolitis (NEC). For each, we reviewed randomized controlled trials, meta-analyses, and guidelines. For acute gastroenteritis we found 12 guidelines: 5 recommended probiotics and 7 did not. However, the guidelines containing positive recommendations provided proof of evidence from clinical trials and meta-analyses. Lactobacillus rhamnosus GG (LGG) and Saccharomyces boulardii had the most compelling evidence of efficacy as they reduced the duration of the disease by 1 day. For AAD 4 meta-analyses were found, reporting variable efficacy of probiotics in preventing diarrhea, based on the setting, patient's age, and antibiotics. The most effective strains were LGG and S. boulardii. For NEC, we found 3 randomized controlled trials, 5 meta-analyses, and 4 position papers. Probiotics reduced the risk of NEC enterocolitis and mortality in preterm babies. Guidelines did not support a routine use of probiotics and asked for further data for such sensitive implications. In conclusion, there is strong and solid proof of efficacy of probiotics as active treatment of gastroenteritis in addition to rehydration. There is solid evidence that probiotics have some efficacy in prevention of AAD, but the number needed to treat is an issue. For both etiologies LGG and S. boulardii have the strongest evidence. In NEC the indications are more debated, yet on the basis of available data and their implications, probiotics should be carefully considered.

Respiratory viruses and their impact in healthcare

PURPOSE OF REVIEW

As viral respiratory infections are responsible for significant morbidity and mortality, and are associated with numerous challenges for infection control, we provide an overview of the most recent publications on healthcare-associated respiratory infections.

RECENT FINDINGS

Populations most susceptible to respiratory viruses include neonates, immunocompromised and elderly populations. Newer polymerase chain reaction-based assays are more sensitive and are able to detect multiple respiratory viruses. The significance of virus detection among asymptomatic individuals, however, remains unclear. There is more evidence of airborne transmission of influenza, but currently N95 masks are recommended only for aerosol generating procedures. Transocular transmission of influenza has been demonstrated in the experimental setting, but further research is needed of transocular transmission of other respiratory viruses. Mandatory vaccination of healthcare workers against influenza has been shown to reduce influenza rates and patient mortality.

SUMMARY

Infection control measures can be supplemented with use of polymerase chain reaction testing to determine causes, but the cornerstone of prevention relies on enforcing appropriate isolation measures for patients: hand hygiene; appropriate use of personal protective equipment by healthcare workers; illness screening of visitors; and influenza vaccination of healthcare workers, patients and families.

Preventing the Spread of Pertussis in Pediatric Healthcare Settings

The surge in pertussis incidence in recent years underscores a critical need for effective plans to prevent transmission in pediatric healthcare settings. Adolescents and adults are common sources of infection for unimmunized or incompletely immunized infants and children with waning immunity. Despite documented outbreaks being limited in size, pertussis poses a threat to pediatric healthcare facilities due to the risk for widespread transmission, potentially severe complications among vulnerable patient populations, and high outbreak control-related costs. Healthcare personnel, visitors, and parents have been identified as sources of outbreaks, underscoring the importance of coordinated efforts to prevent transmission in these settings. This comprehensive review demonstrates that the risk of pertussis transmission in pediatric healthcare settings warrants heightened focus on strategies to recognize disease earlier, improve diagnostic evaluation, and facilitate effective contact tracing and post-exposure prophylaxis measures. This review suggests that healthcare personnel can play a significant role in the prevention of healthcare-associated pertussis.

Bacteremia in children: epidemiology, clinical diagnosis and antibiotic treatment

The diagnosis of bacteremia in children is important and it can be clinically challenging to recognize the signs and symptoms. The reported rates of bacteremia are higher in young children but with the increasing vaccine coverage, there has been a decrease in bacteremia due to the three vaccine preventable bacteria (Streptococcus pneumoniae, Haemophilus influenzae group b and Neisseria meningitidis). Notably, there have been increases in healthcare-associated bacteremias with a rise in Staphylococcus aureus and Gram negative bacteremias. This review provides a brief overview of the clinical diagnosis of bacteremia in children, focusing on the epidemiology, clinical characteristics, risk factors, antibiotic treatment, outcomes and preventative measures to reduce the incidence of bacteremia and improve morbidity and mortality.

Bifidobacterium animalis subsp. lactis fails to prevent common infections in hospitalized children: a randomized, double-blind, placebo-controlled study

BACKGROUND

The incidence of nosocomial infections in children in developed countries is still high, ranging from 8% to 30%, and standard preventive measures, such as increased hygiene, are not sufficiently efficacious. One of the potential strategies for their prevention is the use of probiotics.

OBJECTIVE

The aim of the study was to investigate the role of Bifidobacterium animalis subsp. lactis in preventing nosocomial infections in the acute hospital setting.

DESIGN

We conducted a randomized, double-blind, placebo-controlled trial in 727 hospitalized children (aged 1-18 y). The children were randomly allocated to receive placebo (placebo group, n = 365) or B. animalis subsp. lactis at a dose of 10(9) colony-forming units/d (intervention group, n = 362) once daily for the entire duration of the hospital stay. Nosocomial infections were defined as infections that occurred >48 h after hospital admission and that were not present or incubating at the time of admission.

RESULTS

Analysis was performed on an intention-to-treat basis. There was no difference in the study primary outcome or incidence of common nosocomial gastrointestinal and respiratory tract infections between groups (22 vs. 29 infections, respectively; incidence rate ratio = 0.76; 95% CI: 0.41, 1.36; P = 0.32). No difference was found for the duration of common nosocomial infections [mean (range): 3.58 (1-7) vs. 3.79 (1-8) d, in placebo vs. intervention group; P = 0.74]. There was also no difference between the intervention and placebo groups for any of the other secondary outcomes (incidence of gastrointestinal and respiratory tract infections separately, duration of gastrointestinal and respiratory infections, and duration of hospitalization) and exploratory outcomes (gastrointestinal and respiratory symptoms, severity of gastrointestinal and respiratory tract infections, and the use of antibiotics).

CONCLUSIONS

The results of this study show that the use of B. animalis subsp. lactis failed to prevent nosocomial infections in an acute-setting pediatric hospital in children who were >1 y of age. However, it should be taken into account that the overall incidence of nosocomial infections was lower than expected. This trial was registered at clinicaltrials.gov as NCT01702766.

Are well-child visits a risk factor for subsequent influenza-like illness visits?

OBJECTIVE

To determine whether well-child visits are a risk factor for subsequent influenza-like illness (ILI) visits within a child's family.

DESIGN

Retrospective cohort.

METHODS

Using data from the Medical Expenditure Panel Survey from the years 1996-2008, we identified 84,595 families. For each family, we determined those weeks in which a well-child visit or an ILI visit occurred. We identified 23,776 well-child-visit weeks and 97,250 ILI-visit weeks. We fitted a logistic regression model, where the binary dependent variable indicated an ILI clinic visit in a particular week. Independent variables included binary indicators to denote a well-child visit in the concurrent week or one of the previous 2 weeks, the occurrence of the ILI visit during the influenza season, and the presence of children in the family in each of the age groups 0-3, 4-7, and 8-17 years. Socioeconomic variables were also included. We also estimated the overall cost of well-child-exam-related ILI using data from 2008.

RESULTS

We found that an ILI office visit by a family member was positively associated with a well-child visit in the same or one of the previous 2 weeks (odds ratio, 1.54). This additional risk translates to potentially 778,974 excess cases of ILI per year in the United States, with a cost of $500 million annually.

CONCLUSIONS

Our results should encourage ambulatory clinics to strictly enforce infection control recommendations. In addition, clinics could consider time-shifting of well-child visits so as not to coincide with the peak of the influenza season.

[Sensitivity profile of Staphylococcus spp. and Streptococcus spp. isolated from toys used in a teaching hospital playroom]

Objective:

To evaluate the presence of microorganisms of the genus Staphylococcus and Streptococcus on toys in the playroom of a teaching hospital, as well to as analyze the antimicrobial resistance from isolated strains.

Methods:

Samples were collected from 60 toys, using wet swabs, soon after being used by the children. The samples were inoculated in enriched and selective agar for isolation and later identification of the microorganisms. Antibiogram testing was performed by agar diffusion technique.

Results:

The genus Staphylococcus was present in 87.0% (52/60) of the toys. Seventy-three strains were isolated, with 29.0% (21/73) coagulase-positive and 71.0% (52/73) coagulasenegative. Among the coagulase-negative strains, 90.4% were resistant to penicillin, 65.4% to oxacillin, 28.8% to clarithromycin, 61.5% to clindamycin, and none to vancomycin. Among the coagulase-positive strains, 76.2% were resistant to penicillin, 23.8% to oxacillin, 23.8% to clarithromycin, 47.6% to clindamycin, and none to vancomycin. The genus Streptococcus was not detected in any of the evaluated toys.

Conclusions:

Toys can be contaminated with potentially pathogenic bacteria with antimicrobial resistance, representing a possible source of nosocomial infection for patients who are already debilitated.

Pattern of Blood Stream Infections within Neonatal Intensive Care Unit, Suez Canal University Hospital, Ismailia, Egypt

Introduction. Blood stream infection (BSI) is a common problem of newborn in neonatal intensive care units (NICUs). Monitoring neonatal infections is increasingly regarded as an important contributor to safe and high-quality healthcare. It results in high mortality rate and serious complications. So, our aim was to determine the incidence and the pattern of BSIs in the NICU of Suez Canal University Hospital, Egypt, and to determine its impact on hospitalization, mortality, and morbidity. Methods. This study was a prospective one in which all neonates admitted to the NICUs in Suez Canal University hospital between January, 2013 and June 2013 were enrolled. Blood stream infections were monitored prospectively. The health care associated infection rate, mortality rate, causative organism, and risk factors were studied. Results. A total of 317 neonates were admitted to the NICU with a mortality rate of 36.0%. During this study period, 115/317 (36.3%) developed clinical signs of sepsis and were confirmed as BSIs by blood culture in only 90 neonates with 97 isolates. The total mean length of stay was significantly longer among infected than noninfected neonates (34.5 ± 18.3 and 10.8 ± 9.9 days, resp., P value < 0.001). The overall mortality rates among infected and noninfected neonates were 38.9% and 34.8%, respectively, with a significant difference. Klebsiella spp. were the most common pathogen (27.8%) followed by Pseudomonas (21.6%) and Staphylococcus aureus (15.4%). Conclusion. The rate of BSIs in NICU at Suez Canal University Hospital was relatively high with high mortality rate (36.0%).

Antibiotics for preventing suppurative complications from undifferentiated acute respiratory infections in children under five years of age

BACKGROUND

Undifferentiated acute respiratory infections (ARIs) are a large and heterogeneous group of infections not clearly restricted to one specific part of the upper respiratory tract, which last for up to seven days. They are more common in pre-school children in low-income countries and are responsible for 75% of the total amount of prescribed antibiotics in high-income countries. One possible rationale for prescribing antibiotics is the wish to prevent bacterial complications.

OBJECTIVES

To assess the effectiveness and safety of antibiotics in preventing complications in children aged two to 59 months with undifferentiated ARIs.

SEARCH METHODS

We searched CENTRAL 2013, Issue 4, MEDLINE (1950 to May week 2, 2013) and EMBASE (1974 to May 2013).

SELECTION CRITERIA

Randomised controlled trials (RCT) or quasi-RCTs comparing antibiotic prescriptions with placebo or non-treatment in children up to 59 months with an undifferentiated ARI for up to seven days.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted and analysed data using the standard Cochrane methodological procedures.

MAIN RESULTS

We identified four trials involving 1314 children. Three trials investigated the use of amoxicillin/clavulanic acid to prevent otitis and one investigated ampicillin to prevent pneumonia.The use of amoxicillin/clavulanic acid compared to placebo to prevent otitis showed a risk ratio (RR) of 0.70 (95% confidence interval (CI) 0.45 to 1.11, three trials, 414 selected children, moderate-quality evidence). Methods of random sequence generation and allocation concealment were not clearly stated in two trials. Performance, detection and reporting bias could not be ruled out in three trials.Ampicillin compared to supportive care (continuation of breastfeeding, clearing of the nose and paracetamol for fever control) to prevent pneumonia showed a RR of 1.05 (95% CI 0.74 to 1.49, one trial, 889 selected children, moderate-quality evidence). The trial was non-blinded. Random sequence generation and allocation concealment methods were not clearly stated so the possibility of reporting bias could not be ruled out.Harm outcomes could not be analysed as they were expressed only in percentages.No studies were found assessing mastoiditis, quinsy, abscess, meningitis, hospital admission or death.

AUTHORS' CONCLUSIONS

The quality of evidence currently available does not provide strong support for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up to five years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness of antibiotics in this population.

Health care worker exposures to pertussis: missed opportunities for prevention

OBJECTIVE

Pediatric health care workers (HCWs) are at particular risk for pertussis exposure, infection, and subsequent disease transmission to susceptible patients. This cross-sectional study describes the epidemiology of occupational exposures to pertussis and identifies factors that may inform interventions to promote effective implementation of infection prevention and control (IPC) guidelines.

METHODS

We abstracted data from occupational health (OH) and IPC records for pertussis cases that resulted in an exposure investigation in a large quaternary pediatric care network, January 1, 2002 to July 18, 2011. We calculated the frequency of occupational exposures and measured associated characteristics. To assess the frequency of potential missed exposures, we reviewed electronic health record (EHR) data identifying laboratory-confirmed pertussis cases not documented in OH or IPC records.

RESULTS

A total of 1193 confirmed HCW pertussis exposures were associated with 219 index cases during the study period. Of these, 38.8% were infants <6 months old and 7 were HCWs. Most (77.5%) of exposures occurred in the emergency department or an ambulatory site; 27.0% of exposures occurred after documented initiation of IPC precautions. We identified 450 laboratory-confirmed pertussis cases through EHR review, of which 49.8% (N = 224) had no OH or IPC investigation. The majority of uninvestigated cases (77.2%) were from ambulatory sites.

CONCLUSIONS

Occupational exposures to pertussis occur frequently in pediatric health care settings despite appropriate IPC guidelines. Interventions are needed to ensure consistent implementation of IPC practices and timely identification and reporting of pertussis index cases to prevent HCW exposures and potential transmission to patients.

Hand hygiene compliance in transplant and other special patient groups: an observational study

BACKGROUND

This study evaluates hand hygiene behavior of health care workers in a German university hospital stratified for treatment of special patient groups (eg, transplant patients).

METHODS

From 2008 to 2010, comprehensive education and training of all health care workers was implemented to improve hand hygiene compliance. Consumption rates of alcohol-based hand rub and gloves were collected and evaluated.

RESULTS

Of the 5,647 opportunities of hand disinfection evaluated, 1,607 occurred during care for transplant patients. To our knowledge, this is the largest survey of hand hygiene compliance in special patient groups on intensive care units in a university hospital in Germany. Health care workers on surgical intensive care units showed lower hand hygiene compliance compared with health care workers on other types of intensive care units. Compliance toward hand hygiene was significantly higher on hemato-oncologic and pediatric wards. In general, hand disinfection was performed significantly more frequently after an intervention than before (P < .05, 95% confidence interval: 1.24-1.84). Overall, there was no significant difference in hand hygiene compliance when caring for transplant patients or other patients (odds ratio, 1.16; 95% confidence interval: 0.95-1.42). Nurse's and physician's hand hygiene compliance improved because of education.

CONCLUSION

Hand hygiene compliance is not increased in the care for transplant patients (despite their predisposition for nosocomial infections) compared with other patients. Additional studies will be necessary to further investigate these findings.

Infecciones nosocomiales en pediatría

Numerosas son las particularidades de la población pediátrica que deben intervenir, en nuestra opinión, en el control de las infecciones nosocomiales. Los riesgos y los agentes patógenos responsables son diferentes en función del tipo de población (prematuros, recién nacidos, otros). Además, esta población, que comparte los mismos factores de riesgo de infecciones nosocomiales que la población adulta (hospitalización en reanimación, cateterismos, etc.), se distingue no sólo por la inmadurez del sistema inmunitario de los recién nacidos, sino también por la multiplicidad de los participantes, desde los sanitarios hasta los padres, pasando por los educadores y los acompañantes (visitantes de todo tipo, etc.) necesarios para el desarrollo conductual y emocional del niño. Además, es importante subrayar el aumento del riesgo ligado a los contactos frecuentes, cercanos e íntimos que están parcial e incluso totalmente ausentes en el ámbito hospitalario «adulto». Así como existen riesgos de transmisión cruzada a través del principal vector constituido por los sanitarios, el control del riesgo no puede excluir a los educadores, a los acompañantes, a los padres y a los mismos niños. Si el riesgo en la esfera adulta está limitado a las actividades médicas, en la esfera pediátrica se comparte con las demás actividades (juegos, enseñanza, etc.), que con frecuencia son comunes. Todos estos riesgos son todavía mayores debido a la prevalencia de los agentes patógenos como los virus (respiratorios y digestivos), la frecuencia de las antibioticoterapias y la dificultad de los diagnósticos etiológicos, dada la inespecificidad de los signos clínicos y la actitud diagnóstica poco o nada invasiva. De esta manera, el control del riesgo infeccioso nosocomial se resume en los siguientes elementos: un reservorio importante y difícilmente identificable, numerosos vectores potenciales, una población expuesta de manera variable al riesgo, todo ello sin olvidar las necesidades emocionales de los niños y los comportamientos «culturales».

Clinical and economical impact of multiplex respiratory virus assays

During the last decade, a variety of molecular assays targeting respiratory viruses have been developed and commercialized. Therefore, multiplex PCR are increasingly used in everyday clinical practice. This improves our understanding of respiratory virus epidemiology and enhances our concerns about their clinical impact in specific patient populations. However, questions remain regarding cost-effectiveness of performing these diagnostic tests in routine and their real impact on patient care. This article will review available data and highlight unresolved questions about cost-effectiveness, infection control, clinical utility and public health impact of multiplex respiratory virus assays.

The value of intermittent point-prevalence surveys of healthcare-associated infections for evaluating infection control interventions at Angkor Hospital for Children, Siem Reap, Cambodia

Background

There are limited data on the epidemiology of paediatric healthcare-associated infection (HCAI) and infection control in low-income countries. We describe the value of intermittent point-prevalence surveys for monitoring HCAI and evaluating infection control interventions in a Cambodian paediatric hospital.

Methods

Hospital-wide, point-prevalence surveys were performed monthly in 2011. Infection control interventions introduced during this period included a hand hygiene programme and a ventilator-associated pneumonia (VAP) care bundle.

Results

Overall HCAI prevalence was 13.8/100 patients at-risk, with a significant decline over time. The highest HCAI rates (50%) were observed in critical care; the majority of HCAIs were respiratory (61%). Klebsiella pneumoniae was most commonly isolated and antimicrobial resistance was widespread. Hand hygiene compliance doubled to 51.6%, and total VAP cases/1000 patient-ventilator days fell from 30 to 10.

Conclusion

Rates of HCAI were substantial in our institution, and antimicrobial resistance a major concern. Point-prevalence surveys are effective for HCAI surveillance, and in monitoring trends in response to infection control interventions.

Improvement of adherence to hand hygiene practice using a multimodal intervention program in a neonatal intensive care

Nosocomial infections are serious complications among preterm infants admitted to neonatal intensive care units (NICU). Hand hygiene is one of the most effective measures to prevent these infections. This study, performed in a tertiary level NICU, highlights the importance of a multimodal intervention program for adherence to hand hygiene. The compliance with hand hygiene among health care workers of the NICU increased significantly from 23% in the baseline assessment to 50% in the second assessment and the incidence of sepsis decreased from 13.4% to 11.3% after implementation of an intervention program.

Risk of parenteral nutrition in neonates--an overview

Healthcare-associated infections (HAI) in preterm infants are a challenge to the care of these fragile patients. HAI-incidence rates range from 6 to 27 infections per 1000 patient-days. Most nosocomial infections are bloodstream infections and of these, the majority is associated with the use of central venous catheters. Many studies identified parenteral nutrition as an independent risk factor for HAI, catheter-associated bloodstream infection, and clinical sepsis. This fact and various published outbreaks due to contaminated parenteral nutrition preparations highlight the importance of appropriate standards in the preparation and handling of intravenous solutions and parenteral nutrition. Ready-to-use parenteral nutrition formulations may provide additional safety in this context. However, there is concern that such formulations may result in overfeeding and necrotizing enterocolitis. Given the risk for catheter-associated infection, handling with parenteral nutrition should be minimized and the duration shortened. Further research is required about this topic.

Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil

INTRODUCTION

Catheter-associated bloodstream infection (CA-BSI) is the most common nosocomial infection in neonatal intensive care units. There is evidence that care bundles to reduce CA-BSI are effective in the adult literature. The aim of this study was to reduce CA-BSI in a Brazilian neonatal intensive care unit by means of a care bundle including few strategies or procedures of prevention and control of these infections.

METHODS

An intervention designed to reduce CA-BSI with five evidence-based procedures was conducted.

RESULTS

A total of sixty-seven (26.7%) CA-BSIs were observed. There were 46 (32%) episodes of culture-proven sepsis in group preintervention (24.1 per 1,000 catheter days [CVC days]). Neonates in the group after implementation of the intervention had 21 (19.6%) episodes of CA-BSI (14.9 per 1,000 CVC days). The incidence of CA-BSI decreased significantly after the intervention from the group preintervention and postintervention (32% to 19.6%, 24.1 per 1,000 CVC days to 14.9 per 1,000 CVC days, p=0.04). In the multiple logistic regression analysis, the use of more than 3 antibiotics and length of stay >8 days were independent risk factors for BSI.

CONCLUSIONS

A stepwise introduction of evidence-based intervention and intensive and continuous education of all healthcare workers are effective in reducing CA-BSI.

Lack of an effect of Lactobacillus reuteri DSM 17938 in preventing nosocomial diarrhea in children: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the efficacy of administering Lactobacillus reuteri DSM 17938 for the prevention of nosocomial diarrhea.

STUDY DESIGN

Children (n = 106; aged 1-48 months) admitted to the hospital for reasons other than diarrhea were enrolled in a randomized, double-blind, placebo-controlled trial. They received L reuteri DSM 17938 at a dose of 10(8) colony-forming units (n = 54) or a placebo (n = 52) orally, once daily, for the duration of the hospital stay.

RESULTS

Data from all children were included in the final analysis. L reuteri DSM 17938 did not significantly affect the risk of developing nosocomial diarrhea, defined as 3 loose or watery stools per day in a 24-hour period that occurred >72 hours after admission (risk ratio 1.06, 95% CI 0.7-1.5) or rotavirus infection (1.04, 0.6-1.6). There was also no difference between the probiotic and placebo groups for any of the other secondary outcomes (ie, incidence of rotavirus infection, incidence of diarrhea, duration of diarrhea, incidence of recurrent diarrhea, incidence of chronic diarrhea, length of hospital stay in days, and frequency of need for rehydration). No adverse events were reported.

CONCLUSION

In hospitalized children, the administration of L reuteri DSM 17938 compared with placebo had no effect on the overall incidence of nosocomial diarrhea, including rotavirus infection.

Bench-to-bedside review: Neonatal sepsis-redox processes in pathogenesis

The present review is aimed at elucidating the neonatal 'sepsis redox cycle' - the cascade of inflammatory and redox events involved in the pathogenesis of sepsis in neonates. While adult and neonatal sepses share some common features, there are some substantial differences: higher mortality rates occur in adult sepsis and worse long-term effects are evident in neonatal sepsis survivors. Such epidemiological data may be explained by the lower ability of IL6 and IL8 to activate NF-κB-regulated transcription in neonatal sepsis in comparison to TNF-α, which is involved in the mechanisms of adult sepsis. The activation of NF-κB in neonatal sepsis is further promoted by hydrogen peroxide and results in mitochondrial dysfunction and energy failure as septic neonates experience decreased O₂ consumption as well as lower heat production and body temperature in comparison to healthy peers. In neonates, specific organs that are still under development are vulnerable to sepsis-provoked stress, which may lead to brain, lung, and heart injury, as well as vision and hearing impairments. In the light of the processes integrated here, it is clear that therapeutic approaches should also target specific steps in the neonatal 'sepsis redox cycle' in addition to the current therapeutic approach that is mainly focused on pathogen eradication.