Comparison of hospital-acquired infection rates in paediatric burn patients

A Nomogram of Predicting Healthcare-Associated Infections in Burned Children

BACKGROUND

Healthcare-associated infections (HAIs) are a common clinical concern associated with adverse prognosis and mortality in burned children. This study aimed to construct a predictive nomogram of the risk of HAIs in burned children.

METHODS

Children admitted to the burn unit of Wuhan Third Hospital between 2020 and 2022 were included. The univariate and multivariate logistic regression analyses were adopted to ascertain predictors of HAIs. A nomogram was developed to predict the HAI risk of each patient, with receiver operating characteristic curves and calibration curves being generated to assess its predictive ability. Furthermore, decision and impact curves were used to assess the clinical utility.

RESULTS

Of 1122 burned children, 61 (5.5%) patients experienced HAIs. The multivariate analysis indicated that total burn surface area, length of stay, surgery, central venous catheter use and urinary catheter use were the independent risk factors of HAIs. Using these variables, we developed a predictive nomogram of the occurrence of HAIs in burned children, and the internal validation results demonstrated good discrimination and calibration of the nomogram. The area under the curve values of the nomogram was 0.926 (95% CI, 0.896-0.957). The calibration curve showed high consistency between the actual and predicted HAIs. The decision and impact curve indicated that the nomogram was of good clinical utility and more credible net clinical benefits in predicting HAIs.

CONCLUSIONS

The present study constructed a nomogram for predicting the risk of HAIs in burned children. This nomogram may strengthen the effective screening of patients at high risk of HAIs.

Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study

Background and Purpose :

Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients.

Materials and Methods:

Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group.

Results:

A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results, C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia.

Conclusion:

Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors.

Pediatric Burn Infection

Background: Severe burns lead to a profound hypermetabolic, hypercatabolic, hyper-inflammatory state. Pediatric burn patients are at significantly increased risk for infection and sepsis secondary to loss of the skin barrier and subsequent immunosuppression. Infection is the most common cause of morbidity and death in pediatric burn patients, and the mortality rate from sepsis remains high. Methods: Review of pertinent English-language literature pertaining to infection among pediatric burn patients. Results: Established risk factors for infection in pediatric burn patients are the depth of injury, presence of inhalation injury, indwelling devices, and total body surface area burned. Total body surface area remains one of the most important risk factors for the development of infectious complications, and mortality risks increase significantly if the burn size is >40%. The predominant colonization of burn wound starts with gram-positive organisms, which are replaced later by gram-negative organisms. Most cases of sepsis in burn patients originate from infected burn wounds. Treatment options include topical and systemic antimicrobial drugs, but surgical intervention often is the most definitive treatment. Excision of burn eschar to remove the source of potential infection is a key component of the treatment as well as prevention of infection. Conclusion: Key principles in improving outcomes for septic pediatric burn patients is early recognition, resuscitation, and adherence to management strategies such as prompt antimicrobial drug administration and source control.

Infections in Pediatric Burn Patients: An Analysis of One Hundred Eighty-One Patients

Background: Infectious complications are one of the most life-threatening complications and result in substantial mortality and morbidity in children who have been burned. The goal of the study is to assess the risk factors for sepsis in pediatric burn patients in a referral hospital. Methods: This study was performed at the Pediatric Burn Unit of Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital during the period between January 2014 and June 2017. The patients were evaluated for age, sex, burn etiology, burned body surface area (BSA), the presence of inhalation injury, sepsis, positive cultures, the micro-organisms cultured samples, and septic focus. Results: A total of 181 patients were included in the study. The most common cause of burns was scalds in 120 patients (66.3%). Forty-one patients (22.7%) developed health-care-associated infection and sepsis. Gram-negative micro-organisms were isolated in 40 (97.6%) patients (Acinetobacter spp., Pseudomonas aeruginosa, Klebsiella pneumonia) with sepsis. Carbapenem resistance was detected in 31 (93.8%) of 40 patients. Mortality was observed in 11 patients (6.1%) in the group with sepsis. Burn surface area, burn depth, C-reactive protein (CRP) values, mortality, Garcés index, and Baux index were higher in the group with sepsis (p < 0.05). Multiple regression analysis revealed that mechanism of injury (flame), burned BSA ≥25%, C-reactive protein ≥6 mg/dL (area under the curve [AUC]: 0.76 p < 0.001 and AUC: 0.90, p < 0.001, respectively) at admission were independent parameters for development of sepsis in pediatric burn patients. Conclusion: Multi-drug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii were important agents of blood stream infection in burned children. Burned BSA ≥25% and CRP ≥6 mg/dL were risk factors for developing sepsis in pediatric burn patients.

An Outcomes Study on the Effects of the Singapore General Hospital Burns Protocol

INTRODUCTION

The Singapore General Hospital Burns Protocol was implemented in May 2014 to standardize treatment for all burns patients, incorporate new techniques and materials, and streamline the processes and workflow of burns management. This study aims to analyze the effects of the Burns Protocol 2 years after its implementation.

METHODS

Using a REDCap electronic database, all burns patients admitted from May 2013 to April 2016 were included in the study. The historical preimplementation control group composed of patients admitted from May 2013 to April 2014 (n = 96). The postimplementation prospective study cohort consisted of patients admitted from May 2014 to April 2016 (n = 243). Details of the patients collected included age, sex, comorbidities, total body surface area (TBSA) burns, time until surgery, number of surgeries, number of positive tissue and blood cultures, and length of hospital stay.

RESULTS

There was no statistically significant difference in the demographics of both groups. The study group had a statistically significant shorter time to surgery compared with the control group (20.8 vs 38.1, P < 0.0001). The study group also averaged fewer surgeries performed (1.96 vs 2.29, P = 0.285), which, after accounting for the extent of burns, was statistically significant (number of surgeries/TBSA, 0.324 vs 0.506; P = 0.0499). The study group also had significantly shorter length of stay (12.5 vs 16.8, P = 0.0273), a shorter length of stay/TBSA burns (0.874 vs 1.342, P = 0.0101), and fewer positive tissue cultures (0.6 vs 1.3, P = 0.0003). The study group also trended toward fewer positive blood culture results (0.09 vs 0.35, P = 0.0593), although the difference was just shy of statistical significance.

CONCLUSIONS

The new Singapore General Hospital Burns Protocol had revolutionized Singapore burns care by introducing a streamlined, multidisciplinary burns management, resulting in improved patient outcomes, lowered health care costs, and improved system resource use.

[Risk factors for nosocomial infection in pediatric burn patients]

OBJECTIVE

The aim of our study was to determine risk factors associated with nosocomial infections in children hospitalized for skin burn.

STUDY DESIGN

Prospective study including children hospitalized for skin burn.

METHODS

We collected demographic characteristic, mode of admission, mechanism of burn, extent of burn surface by the tables of Lund and Browder, depth of the lesions according to clinical criteria and evolution, type of invasive care (urinary catheterization, central catheterization or mechanical ventilation), nosocomial infection and its time of occurrence, prescription of empirical antibiotic therapy and evolution during hospitalization. The criteria for "American Burn Association" were used to define a severe burn in children.

RESULTS

One hundred eighty-two children were included. In univariate analysis, six risk factors were significantly associated with the occurrence of nosocomial infection: extent of burn surface, severe burn, urinary catheterization and its duration and central catheterization and its duration. Extent of burn surface greater than 10% of total body surface is an independent factor of the occurrence of nosocomial infection (P=0.009) in Multivariate analysis.

CONCLUSION

In our study, extent of burn surface greater than 10% of total body surface is as an independent risk factor for the occurrence of nosocomial infection.

Ventilator-associated pneumonia in the pediatric intensive care unit: characterizing the problem and implementing a sustainable solution

OBJECTIVES

To characterize ventilator-associated pneumonia (VAP) in our pediatric intensive care unit (PICU), implement an evidence-based pediatric VAP prevention bundle, and reduce VAP rates.

STUDY DESIGN

The setting is a 25-bed PICU in a 475-bed free-standing pediatric academic medical center. VAP was diagnosed according to Centers for Disease Control and National Nosocomial Infections Surveillance System definitions. A pediatric VAP prevention bundle was established and implemented. Baseline VAP rates were compared with implementation and post-bundle-implementation periods.

RESULTS

VAP is significantly associated with increased PICU length of stay, mechanical ventilator days, and mortality rates (length of stay VAP 19.5+/-15.0 vs non-VAP 7.5+/-9.2, P< .001; ventilator days VAP 16.3+/-14.7 vs non-VAP 5.3+/-8.4, P< .001; mortality VAP 19.1% vs non-VAP 7.2%, P= .01). The VAP rate was reduced from 5.6 (baseline) to 0.3 infections per 1000 ventilator days after bundle implementation; P< .0001. Subglottic/tracheal stenosis, trauma, and tracheostomy are significantly associated with VAP.

CONCLUSIONS

PICU VAP is associated with increased morbidity and mortality rates. A multidisciplinary improvement team can implement a sustainable pediatric-specific VAP prevention bundle, resulting in VAP rate reduction.

Positive fungal cultures in burn patients: a multicenter review

Fungal infections are increasingly common in burn patients. We performed this study to determine the incidence and outcomes of fungal cultures in acutely burned patients. Members of the American Burn Association's Multicenter Trials Group were asked to review patients admitted during 2002-2003 who developed one or more cultures positive for fungal organisms. Data on demographics, site(s), species and number of cultures, and presence of risk factors for fungal infections were collected. Patients were categorized as untreated (including prophylactic topical antifungals therapy), nonsystemic treatment (nonprophylactic topical antifungal therapy, surgery, removal of foreign bodies), or systemic treatment (enteral or parenteral therapy). Fifteen institutions reviewed 6918 patients, of whom 435 (6.3%) had positive fungal cultures. These patients had mean age of 33.2 +/- 23.6 years, burn size of 34.8 +/- 22.7%TBSA, and 38% had inhalation injuries. Organisms included Candida species (371 patients; 85%), yeast non-Candida (93 patients, 21%), Aspergillus (60 patients, 14%), other mold (39 patients, 9.0%), and others (6 patients, 1.4%). Systemically treated patients were older, had larger burns, more inhalation injuries, more risk factors, a higher incidence of multiple positive cultures, and significantly increased mortality (21.2%), compared with nonsystemic (mortality 5.0%) or untreated patients (mortality 7.8%). In multivariate analysis, increasing age and burn size, number of culture sites, and cultures positive for Aspergillus or other mold correlated with mortality. Positive fungal cultures occur frequently in patients with large burns. The low mortality for untreated patients suggests that appropriate clinical judgment was used in most treatment decisions. Nonetheless, indications for treatment of fungal isolates in burn patients remain unclear, and should be developed.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Infection control in pediatric extended care facilities

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 not applicable to long-term care facilities that serve pediatric patients. This article reviews the characteristics of pediatric extended care facilities and their residents, and the epidemic and endemic nosocomial infections, infection control programs, and antimicrobial resistance profiles found in pediatric extended care facilities.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Analysis of pediatric burns in Nagasaki University from 1983 to 2002

Pediatric burns are frequently observed: twenty-year burn analysis was performed in a single department, and 354 cases, aged 0-6 years old. The major cause of pediatric burns was scalding (68%) and hot water comprised over half of the scald burns. At 1 year old and younger, the total burn surface area (TBSA) was significantly smaller than from 1 to 6 years old (4.8+/-9.56 versus 10.5+/-18.86%, respectively, p<0.001). TBSA of scald burns was significantly greater than contact burns (8.9+/-15.76 versus 0.9+/-2.0%, respectively, p<0.05). Surgery was performed for 65 patients (18%) and 126 patients were hospitalized (34%). Compared to the first decade of analysis, the second decade had fewer patients (222 versus 142 cases) and lower severity (7.4+/-14.6% versus 6.6+/-13.26%, TBSA). Pediatric burns in younger children should be studied closely as to their causes and with further follow-up.