Healthcare-Associated Infections at a Children's Cancer Hospital, 1983-2008

Outcomes of Care-bundle Implementation for Children With Cancer and Suspected Bloodstream Infection in a Pediatric Oncology Unit in a Resource-limited Setting

Bloodstream infections (BSIs) are a major cause of mortality among pediatric oncology patients in resource-limited settings. Effective, innovative strategies are needed to improve care and survival. In a pediatric oncology unit in Mexico, we retrospectively analyzed the risk factors for mortality related to BSI and the results of using a care-bundle intervention. The care-bundle consisted of a swift clinical evaluation, initial fluid-resuscitation support, obtaining blood cultures, and administration of effective empirical antibiotic therapy for suspected BSI. The outcomes of patients who received the care-bundle during a 12-month period were compared with those of patients treated with standard care during the 12 months preceding its implementation. The primary outcomes were BSI diagnosis, choice of antibiotics, and mortality. Of the 261 suspected BSIs treated with standard care, 33 (12.6%) infections were confirmed, and of the 308 treated with the care-bundle, 67 (21.7%) BSIs were confirmed. Thus, after implementation of the care-bundle, significantly more BSIs were diagnosed ( P =0.004), and BSI-related mortality was significantly reduced by 22.2% ( P = 0.035). Surgical resection and mechanical ventilation support were independently associated with BSI-related mortality, and receiving effective initial empirical antibiotic therapy was protective against mortality (odds ratio, 0.013; 95% CI: 0.002-0.105; P =0.001), which comprising cefepime plus amikacin or meropenem in 44 (80.0%) of the cases alive. Consistent use of a care-bundle with initial fluid resuscitation, obtaining a blood culture, and administering effective antibiotics to children with cancer and suspected BSI can decrease mortality.

Impact of dry hydrogen peroxide on hospital-acquired infection at a pediatric oncology hospital

BACKGROUND

This study aims to describe the effect of Dry Hydrogen Peroxide (DHP), as an adjunct to environmental cleaning and disinfection, on the incidence of hospital-acquired infections (HAIs) at Unidad Nacional de Oncologia Pediatrica (UNOP) in Guatemala City, Guatemala.

METHODS

A retrospective study of all HAI data from the hospital's surveillance system, which follows Centers for Disease Control and Prevention (CDC) protocols, was conducted from January 2019 to November 2020. DHP was installed in all Pediatric Intensive Care Unit (PICU) rooms in January 2020, but nowhere else in the hospital, including the Intermediate Care Unit (IMCU).

RESULTS

There were 189 HAI cases during the study period, with 173 occurring in either the PICU or IMCU. A statistically significant decrease in HAI incidence rates occurred in the PICU in 2020 compared to 2019 (P = .028), including Clostridiodes-associated gastroenteritis (P = .048). Logistic multivariate regression yielded a significant association between DHP exposure and reduced odds of developing an HAI during the study (OR = 0.3857, P = .029).

CONCLUSION

The use of DHP as an adjunct technology for environmental cleaning and disinfection contributed to the reduction in HAIs in the PICU. Our study highlights the value of such an approach as an addition to manual cleaning to decrease the risk of infection from environmental contamination.

Clinical Significance of Isolates Known to Be Blood Culture Contaminants in Pediatric Patients

Background and objectives: The objective of this study was to investigate the clinical significance of isolates from blood stream infection known to be blood culture contaminants in pediatric patients. Materials and Methods: Microbiological reports and medical records of all blood culture tests issued from 2002 to 2012 (n = 76,331) were retrospectively reviewed. Evaluation for potential contaminants were done by reviewing medical records of patients with the following isolates: coagulase-negative Staphylococcus, viridans group Streptococcus, Bacillus, Corynebacterium, Micrococcus, Aerococcus, and Proprionibacterium species. Repeated cultures with same isolates were considered as a single case. Cases were evaluated for their status as a pathogen. Results: Coagulase-negative Staphylococcus had clinical significance in 23.8% of all cases. Its rate of being a true pathogen was particularly high in patients with malignancy (43.7%). Viridans group Streptococcus showed clinical significance in 46.2% of all cases. Its rate of being a true pathogen was similar regardless of the underlying morbidity of the patient. The rate of being a true pathogens for remaining isolates was 27.7% for Bacillus and 19.0% for Corynebacterium species. Conclusions: Coagulase-negative Staphylococcus and viridans group Streptococcus isolates showed high probability of being true pathogens in the pediatric population, especially in patients with underlying malignancy.

Effect of a shielded continuous ultraviolet-C air disinfection device on reduction of air and surface microbial contamination in a pediatric oncology outpatient care unit

BACKGROUND

For a clean hospital environment, we evaluated whether ultraviolet-C (UV-C) air disinfection reduces airborne and surface microbial contamination in an outpatient pediatric oncology center.

METHODS

A pre- and post-intervention study compared 6 test locations, where continuous shielded UV-C air disinfection devices were installed, with 10 control locations without UV-C. Pre- and post-intervention air and surface samples were collected for bacterial and fungal cultures. Percent changes in colony forming unit (CFU) counts in the test and control locations were compared.

RESULTS

Mean bacterial CFU count per cubic meter air and per surface contact plates decreased by 27% (P = .219) and 37% (P = .01), respectively, in test locations compared to 40% (P = .054) and 30% (P = .006) reductions in control locations. Mean fungal CFU count per cubic meter air and per surface contact plates increased by 14% (P = .156) and 19% (P = .048), respectively, in test locations compared to 24% (P = .409) and 2% (P = .34) increases in control locations.

CONCLUSIONS

There were no consistent statistically significant differences in the air and surface culture results between test locations where UV-C devices were installed and control locations. The effectiveness of UV-C air disinfection in reducing air and surface microbial contamination in outpatient clinical areas where immunocompromised children are encountered was not proven.

Levofloxacin Prophylaxis During Induction Therapy for Pediatric Acute Lymphoblastic Leukemia

BACKGROUND

Infection is the most important cause of treatment-related morbidity and mortality in pediatric patients treated for acute lymphoblastic leukemia (ALL). Although routine in adults with leukemia, antibacterial prophylaxis is controversial in pediatrics because of insufficient evidence for its efficacy or antibiotic choice and concerns about promoting antibiotic resistance and Clostridium difficile infection.

METHODS

This was a single-center, observational cohort study of patients with newly diagnosed ALL, comparing prospectively collected infection-related outcomes in patients who received no prophylaxis, levofloxacin prophylaxis, or other prophylaxis during induction therapy on the total XVI study. A propensity score-weighted logistic regression model was used to adjust for confounders.

RESULTS

Of 344 included patients, 173 received no prophylaxis, 69 received levofloxacin prophylaxis, and 102 received other prophylaxis regimens. Patients receiving prophylaxis had longer duration of neutropenia. Prophylaxis reduced the odds of febrile neutropenia, likely bacterial infection, and bloodstream infection by ≥70%. Levofloxacin prophylaxis alone reduced these infections, but it also reduced cephalosporin, aminoglycoside, and vancomycin exposure and reduced the odds of C. difficile infection by >95%. No increase in breakthrough infections with antibiotic-resistant organisms was seen, but this cannot be excluded.

CONCLUSIONS

This is the largest study to date of antibacterial prophylaxis during induction therapy for pediatric ALL and the first to include a broad-spectrum fluoroquinolone. Prophylaxis prevented febrile neutropenia and systemic infection. Levofloxacin prophylaxis also minimized the use of treatment antibiotics and drastically reduced C. difficile infection. Although long-term antibiotic-resistance monitoring is needed, these data support using targeted prophylaxis with levofloxacin in children undergoing induction chemotherapy for ALL.

CLINICAL TRIALS REGISTRATION

NCT00549848.

Staphylococcus aureus - antimicrobial resistance and the immunocompromised child

Children with immunocompromising conditions represent a unique group for the acquisition of antimicrobial resistant infections due to their frequent encounters with the health care system, need for empiric antimicrobials, and immune dysfunction. These infections are further complicated in that there is a relative paucity of literature on the clinical features and management of Staphylococcus aureus infections in immunocompromised children. The available literature on the clinical features, antimicrobial susceptibility, and management of S. aureus infections in immunocompromised children is reviewed. S. aureus infections in children with human immunodeficiency virus (HIV) are associated with higher HIV viral loads and a greater degree of CD4 T-cell suppression. In addition, staphylococcal infections in children with HIV often exhibit a multidrug resistant phenotype. Children with cancer have a high rate of S. aureus bacteremia and associated complications. Increased tolerance to antiseptics among staphylococcal isolates from pediatric oncology patients is an emerging area of research. The incidence of S. aureus infections among pediatric solid organ transplant recipients varies considerably by the organ transplanted; in general however, staphylococci figure prominently among infections in the early posttransplant period. Staphylococcal infections are also prominent pathogens among children with a number of immunodeficiencies, notably chronic granulomatous disease. Significant gaps in knowledge exist regarding the epidemiology and management of S. aureus infection in these vulnerable children.