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Abstract
OBJECTIVES Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions. DATA SOURCES Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021. STUDY SELECTION We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening. DATA EXTRACTION We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed. DATA SYNTHESIS Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18). CONCLUSIONS Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.
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Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis. Pediatr Crit Care Med 2013; 14:89-97. [PMID: 22805154 DOI: 10.1097/pcc.0b013e3182417871] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined the impact of selective decontamination of the digestive tract on morbidity and mortality in critically ill children. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and previous meta-analyses. STUDY SELECTION We included all randomized controlled trials comparing administration of enteral antimicrobials in selective decontamination of the digestive tract with or without a parenteral component with placebo or standard therapy used in the controls. DATA EXTRACTION The primary end point was the number of acquired pneumonias. Secondary end points were number of infections and overall mortality. Odds ratios were pooled with the random effect model. DATA SYNTHESIS Four randomized controlled trials including 335 patients were identified. Pneumonia was diagnosed in five of 170 patients (2.9%) for selective decontamination of the digestive tract and 16 of 165 patients (9.7%) for controls (odds ratio 0.31; 95% confidence interval 0.11-0.87; p = .027). Overall mortality for selective decontamination of the digestive tract was 13 of 170 (7.6%) vs. control, 11 of 165 (6.7%) (odds ratio 1.18; 95% confidence interval 0.50-2.76; p = .70). In three studies (n = 109), infection occurred in ten of 54 (18.5%) patients on selective decontamination of the digestive tract and 24 of 55 (43.6%) in the controls (odds ratio 0.34; 95% confidence interval 0.05-2.18; p = .25). CONCLUSIONS In the four available pediatric randomized controlled trials, selective decontamination of the digestive tract significantly reduced the number of children who developed pneumonia.
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Gut microbial translocation in critically ill children and effects of supplementation with pre- and pro biotics. Int J Microbiol 2012; 2012:151393. [PMID: 22934115 PMCID: PMC3426218 DOI: 10.1155/2012/151393] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Accepted: 07/12/2012] [Indexed: 12/19/2022] Open
Abstract
Bacterial translocation as a direct cause of sepsis is an attractive hypothesis that presupposes that in specific situations bacteria cross the intestinal barrier, enter the systemic circulation, and cause a systemic inflammatory response syndrome. Critically ill children are at increased risk for bacterial translocation, particularly in the early postnatal age. Predisposing factors include intestinal obstruction, obstructive jaundice, intra-abdominal hypertension, intestinal ischemia/reperfusion injury and secondary ileus, and immaturity of the intestinal barrier per se. Despite good evidence from experimental studies to support the theory of bacterial translocation as a cause of sepsis, there is little evidence in human studies to confirm that translocation is directly correlated to bloodstream infections in critically ill children. This paper provides an overview of the gut microflora and its significance, a focus on the mechanisms employed by bacteria to gain access to the systemic circulation, and how critical illness creates a hostile environment in the gut and alters the microflora favoring the growth of pathogens that promote bacterial translocation. It also covers treatment with pre- and pro biotics during critical illness to restore the balance of microbial communities in a beneficial way with positive effects on intestinal permeability and bacterial translocation.
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Silvestri L, van Saene HKF, Petros AJ. Selective digestive tract decontamination in critically ill patients. Expert Opin Pharmacother 2012; 13:1113-29. [PMID: 22533385 DOI: 10.1517/14656566.2012.681778] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Siegel JD. Pediatric Infection Prevention and Control. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2012. [PMCID: PMC7151971 DOI: 10.1016/b978-1-4377-2702-9.00101-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study. Intensive Care Med 2011; 37:1458-65. [DOI: 10.1007/s00134-011-2307-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 06/27/2011] [Indexed: 10/18/2022]
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Abecasis F, Sarginson RE, Kerr S, Taylor N, van Saene HK. Is Selective Digestive Decontamination Useful in Controlling Aerobic Gram-Negative Bacilli Producing Extended Spectrum Beta-Lactamases? Microb Drug Resist 2011; 17:17-23. [DOI: 10.1089/mdr.2010.0060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francisco Abecasis
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Richard E. Sarginson
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Steve Kerr
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Nia Taylor
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
| | - Hendrik K.F. van Saene
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
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Levy S, Mello M, Gusmão-filho F, Correia J. Colonisation by extended-spectrum β-lactamase-producing Klebsiella spp. in a paediatric intensive care unit. J Hosp Infect 2010; 76:66-9. [DOI: 10.1016/j.jhin.2010.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2009] [Accepted: 03/12/2010] [Indexed: 10/19/2022]
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Gursel G, Aydogdu M, Nadir Ozis T, Tasyurek S. Comparison of the value of initial and serial endotracheal aspirate surveillance cultures in predicting the causative pathogen of ventilator-associated pneumonia. ACTA ACUST UNITED AC 2010; 42:341-6. [PMID: 20095937 DOI: 10.3109/00365540903505203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in the intensive care unit (ICU) and its outcome is affected by the adequacy and timing of initial antibiotic therapy. Recent studies have suggested that surveillance cultures of the lower airways may provide microbiological guidance for initial antibiotic prescription and increase the use of appropriate antibiotic therapy. This study aimed to compare the predictive value of initial and serial surveillance cultures of endotracheal aspirates in predicting the causative pathogen of VAP in patients receiving antibiotic therapy. This was an observational prospective cohort study. Ninety-two patients ventilated for at least 4 days were recruited into the study. Initial (IS-ETA) and serial (SS-ETA) endotracheal aspirate surveillance cultures were obtained on the day of intubation and every second day, respectively. The sensitivity, specificity, and positive and negative predictive values for the causative pathogens of VAP were calculated for each surveillance culture. Ninety-two initial and 252 serial surveillance cultures were obtained during the study period. The sensitivity of IS-ETA culture was 12% and of SS-ETA culture was 44%. The sensitivity of SS-ETA in late-onset VAP was 51%. The value of SS-ETA surveillance cultures was better than IS-ETA surveillance in predicting the causative pathogen of VAP, particularly in late-onset pneumonia.
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Affiliation(s)
- Gul Gursel
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, Besevler, Ankara, Turkey.
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Impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome: systematic review of randomized controlled trials. Crit Care Med 2010; 38:1370-6. [PMID: 20308882 DOI: 10.1097/ccm.0b013e3181d9db8c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We examined the impact of selective decontamination of the digestive tract on multiple organ dysfunction syndrome. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and meetings proceedings. STUDY SELECTION We included all randomized trials comparing both oropharyngeal and intestinal administration of antibiotics in selective decontamination of the digestive tract with or without a parenteral component, with placebo or standard therapy used in the controls. DATA EXTRACTION Two reviewers independently applied selection criteria, performed quality assessment, and extracted the data. The primary end point was the number of patients with multiple organ dysfunction syndrome developing during intensive care unit stay. Secondary end points were overall mortality and multiple organ dysfunction syndrome-related mortality. Odds ratios were pooled with the random effect model. DATA SYNTHESIS We identified seven randomized trials including 1270 patients. Multiple organ dysfunction syndrome was found in 132 of 637 patients (20.7%) in the selective decontamination of the digestive tract group and in 219 of 633 patients (34.6%) in the control group (odds ratio, 0.50; 95% confidence interval, 0.34-0.74; p < .001). Overall mortality for selective decontamination of the digestive tract vs. control patients was 119 of 637 (18.7%) and 145 of 633 (22.9%), respectively, demonstrating a nonsignificant reduction in the odds of death (odds ratio, 0.82; 95% confidence interval, 0.51-1.32; p = .41). In five studies including 472 patients, multiple organ dysfunction syndrome-related mortality was demonstrated in 31 of 239 (13%) patients in selective decontamination of the digestive tract group and 37 of 233 (15.9%) in the controls (odds ratio, 0.84; 95% confidence interval, 0.48-1.41; p = .54). CONCLUSIONS Selective decontamination of the digestive tract reduces the number of patients with multiple organ dysfunction syndrome. Mortality was not significantly reduced, probably because of the small sample size.
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Abstract
BACKGROUND Acute lung injury (ALI) and its more severe form, acute respiratory distress syndrome (ARDS), are devastating disorders of overwhelming pulmonary inflammation and hypoxemia, resulting in high morbidity and mortality. AIM To provide the clinician with a summary of the literature on the epidemiology, diagnosis, and an evidence-base for management of ALI/ARDS in children. DATA SELECTION PubMed search for clinical trials, selected literature review of other relevant studies on epidemiology and diagnosis. DATA SYNTHESIS AND RECOMMENDATIONS: Lower mortality combined with a relatively lower frequency of ALI/ARDS in children makes performance of clinical trials challenging. Based on expert opinion, the following are recommended: 1) avoid tidal volumes > or =10 mL/kg body weight; 2) keep plateau pressure < or =30 cm H2O, arterial pH at 7.30 to 7.45, and Pao2 60 to 80 torr (8 to 10.7 kPa) (Spo2 > or =90%); 3) provide sedation, analgesia, and stress ulcer prophylaxis; and 4) use a 10 g/dL hemoglobin threshold for packed red blood cell transfusion in unstable patients (shock or profound hypoxia). Evidence supports dropping the hemoglobin transfusion threshold to 7 g/dL once profound hypoxia and shock have resolved. Promising therapies for pediatric ALI/ARDS based on pediatric studies include endotracheal surfactant, high-frequency oscillatory ventilation, noninvasive ventilation, and use of extracorporeal membrane oxygenation as a rescue therapy. Promising therapies based on adult trials include use of corticosteroids for lung inflammation and fibrosis, use of 4 to 6 mL/kg tidal volumes and restrictive fluid management. Prone positioning, bronchodilators, inhaled nitric oxide, tight glucose control, and high-flow nasal cannula (HFNC) oxygen are therapies that require further study before they can be recommended for children with ALI/ARDS.
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Silvestri L, van Saene HKF, Weir I, Gullo A. Survival benefit of the full selective digestive decontamination regimen. J Crit Care 2009; 24:474.e7-14. [PMID: 19327325 DOI: 10.1016/j.jcrc.2008.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 10/17/2008] [Accepted: 11/23/2008] [Indexed: 01/15/2023]
Abstract
PURPOSE We assessed the impact of the full protocol of selective decontamination of the digestive tract (SDD) using parenteral and enteral antimicrobials on mortality. MATERIALS AND METHODS A systematic review was performed searching MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, previous meta-analyses, and conferences proceedings. We included all randomized controlled trials (RCTs) comparing the full protocol of SDD, including oropharyngeal and intestinal administration of antibiotics combined with the parenteral component, with no treatment or placebo. The primary end points were overall mortality, mortality attributable to infection, early, and late mortality. RESULTS Twenty-one RCTs on 4902 patients were included. Overall mortality was significantly reduced (odds ratio [OR], 0.71; 95% confidence interval [CI]; 0.61-0.82; P < .001). There was a nonsignificant reduction in infection-related mortality (6 RCTs; OR, 0.40; 95% CI, 0.10-1.59; P = .19) and early mortality (4 RCTs; OR, 0.64; 95% CI, 0.34-1.19; P = 0.16), and a significant reduction in late mortality (5 RCTs; OR, 0.56; 95% CI, 0.40-0.77; P < .001). The subgroup analysis showed a significant mortality reduction in successfully decontaminated patients (OR, 0.58; 95% CI, 0.45-0.77; P < .001), and when parenteral and enteral antimicrobials were administered to every patient receiving treatment in the intensive care unit (OR, 0.59; 95% CI, 0.42-0.82; P < .001). CONCLUSIONS The findings strongly indicated that the full protocol of SDD reduces mortality in critically ill patients, in particular when successful decontamination is obtained. Eighteen patients should be treated with SDD to prevent one death.
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Affiliation(s)
- Luciano Silvestri
- Unit of Anesthesia and Intensive Care, Department of Emergency, Presidio Ospedaliero di Gorizia, 34170 Gorizia, Italy.
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Fuster Jorge P, Fernández Sarabia J, Delgado Melian T, Doménech Martínez E, Sierra López A. Control de calidad en la infección nosocomial en la UCIP. An Pediatr (Barc) 2008; 69:39-45. [DOI: 10.1157/13124217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Silvestri L, Van Saene HKF, Casarin A, Berlot G, Gullo A. Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials. Anaesth Intensive Care 2008; 36:324-38. [PMID: 18564793 DOI: 10.1177/0310057x0803600304] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.
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Affiliation(s)
- L. Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
| | - H. K. F. Van Saene
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Medical Microbiology, University of Liverpool and Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - A. Casarin
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada
| | - G. Berlot
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anesthesia, Intensive Care and Pain Therapy, University Hospital, Trieste, Italy
| | - A. Gullo
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anaesthesia and Intensive Care, Policlinico University Hospital, Catania, Italy
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Comment on "Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008" by Dellinger et al. Intensive Care Med 2008; 34:1160-2; author reply 1163-4. [PMID: 18415078 PMCID: PMC2480487 DOI: 10.1007/s00134-008-1089-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 01/04/2023]
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Siegel JD, Grossman L. Pediatric Infection Prevention and Control. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASE 2008. [PMCID: PMC7315330 DOI: 10.1016/b978-0-7020-3468-8.50008-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. Am J Infect Control 2007; 35:S65-164. [PMID: 18068815 PMCID: PMC7119119 DOI: 10.1016/j.ajic.2007.10.007] [Citation(s) in RCA: 1633] [Impact Index Per Article: 96.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Taylor N, van Saene HKF, Abella A, Silvestri L, Vucic M, Peric M. [Selective digestive decontamination. Why don't we apply the evidence in the clinical practice?]. Med Intensiva 2007; 31:136-45. [PMID: 17439769 DOI: 10.1016/s0210-5691(07)74792-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Selective digestive decontamination (SDD) is a prophylactic strategy whose objective is to reduce the incidence of infections, mainly mechanical ventilation associated pneumonia in patients who require intensive cares, preventing or eradicating the oropharyngeal and gastrointestinal carrier state of potentially pathogenic microorganisms. Fifty-four randomized clinical trials (RCTs) and 9 meta-analysis have evaluated SDD. Thirty eight RCTs show a significant reduction of the infections and 4 of mortality. All the meta-analyses show a significant reduction of the infections and 5 out of the 9 meta-analyses report a significant reduction in mortality. Thus, 5 patients from the ICU with SDD must be treated to prevent pneumonia and 12 patients from the ICU should be treated to prevent one death. The data that show benefit of the SDD on mortality have an evidence grade 1 or recommendation grade A (supported by at least two level 1 investigations). The aim of this review is to explain the pathogeny of infections in critical patients, describe selective digestive decontamination, analyze the evidence available on it efficacy and the potential adverse effects and discuss the reasons published by the experts who advise against the use of SDD, even though it is recognized as the best intervention evaluated in intensive cares to reduce morbidity and mortality of the infections.
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Affiliation(s)
- N Taylor
- Department of Medical Microbiology, University of Liverpool, Reino Unido
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Verma N, Clarke RW, Bolton-Maggs PHB, van Saene HKF. Gut overgrowth of vancomycin-resistant enterococci (VRE) results in linezolid-resistant mutation in a child with severe congenital neutropenia: a case report. J Pediatr Hematol Oncol 2007; 29:557-60. [PMID: 17762497 DOI: 10.1097/mph.0b013e3180f61b81] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A child with severe congenital neutropenia was monitored with microbiologic surveillance cultures for 3 years. He had recurrent bacterial infections and carriage of vancomycin-resistant enterococci. Resistance to linezolid emerged in the colonizing vancomycin-resistant enterococci after each course of this antibiotic when enterococci were present in overgrowth in the gut before treatment. The child was successfully treated for his congenital neutropenia by unrelated donor stem cell transplantation.
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Affiliation(s)
- Nitin Verma
- Department of Haematology and Oncology, Royal Liverpool Children's NHS Trust, Alder Hey, Liverpool
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Silvestri L, van Saene HKF, Milanese M, Gregori D, Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients. Systematic review of randomized, controlled trials. J Hosp Infect 2007; 65:187-203. [PMID: 17244516 DOI: 10.1016/j.jhin.2006.10.014] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 10/06/2006] [Indexed: 01/13/2023]
Abstract
A systematic review and meta-analysis of randomized controlled trials (RCTs) of selective decontamination of the digestive tract (SDD) was undertaken to evaluate the impact of this procedure on bacterial bloodstream infection and mortality. Data sources were Medline, Embase, Cochrane Register of Controlled Trials, previous meta-analyses, and conference proceedings, without restriction of language or publication status. RCTs were retrieved that compared oropharyngeal and/or intestinal administration of antibiotics as part of the SDD protocol, with or without a parenteral component, with no treatment or placebo in the controls. The three outcome measures were patients with bloodstream infection, causative micro-organisms, and total mortality. Fifty-one RCTs conducted between 1987 and 2005, comprising 8065 critically ill patients were included in the review; 4079 patients received SDD and 3986 were controls. SDD significantly reduced overall bloodstream infections [odds ratio (OR), 0.73; 95% confidence interval (CI), 0.59-0.90; P=0.0036], gram-negative bloodstream infections (OR, 0.39; 95% CI, 0.24-0.63; P<0.001) and overall mortality (OR, 0.80; 95% CI, 0.69-0.94; P=0.0064), without affecting gram-positive bloodstream infections (OR, 1.06; 95% CI, 0.77-1.47). The subgroup analysis showed an even larger impact of SDD using parenteral and enteral antimicrobials on overall bloodstream infections, bloodstream infections due to gram-negative bacteria and overall mortality with ORs of 0.63 (95% CI, 0.46-0.87; P=0.005), 0.30 (95% CI, 0.16-0.56; P<0.001), and 0.74 (95% CI, 0.61-0.91; P=0.0034), respectively. Twenty patients need to be treated with SDD to prevent one gram-negative bloodstream infection and 22 patients to prevent one death.
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Affiliation(s)
- L Silvestri
- Department of Anaesthesia and Intensive Care, Presidio Ospedaliero, Gorizia, Italy.
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Stoutenbeek CP, van Saene HKF, Little RA, Whitehead A. The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial. Intensive Care Med 2006; 33:261-70. [PMID: 17146635 DOI: 10.1007/s00134-006-0455-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 10/17/2006] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). METHODS A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n=200) or SDD (n=201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. RESULTS Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. CONCLUSION This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.
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Affiliation(s)
- C P Stoutenbeek
- Department Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
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23
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Thorburn K, Taylor N, Saladi SM, van Saene HKF. Use of surveillance cultures and enteral vancomycin to control methicillin-resistant Staphylococcus aureus in a paediatric intensive care unit. Clin Microbiol Infect 2006; 12:35-42. [PMID: 16460544 DOI: 10.1111/j.1469-0691.2005.01292.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study assessed the effects of throat and gut surveillance, combined with enteral vancomycin, on gut overgrowth, transmission of methicillin-resistant Staphylococcus aureus (MRSA), infections and mortality in patients admitted to a paediatric intensive care unit (PICU). A 4-year prospective observational study was undertaken with 1241 children who required ventilation for >or=4 days. Patients identified as MRSA carriers following surveillance cultures of throat and rectum received enteral vancomycin. Twenty-nine (2.4%) children carried MRSA, 19 on admission and nine during treatment in the PICU; one patient was not able to be evaluated. Overgrowth was present in 22 (75%) of the carriers. Ten (0.8%) children developed 21 MRSA infections (15 exogenous infections in eight children at a median of 8 days (IQR 3-10.5); five primary endogenous infections at a median of 3 days (IQR 1-25) in three children when they were in overgrowth status; one child developed both types of infection). Enteral vancomycin reduced gut overgrowth significantly, completely preventing secondary endogenous infections. Transmission occurred on nine occasions over a period of 4 years. Four patients died, two (5.9%) with MRSA infection, giving a mortality (11.8%) similar to the study population (9.8%). No emergence of vancomycin-resistant enterococci or S. aureus with intermediate susceptibility to vancomycin was detected. A policy based on throat and gut surveillance, combined with enteral vancomycin, for critically-ill children who were MRSA carriers was found to be effective and safe, and challenges the recommended guidelines of nasal swabbing followed by topical mupirocin.
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Affiliation(s)
- K Thorburn
- Paediatric Intensive Care Unit, Royal Liverpool Children's Hospital, Alder Hey, Liverpool L12 2AP, UK.
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24
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Thorburn K, Harigopal S, Reddy V, Taylor N, van Saene HKF. High incidence of pulmonary bacterial co-infection in children with severe respiratory syncytial virus (RSV) bronchiolitis. Thorax 2006; 61:611-5. [PMID: 16537670 PMCID: PMC2104657 DOI: 10.1136/thx.2005.048397] [Citation(s) in RCA: 210] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is the most common cause of viral lower respiratory tract infections (LRTI). Viral LRTI is a risk factor for bacterial superinfection, having an escalating incidence with increasing severity of respiratory illness. A study was undertaken to determine the incidence of pulmonary bacterial co-infection in infants and children with severe RSV bronchiolitis, using paediatric intensive care unit (PICU) admission as a surrogate marker of severity, and to study the impact of the co-infection on morbidity and mortality. METHODS A prospective microbiological analysis was made of lower airways secretions on all RSV positive bronchiolitis patients on admission to the PICU during three consecutive RSV seasons. RESULTS One hundred and sixty five children (median age 1.6 months, IQR 0.5-4.6) admitted to the PICU with RSV bronchiolitis were enrolled in the study. Seventy (42.4%) had lower airway secretions positive for bacteria: 36 (21.8%) were co-infected and 34 (20.6%) had low bacterial growth/possible co-infection. All were mechanically ventilated (median 5.0 days, IQR 3.0-7.3). Those with bacterial co-infection required ventilatory support for longer than those with only RSV (p<0.01). White cell count, neutrophil count, and C-reactive protein did not differentiate between the groups. Seventy four children (45%) received antibiotics prior to intubation. Sex, co-morbidity, origin, prior antibiotics, time on preceding antibiotics, admission oxygen, and ventilation index were not predictive of positive bacterial cultures. There were 12 deaths (6.6%), five of which were related to RSV. CONCLUSIONS Up to 40% of children with severe RSV bronchiolitis requiring admission to the PICU were infected with bacteria in their lower airways and were at increased risk for bacterial pneumonia.
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Affiliation(s)
- K Thorburn
- Department of Paediatric Intensive Care, Royal Liverpool Children's Hospital, Liverpool L12 2AP, UK.
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25
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Suz P, Vavilala MS, Souter M, Muangman S, Lam AM. Clinical Features of Fever Associated With Poor Outcome in Severe Pediatric Traumatic Brain Injury. J Neurosurg Anesthesiol 2006; 18:5-10. [PMID: 16369134 DOI: 10.1097/01.ana.0000189079.26212.37] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We describe the incidence and etiology of fever and the relationship between fever characteristics and outcome in children with severe traumatic brain injury (TBI). We conducted a retrospective study of children <14 years and with Glasgow Coma Scale (GCS) score of <9 admitted to a level I pediatric trauma center intensive care unit (PICU) between 1998 and 2003. We examined whether fever characteristics were associated with poor outcome (hospital discharge GCS score <13 and discharge disposition of either death or discharge to a skilled nursing facility). PICU length of stay (LOS) and hospital LOS were also examined. Data are presented as means and medians (SD), and P < 0.05 reflects significance. Ninety-three records were reviewed. Patients were 5.7 (SD 4.1) years old, 70% were male, and the average admission GCS score was 5. Mortality rate was 14%. Forty-eight (52%) patients had fever, and 23 (48%) of those patients had infectious fever. Each additional febrile episode was associated with a twofold higher risk of patients having a hospital discharge GCS score of <13 (odds ratio 2.4, 95% confidence interval 1.2-5.0) and having a 0.4-day longer PICU LOS (P < 0.001). Patients with infectious fever had a 0.9-day longer PICU LOS (P < 0.001). Patients with any fever in the PICU had an increased HLOS (0.9 days; P < 0.001). Our data suggest that in severe pediatric TBI, both fever and infection were common, and both were associated with longer LOS. Patients with higher fever burden had poor hospital discharge GCS score.
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Affiliation(s)
- Pilar Suz
- Department of Anesthesiology, University of Washington, Seattle, WA 98104, USA
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26
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Silvestri L, van Saene HKF, de la Cal MA, Gullo A. Adult Hospital and Ventilator-associated Pneumonia Guidelines: Eminence- rather than Evidence-based. Am J Respir Crit Care Med 2006; 173:131-3; author reply 133. [PMID: 16368795 DOI: 10.1164/ajrccm.173.1.131] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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27
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Abstract
A significant percentage of pediatric patients admitted to an ICU have an infectious disease process. Many infants and children go on to develop sepsis, a major cause of death in the intensive care unit. Caring for these children presents a collaborative challenge because of the multifactorial etiology and the complicated pathophysiology. This article focuses on the specific implications of sepsis for infants and children.
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Affiliation(s)
- Patricia A Moloney-Harmon
- Children's Services, Sinai Hospital of Baltimore, 2401 W. Belvedere Avenue, Baltimore MD 21215, USA.
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28
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Belli ML, Ugolotti E, Fenu ML, Mantero E, Ceccarelli R. A comparison of two blood culture procedures for the isolation of staphylococci in a paediatric intensive care unit. Clin Microbiol Infect 2005; 11:1035-7. [PMID: 16307560 DOI: 10.1111/j.1469-0691.2005.01269.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Blood culture results obtained between January 2000 and July 2003 were reviewed for 1360 patients in a paediatric intensive care unit (PICU). The BacT/Alert FA aerobic medium was used with a blood volume of 1.5 mL for the first 23 months, and the BacT/Alert PF paediatric medium was used with a 0.5-mL volume for the remaining 18 months. The isolation rates were similar during both periods (13.4% vs. 13.1%), and staphylococci were the most common isolates (72.8%). There was a shorter time to detection of staphylococci with the smaller-volume (PF) procedure, which thus seems suitable for use in the diagnosis of staphylococcal bacteraemia in the PICU.
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Affiliation(s)
- M L Belli
- Laboratory for Immunocompromised Host, Gaslini Children's Hospital, Genoa, Italy.
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29
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Thorburn K, Taylor N, Lopez-Rodriguez L, Ashworth M, de la Cal MA, van Saene HKF. High mortality of invasive pneumococcal disease compared with meningococcal disease in critically ill children. Intensive Care Med 2005; 31:1550-7. [PMID: 16167128 DOI: 10.1007/s00134-005-2803-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Accepted: 08/09/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To ascertain outcome, patterns of disease, incidence of concurrent infection, superinfection and penicillin resistance in children requiring intensive care for Streptococcus pneumoniae infection and compare it to a similar disease pattern, namely Neisseria meningitidis b infection. DESIGN AND SETTING Prospective cohort study in a regional paediatric intensive care unit (PICU). PATIENTS AND PARTICIPANTS Children with invasive pneumococcal and meningococcal disease requiring intensive care. MEASUREMENTS AND RESULTS The study included 22 children with invasive pneumococcal disease (IPD), median age 14 months (interquartile range 3-52), median Paediatric Index of Mortality (PIM) 0.051 (0.028-0.066), median length of PICU stay 8.5 days (4-13). Four patients died, three (13.5%) attributable to IPD. Incidence of concurrent infection 27%. There were no superinfections. All S. pneumoniae were sensitive to cefotaxime; one isolate (3.7%) was resistant to penicillin. There were 186 children with meningococcal disease (MD), with a higher PIM (median 0.068, 0.033-0.108), older age (29 months, 10.7-77.9) and shorter length of PICU stay (median 3 days, 2-6). Eight (4.3%) children died from MD. Incidence of concurrent and superinfection was 18% and 6%, respectively in children with MD. All N. meningitidis cases were sensitive to cefotaxime and penicillin. The standardized mortality ratio was considerably higher with IPD (2.0) than with MD (0.52). CONCLUSIONS In invasive pneumococcal disease preventative measures including early recognition, immediate antibiotic therapy and vaccination need to be taken in the community, similar to the control of meningococcal disease. Invasive pneumococcal disease should command the same respect as meningococcal disease.
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Affiliation(s)
- Kentigern Thorburn
- Department of Paediatric Intensive Care, Royal Liverpool Children's Hospital, Alder Hey Hospital, Liverpool, L12 2AP, UK
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30
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Paulus SC, van Saene HKF, Hemsworth S, Hughes J, Ng A, Pizer BL. A prospective study of septicaemia on a paediatric oncology unit: A three-year experience at The Royal Liverpool Children’s Hospital, Alder Hey, UK. Eur J Cancer 2005; 41:2132-40. [PMID: 16129600 DOI: 10.1016/j.ejca.2005.04.037] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Revised: 03/22/2005] [Accepted: 04/05/2005] [Indexed: 11/21/2022]
Abstract
Septicaemia in neutropaenic patients is predominantly due to gut translocation [endogenous septicaemia] and contamination of the central venous catheter by microorganisms not carried by the patient [exogenous septicaemia]. To control both types of infection, a protocol was implemented based on pre 1990's parenteral and enteral antimicrobials together with strict hygiene. Surveillance cultures of throat/rectum were taken to distinguish exogenous from endogenous septicaemia and enteral non-absorbable antibiotics are administered as part of selective decontamination of the digestive tract (SDD). This protocol was evaluated in a 14-bedded paediatric oncology unit over a period of 3 years. 313 Septicaemia episodes were recorded in 131 children. 28.4% of the septicaemias were caused by microorganisms associated with the unit, equivalent to 0.82 episodes per 100 patient days. Low-level pathogens such as coagulase-negative staphylococci caused more than 70% of infections. Amongst the potential pathogens, Pseudomonas species (7.8%) and Staphylococcus aureus (5.5%) were predominant. Antibiotic resistance was rare with no superinfections or outbreaks. Four patients (3%) died, two due to Candida species and two due to Pseudomonas aeruginosa. We believe that the addition of enteral non-absorbable antibiotics to systemic antibiotics maintained a low level of resistance and mortality but a randomised controlled trial is indicated to confirm these observations.
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Affiliation(s)
- S C Paulus
- Department of Paediatric Oncology, The Royal Liverpool Children's Hospital, Eaton Road, Liverpool L12 2AP, United Kingdom
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31
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Fox MA, Sarginson RE, Zandstra DF, Meynaar I, van Saene HK. Comment on “Risk factors for late-onset ventilator-associated pneumonia in trauma patients receiving selective digestive decontamination” by Leone et al. Intensive Care Med 2005; 31:999; author reply 1000. [PMID: 15838677 DOI: 10.1007/s00134-005-2636-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2005] [Indexed: 11/30/2022]
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Silvestri L, Petros AJ, Sarginson RE, de la Cal MA, Murray AE, van Saene HKF. Handwashing in the intensive care unit: a big measure with modest effects. J Hosp Infect 2005; 59:172-9. [PMID: 15694973 DOI: 10.1016/j.jhin.2004.11.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Handwashing is widely accepted as the cornerstone of infection control in the intensive care unit. Nosocomial infections are frequently viewed as an indicator of poor compliance of handwashing. The aim of this review is to evaluate the effectiveness of handwashing on infection rates in the intensive care unit, and to analyse the failure of handwashing. A literature search identified nine studies that evaluated the impact of handwashing or hand hygiene on infection rates, and demonstrated a low level of evidence for the efforts to control infection with handwashing. Poor compliance cannot be blamed as the only reason for the failure of handwashing to control infection. Handwashing on its own does not abolish, but only reduces transmission, as it is dependent on the bacterial load on the hand of healthcare workers. Finally, recent studies, using surveillance cultures of throat and rectum, have shown that, under ideal circumstances, handwashing can only influence 40% of all intensive care unit infections. A randomised clinical trial with the intensive care as randomisation unit is required to support handwashing as the cornerstone of infection control.
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Affiliation(s)
- L Silvestri
- Emergency Department and Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Vittorio Veneto 171, 34170 Gorizia, Italy.
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