Effects of controlled perioperative antimicrobial prophylaxis on infectious outcomes in pediatric cardiac surgery

Multiple Polymerase Chain Reaction for Direct Detection of Bloodstream Infection After Cardiac Surgery in a PICU

Nosocomial infections are a prevalent cause of death and complications in critically ill children. Conventional cultures are able to detect only up to 25% of bacteremia. Several studies have suggested that molecular tests could be a faster and effective tool for detection of bacterial infections. The objective of this study is to compare molecular tests for bacterial detection in whole blood samples, with routine blood culture for the diagnosis of nosocomial bloodstream infections (BSIs).

Peri-Operative Prophylaxis in Patients of Neonatal and Pediatric Age Subjected to Cardiac and Thoracic Surgery: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs) represent a potential complication of surgical procedures, with a significant impact on mortality, morbidity, and healthcare costs. Patients undergoing cardiac surgery and thoracic surgery are often considered patients at high risk of developing SSIs. This consensus document aims to provide information on the management of peri-operative antibiotic prophylaxis for the pediatric and neonatal population undergoing cardiac and non-cardiac thoracic surgery. The following scenarios were considered: (1) cardiac surgery for the correction of congenital heart disease and/or valve surgery; (2) cardiac catheterization without the placement of prosthetic material; (3) cardiac catheterization with the placement of prosthetic material; (4) implantable cardiac defibrillator or epicardial pacemaker placement; (5) patients undergoing ExtraCorporal Membrane Oxygenation; (6) cardiac tumors and heart transplantation; (7) non-cardiac thoracic surgery with thoracotomy; (8) non-cardiac thoracic surgery using video-assisted thoracoscopy; (9) elective chest drain placement in the pediatric patient; (10) elective chest drain placement in the newborn; (11) thoracic drain placement in the trauma setting. This consensus provides clear and shared indications, representing the most complete and up-to-date collection of practice recommendations in pediatric cardiac and thoracic surgery, in order to guide physicians in the management of the patient, standardizing approaches and avoiding the abuse and misuse of antibiotics.

Surgical Antimicrobial Prophylaxis in Neonates and Children with Special High-Risk Conditions: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), which are a potential complications in surgical procedures, are associated with prolonged hospital stays and increased postoperative mortality rates, and they also have a significant economic impact on health systems. Data in literature regarding risk factors for SSIs in pediatric age are scarce, with consequent difficulties in the management of SSI prophylaxis and with antibiotic prescribing attitudes in the various surgical procedures that often tend to follow individual opinions. The lack of pediatric studies is even more evident when we consider surgeries performed in subjects with underlying conditions that may pose an increased risk of complications. In order to respond to this shortcoming, we developed a consensus document to define optimal surgical antimicrobial prophylaxis (SAP) in neonates and children with specific high-risk conditions. These included the following: (1) colonization by methicillin-resistant Staphylococcus aureus (MRSA) and by multidrug resistant (MDR) bacteria other than MRSA; (2) allergy to first-line antibiotics; (3) immunosuppression; (4) splenectomy; (5) comorbidity; (6) ongoing antibiotic therapy or prophylaxis; (7) coexisting infection at another site; (8) previous surgery in the last month; and (9) presurgery hospitalization lasting more than 2 weeks. This work, made possible by the multidisciplinary contribution of experts belonging to the most important Italian scientific societies, represents, in our opinion, the most up-to-date and comprehensive collection of recommendations relating to behaviors to be undertaken in a perioperative site in the presence of specific categories of patients at high-risk of complications during surgery. The application of uniform and shared protocols in these high-risk categories will improve surgical practice with a reduction in SSIs and consequent rationalization of resources and costs, as well as being able to limit the phenomenon of antimicrobial resistance.

Surgical site infection after delayed sternal closure in neonates with congenital heart disease: retrospective case-control study

Objectives

To determine the prevalence of surgical site infections (SSIs) in neonatal congenital heart disease patients undergoing delayed sternal closure (DSC) and evaluate risk factors for SSI.

Methods

Hospital records of 483 consecutive neonates who underwent surgical intervention between January 2013 and December 2017 were reviewed, and perioperative variables were recorded.

Results

We found that the prevalence of SSI was 87.5% when the body weight was less than 1500 g. When the operative age was between seven and 14 days, the probability of no SSI is about 93.9%. When the duration of the aortic cross-clamp was more than 60 min, the prevalence of SSI was 91.2%. The prevalence without SSI was 96.6% when the duration of DSC was less than 24 h. However, when the duration of DSC was more than 120 h, the prevalence of SSI was 88.9% (p = 0.000).

Conclusions

With the prolongation of aortic clamping duration, the probability of occurrence of SSI increased in neonatal CHD with DSC. The age at operation and body weight are closely related to the occurrence of SSI in neonatal CHD patients with DSC.

Invasive Bacterial and Fungal Infections After Pediatric Cardiac Surgery: A Single-center Experience

BACKGROUND

Discrimination of infectious and noninfectious complications in children with inflammatory signs after cardiac surgery is challenging. Given the low prevalence of infectious complications after heart surgery, there might be a risk of excessive antibiotic usage. We performed this study to determine the rate of invasive bacterial or fungal infections in children after cardiac surgery at our institution and to evaluate our postoperative management.

METHODS

This single-center retrospective observational cohort study included children 16 years of age or younger who underwent cardiac surgery at our institution between January 2012 and December 2015.

RESULTS

We analyzed 395 surgical procedures. Thirty-five postoperative invasive bacterial or fungal infections were detected in 29 episodes (7%, 0.42 per 100 admission days). Among bacterial infections, the most common infection sites were bacteremia and pneumonia, accounting for 37% (13/35) and 23% (8/35) of infections respectively. The rate of postoperative infections was associated with surgical complexity score and length of postoperative pediatric intensive care unit (PICU) stay. In 154 (43%) of 357 episodes without microbiologically documented infection, uninterrupted postoperative antibiotic administration was continued for more than 3 days and in 80 (22%) for more than 5 days.

CONCLUSIONS

The rate of postoperative bacterial or fungal infection at our institution is comparable to current literature. High surgical complexity score and prolonged length of PICU stay were risk factors for bacterial or fungal infections in this patient population.

Vancomycin concentrations during cardiopulmonary bypass in pediatric cardiac surgery: a prospective study

INTRODUCTION

Few data are available regarding intraoperative plasma concentrations of vancomycin administered as prophylaxis in pediatric cardiac surgery. The aims of this study were to investigate during pediatric cardiac surgery with cardiopulmonary bypass(CPB) the attainment of the area-under-the-curve of the vancomycin serum concentrations versus time over surgery to minimum inhibitory concentration ratio(AUC_intra/MIC) of 400 (mg × h)/l and/or a target concentration of 15-20 mg/l.

METHODS

In a prospective study, 40 patients divided into four subgroups (neonates, infants, children <10 years-old, ⩾10 years-old) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were enrolled. A slow vancomycin bolus of 20 mg/kg, up to a maximum dose of 1000 mg was administered before skin incision and a further dose of 10 mg/kg (up to 500 mg) at CPB start. Vancomycin samples were collected intraoperatively at four time points.

RESULTS

The median (interquartile range) age was 241.5 days (47-3898) and the median weight was 7.1 kg (3.1-37). The median AUC_intra/MIC was 254.73 (165.89-508.06). In 11 patients the AUC_intra/MIC target was not reached. Neonates displayed the lowest AUC_intra/MIC values, and these were significantly lower than those of children ⩾10 years old (p = 0.02). Vancomycin concentrations were above the maximal target of 20 mg/l in 82.5% and 80% of patients at surgery and CPB start, respectively. At CPB and surgery end, 42.5% of patients showed vancomycin concentrations above 20 mg/l and 42.5% below 15 mg/l. Patients⩾10 years old showed the highest peak values whereas neonates were those with the lowest troughs. AUC_intra/MIC correlated with age(r:0.36, p = 0.02), weight(r:0.35, p = 0.03), intraoperative protein value(r:0.40, p = 0.01), CPB priming volume/kg(r:-0.33, p = 0.04), CPB duration(r:0.36, p = 0.02) and vancomycin troughs(r:0.35, p = 0.04).

CONCLUSIONS

An AUC_intra/MIC ⩾400 target was not reached in one-quarter of children undergoing heart surgery. Vancomycin peaked before the start of surgery and neonates were those with the lowest troughs. Vancomycin concentrations are affected by CPB hemodilution and by patients' age and weight.

Adherence to the guidelines for surgical antimicrobial prophylaxis in a Saudi tertiary care hospital

Objective

The study evaluated the adherence to the guidelines for surgical antimicrobial prophylaxis in a Saudi tertiary care hospital.

Methods

The medical records of 707 patients from the surgical units over a selected 3-month period were selected. The data were reviewed and statistically analysed.

Results

Of the 707 respondents, 51.2% were women and most were older than 50 years. The most common surgical procedures involved orthopaedics (28.3%), followed by vascular surgery (15.1%). One hundred and thirty-eight (19.5%) patients received antibiotics according to the guidelines for surgical prophylaxis. More than half of the patients (399/56.4%) received antibiotics for more than 24 h and 129 (18.2%) received antibiotics for less than 24 h. Single dose antibiotic therapy was used in 179 (25.3%) patients. Two hundred and ninety-seven (42%) patients underwent clean surgery, 284 (40%) clean-contaminated and 128 (18%) contaminated surgery. A significant difference was evident between the antibiotics administered according to the recommended guidelines and the duration of antibiotic therapy (p = 0.001), duration (p = 0.001) and the type of surgical procedure (p = 0.00).

Conclusion

The findings of this study suggest that healthcare professionals do not strictly adhere to the guidelines for surgical antibiotic prophylaxis. Physicians are therefore encouraged to follow the recommendations appropriately and to regularly implement surgical antimicrobial prophylaxis for patient safety.

Assessment of Surgical Antibiotic Prophylaxis Compliance in Pediatrics: A Pre-post Quasi-experimental Study

OBJECTIVE

Data from rigorous evaluations of the impact of interventions on improving surgical antibiotic prophylaxis (SAP) compliance in pediatrics are lacking. Our objective was to assess the impact of a multifaceted intervention on improving pediatric SAP compliance in a hospital without an ongoing antimicrobial stewardship program.

STUDY DESIGN

A multidisciplinary team at the Montreal Children's Hospital performed a series of interventions designed to improve pediatric SAP compliance in June 2015. A retrospective, quasi-experimental study was performed to assess SAP compliance before and following the interventions. Our study included patients under 18 years old undergoing surgery between April and September in 2013 (preintervention) and in 2016 (postintervention). A 10-week washout period was included to rigorously assess the persistence of compliance without ongoing interventions. SAP, when indicated, was qualified as noncompliant, partially compliant (adequate agent and timing) or totally compliant (adequate agent, dose, timing, readministration, duration).

RESULTS

A total of 982 surgical cases requiring SAP were included in our primary analysis. The composite partial and total compliance increased from 51.4% to 55.8% [adjusted odds ratio 1.3; 95% confidence interval: 1.0-1.8; P = 0.06]. Although improvements in correct dose and readministration were significant, there was no significant improvement in correct timing, agent selection or duration.

CONCLUSION

Our study demonstrated that overall SAP compliance did not significantly improve following a washout period, illustrating the importance of ongoing surveillance and feedback from an antimicrobial stewardship program. Our strict approach in evaluating the timing criterion may also explain the lack of a significant impact on SAP compliance.

Effects of an antimicrobial stewardship intervention on perioperative antibiotic prophylaxis in pediatrics

Purpose

This study aims to determine the effectiveness of an Antimicrobial Stewardship Program based on a Clinical Pathway (CP) to improve appropriateness in perioperative antibiotic prophylaxis (PAP).

Materials and methods

This pre-post quasi-experimental study was conducted in a 12 month period (six months before and six months after CP implementation), in a tertiary Pediatric Surgical Centre. All patients from 1 month to 15 years of age receiving one or more surgical procedures were eligible for inclusion. PAP was defined appropriate according to clinical practice guidelines.

Results

Seven hundred sixty-six children were included in the study, 394 in pre-intervention and 372 in post-intervention. After CP implementation, there was an increase in appropriate PAP administration, as well as in the selection of the appropriate antibiotic for prophylaxis, both for monotherapy (p = 0.02) and combination therapy (p = 0.004). Even the duration of prophylaxis decreased during the post-intervention period, with an increase of correct PAP discontinuation from 45.1 to 66.7% (p < 0.001). Despite the greater use of narrow-spectrum antibiotic for fewer days, there was no increase in treatment failures (10/394 (2.5%) pre vs 7/372 (1.9%) post, p = 0.54).

Conclusions

CPs can be a useful tool to improve the choice of antibiotic and the duration of PAP in pediatric patients.

Epidemiology and outcomes of pretransplant methicillin-resistant Staphylococcus Aureus screening in pediatric solid organ transplant candidates

MRSA infection following SOT is an important cause of morbidity and mortality, but epidemiology and risk factors for colonization prior to pediatric SOT remain unclear. A retrospective cohort of SOT patients ≤21 years of age from 2009 to 2014 was evaluated. Demographics, MRSA screens, timing of transplantation, and MRSA infection were abstracted. From 2013 to 2014, 130 SOT candidates were screened or had known prior MRSA infection. Seventeen patients (13%) were MRSA colonized. Liver transplant candidates were least likely to be colonized (OR 0.22, CI:0.06-0.81, P = .02); greatest risk of colonization was in lung (OR 18.7, CI:1.9-182.3, P = .03), abdominal multivisceral (OR 7.5, CI:1.5-38.6, P = .02), and cardiac patients with history of cardiothoracic surgery (OR 8.0, CI:1.7-36.0, P = .007). In univariable analysis, African American patients were more likely to be colonized (OR 7.1, CI:2.49-19.41, P = .0005). There were 3 early MRSA infections in screened patients, incidence of 3.9%; only one in a colonized patient. Thirteen percent of screened pediatric SOT candidates were MRSA colonized, with greatest risk in lung, multivisceral and cardiac patients with prior cardiothoracic surgery. Early MRSA infection occurred in 3.9% of transplanted patients. Cardiothoracic and multivisceral organ transplant candidates may benefit the most from targeted MRSA screening.

Hospital-acquired Infection: Prevalence and Outcome in Infants Undergoing Open Heart Surgery in the Present Era

Background:

The aim of this study is to evaluate the causal relation between hospital-acquired infection (HAI) and clinical outcomes following cardiac surgery in neonates and infants and to identify the risk factors for the development of HAI in this subset of patients.

Materials and Methods:

After Ethics committee approval, one hundred consecutive infants undergoing open heart surgery (OHS) between June 2015 and June 2016 were included in this prospective observational study. Data were prospectively collected. The incidence and distribution of HAI, the microorganisms, their antibiotic resistance and patients’ outcome were determined. The Centers for Disease Control and Prevention criteria were used for defining HAIs. Univariate and multivariate risk factor analysis was done using Stata 14.

Results:

Sixteen infants developed microbiologically documented HAI after cardiac surgery. Neonatal age group was found to be most susceptible. Lower respiratory tract infections accounted for majority of the infections (47.4%) followed by bloodstream infection (31.6%), urinary tract infection (10.5%), and surgical site infection (10.5%). Klebsiella (36.8%) and Acinetobacter (26.3%) were the most frequently isolated pathogens. HAI was associated with prolonged ventilation duration (P = 0.005), Intensive Care Unit stay (P = 0.0004), and hospital stay (P = 0.002). Multivariate risk factor analysis revealed that preoperative hospital stay (odds ratio [OR] 1.22, 95% confidence interval (CI) 1.6-1.39, P = 0.004), and prolonged cardiopulmonary bypass (CPB) (OR 1.03, 95% CI 1.01-1.05, P = 0.001) were associated with the development of HAI.

Conclusion:

HAI still remains a dreaded complication in infants after OHS and contributing to morbidity and mortality. Strategies such as decreasing preoperative hospital stay, CPB time, and early extubation should be encouraged to prevent HAI.

Avoidance of Hospital-Acquired Infections in Pediatric Cardiac Surgical Patients

OBJECTIVES

The objectives of this review are to discuss the prevalence and risk factors associated with the development of hospital-acquired infections in pediatric patients undergoing cardiac surgery and the published antimicrobial prophylaxis regimens and rational approaches to the diagnosis, prevention, and treatment of nosocomial infections in these patients.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

Hospital-acquired infections remain a significant source of potentially preventable morbidity and mortality in pediatric cardiac surgical patients. Through improved understanding of these conditions and implementation of avoidance strategies, centers caring for these patients may improve outcomes in this vulnerable population.

Surgical site infections in a longitudinal cohort of neonatal intensive care unit patients

OBJECTIVE

To estimate the incidence and identify risk factors for surgical site infections (SSIs) among infants in the neonatal intensive care unit (NICU).

STUDY DESIGN

A prospective cohort study of infants undergoing surgical procedures from May 2009 to April 2012 in three NICUs was performed. SSI was identified if documented by an attending neonatologist and treated with intravenous antibiotics. Independent risk factors were identified using logistic regression, adjusting for NICU.

RESULT

A total of 902 infants underwent 1346 procedures and experienced 60 SSIs (incidence: 4.46/100 surgeries). Risk factors for SSIs included younger chronological age (odds ratio (OR) 1.03 per day decrease, 95% confidence interval (CI) 1.01, 1.04), lower gestational age (OR 1.09 per week decrease, CI 1.02, 1.18), male sex (OR 1.17, CI 1.04, 1.34) and use of central venous catheter (OR 4.40, CI 1.19, 9.62). Only 43% had surgical site cultures obtained and Staphylococcus aureus was most commonly isolated.

CONCLUSION

SSIs complicated 4.46% of procedures performed in the NICU. Although few modifiable risk factors for SSIs were identified, future efforts should focus on evaluating the impact of current prevention strategies on the incidence of neonatal SSI.

Optimizing Prophylactic Antibiotic Practice for Cardiothoracic Surgery by Pharmacists' Effects

Pharmacists' role may be ideal for improving rationality of drug prescribing practice. We aimed to study the impact of multifaceted pharmacist interventions on antibiotic prophylaxis in patients undergoing clean or clean-contaminated operations in cardiothoracic department. A pre-test-post-test quasiexperimental study was conducted in a cardiothoracic ward at a tertiary teaching hospital in Suzhou, China. Patients admitted to the ward were collected as baseline group (2011.7-2012.12) and intervention group (2013.7-2014.12), respectively. The criteria of prophylaxis antibiotic utilization were established on the basis of the published guidelines and official documents. During the intervention phase, a dedicated pharmacist was assigned and multifaceted interventions were implemented in the ward. Then we compared the differences in antibiotic utilization, bacterial resistance, clinical and economic outcomes between the 2 groups. Furthermore, patients were collected after the intervention (2015.1-2015.6) to evaluate the sustained effects of pharmacist interventions. 412 and 551 patients were included in the baseline and intervention groups, while 156 patients in postintervention group, respectively. Compared with baseline group, a significant increase was found in the proportion of antibiotic prophylaxis, the proportion of rational antibiotic selection, the proportion of suitable prophylactic antibiotic duration, and the proportion of suitable timing of administration of the first preoperative dose (P < 0.001). Meanwhile, a significant reduction was seen in the rate of unnecessary replacement of antibiotics and the rate of unnecessary combinations (P < 0.001). Besides, pharmacist intervention resulted in favorable outcomes with significantly decreased rates of surgical site infections, prophylactic antibiotic cost, and significantly shortened length of stay (P < 0.05). Furthermore, there were also significant decreases of the rates of antibiotic resistant enterobacter cloacae, klebsiella pneumonia, and staphylococcus aureus (P < 0.05). Moreover, the effects were sustained after discontinuation of the active interventions, as shown in prophylactic antibiotic utilization data. Pharmacist interventions in cardiothoracic surgery result in a high adherence to evidence-based treatment guidelines and a profound culture change in drug prescribing with favorable outcomes. The effects of pharmacist intervention are sustained and the role of pharmacists is emphasized for rational medication and optimal outcomes in clinical treatment.

Implementing a standardized perioperative antibiotic prophylaxis protocol for neonates undergoing cardiac surgery

BACKGROUND

A lack of perioperative antibiotic prophylaxis guidelines for neonates undergoing cardiac surgery has resulted in a wide variation in practice. We sought to do the following: (1) Determine the safety of a perioperative antibiotic prophylaxis protocol for neonatal cardiac surgery as measured by surgical site infections (SSIs) rates before and after implementation of the protocol; and (2) evaluate compliance with selected process measures for perioperative antibiotic prophylaxis.

METHODS

This quasi-experimental study included all cardiac procedures performed on neonates from July 2009 to June 2012 at a single center. An interdisciplinary task force developed a standardized perioperative antibiotic prophylaxis protocol in the fourth quarter of 2010. The SSI rates were compared in the preintervention (July 2009 to December 2010) versus the postintervention periods (January 2011 to June 2012). Compliance with process measures (appropriate drug, dose, timing, and discontinuation of perioperative antibiotic prophylaxis) was compared in the 2 periods.

RESULTS

During the study period, 283 cardiac procedures were performed. The SSI rates were similar in the preintervention and postintervention periods (6.21 vs 5.80 per 100 procedures, respectively). Compliance with the 4 process measures significantly improved postintervention.

CONCLUSIONS

Restricting the duration of perioperative antibiotic prophylaxis after neonatal cardiac surgery to 48 hours in neonates with a closed sternum and to 24 hours after sternal closure was safe and did not increase the rate of SSIs. Compliance with selected process measures improved in the postintervention period. Additional multicenter studies are needed to develop national guidelines for perioperative prophylaxis for this population.

Are children undergoing cardiac surgery receiving antibiotics at subtherapeutic levels?

OBJECTIVES

Perioperative antibiotics have decreased-but not eradicated-postoperative infections. In patients undergoing cardiac surgery with cardiopulmonary bypass, the dilutional effect of the priming and any additional volume given during the procedure may lead to subtherapeutic antibiotic levels. Our aim was to determine if children undergoing cardiac surgery with cardiopulmonary bypass receive perioperative antibiotics at subtherapeutic levels.

METHODS

Using published pharmacokinetic data on cefuroxime, we developed a computer simulation model to generate a nomogram predicting patients at risk for subtherapeutic cefuroxime levels based on time from initial dosing and additional volume given.

RESULTS

A computer-generated 1-compartment pharmacokinetic model was created to predict cefuroxime plasma levels over time for patients of all weights and additional volumes given for both a 25- and 50-mg/kg intravenous dose. For example, following a 25-mg/kg dose, a patient receiving an additional volume of 275 mL/kg is predicted to be subtherapeutic (<16 mg/L=4×minimum inhibitory concentration) at 4 hours. Our nomogram predicts all patients will be subtherapeutic at 8 hours, consistent with general pediatrics dosing schemes. Following a 50-mg/kg dose, levels are predicted to be subtherapeutic after an additional volume of 315 mL/kg at 5.5 hours.

CONCLUSIONS

Our model predicts which patients undergoing cardiac surgery with cardiopulmonary will have subtherapeutic cefuroxime levels. This nomogram enables providers to determine when to administer additional antibiotics in patients receiving large additional volumes during cardiac surgeries. This rational approach to perioperative antibiotic dosing may result in a reduction in postoperative infection in this vulnerable patient population.

Postoperative differences between colonization and infection after pediatric cardiac surgery-a propensity matched analysis

Background

The objective of this study was to identify the postoperative risk factors associated with the conversion of colonization to postoperative infection in pediatric patients undergoing cardiac surgery.

Methods

Following approval from the Institutional Review Board, patient demographics, co-morbidities, surgery details, transfusion requirements, inotropic infusions, laboratory parameters and positive microbial results were recorded during the hospital stay, and the patients were divided into two groups: patients with clinical signs of infection and patients with only positive cultures but without infection during the postoperative period. Using propensity scores, 141 patients with infection were matched to 141 patients with positive microbial cultures but without signs of infection. Our database consisted of 1665 consecutive pediatric patients who underwent cardiac surgery between January 2004 and December 2008 at a single center. The association between the patient group with infection and the group with colonization was analyzed after propensity score matching of the perioperative variables.

Results

179 patients (9.3%) had infection, and 253 patients (15.2%) had colonization. The occurrence of Gram-positive species was significantly greater in the colonization group (p = 0.004). The C-reactive protein levels on the first and second postoperative days were significantly greater in the infection group (p = 0.02 and p = 0.05, respectively). The sum of all the positive cultures obtained during the postoperative period was greater in the infection group compared to the colonization group (p = 0.02). The length of the intensive care unit stay (p < 0.001) was significantly longer in the infection group compared to the control group.

Conclusions

Based on our results, we uncovered independent relationships between the conversion of colonization to infection regarding positive S. aureus and bloodstream results, as well as significant differences between the two groups regarding postoperative C-reactive protein levels and white blood cell counts.

Evaluation of the duration of the antibiotic prophylaxis in paediatric postoperative heart surgery patients

The ideal duration of postoperative antibiotic prophylaxis in heart surgery is unknown. The most recent guidelines recommend a decrease in prophylaxis time to decrease the emergence of multiresistant germs. However, compliance with these recommendations is scant. Our aim was to determine whether a decrease in prophylaxis time entails an increase in the infection rate. A retrospective study was performed between September 2003 and March 2006, including all patients of ages between 1 day and 14 years who were admitted to the intensive care unit after heart surgery. Patients being treated for an infection at the time of surgery were excluded. The appearance of nosocomial infection, localisation, and the causative agent, if isolated, were included; demographic and clinical analytical variables, duration and type of antibiotic prophylaxis, and duration of other invasive devices were also included. Standard analysis and multivariable logistical regression were performed. 194 patients were included in the study. The median duration of antibiotic prophylaxis was 72 h (range 24 to 176), with the most-used prophylaxis regimen being second-generation cephalosporins plus aminoglycosides. The incidence of nosocomial infection, mainly bacteraemia, was 11.9%. The type of antibiotic therapy used for prophylaxis did not affect the incidence of infection. In the multivariable logistical regression, only prolongation of antibiotic prophylaxis >48 h, central venous access maintenance time, and intubation increased the infection rate. The suspension of antibiotic prophylaxis in the 48 h after surgery in pediatric patients undergoing heart surgery does not increase the incidence of nosocomial infection. According to our results, prolongation of prophylaxis >48 h increases the infection rate.

Bedside prediction rule for infections after pediatric cardiac surgery

Purpose

Infections after pediatric cardiac surgery are a common complication, occurring in up to 30% of cases. The purpose of this study was to develop a bedside prediction rule to estimate the risk of a postoperative infection.

Methods

All consecutive pediatric cardiac surgery procedures between April 2006 and May 2009 were retrospectively analyzed. The primary outcome variable was any postoperative infection, as defined by the Center of Disease Control (2008). All variables known to the clinician at the bedside at 48 h post cardiac surgery were included in the primary analysis, and multivariable logistic regression was used to construct a prediction rule.

Results

A total of 412 procedures were included, of which 102 (25%) were followed by an infection. Most infections were surgical site infections (26% of all infections) and bloodstream infections (25%). Three variables proved to be most predictive of an infection: age less than 6 months, postoperative pediatric intensive care unit (PICU) stay longer than 48 h, and open sternum for longer than 48 h. Translation into prediction rule points yielded 1, 4, and 1 point for each variable, respectively. Patients with a score of 0 had 6.6% risk of an infection, whereas those with a maximal score of 6 had a risk of 57%. The area under the receiver operating characteristic curve was 0.78 (95% confidence interval 0.72–0.83).

Conclusions

A simple bedside prediction rule designed for use at 48 h post cardiac surgery can discriminate between children at high and low risk for a subsequent infection.

Bloodstream infections increased after delayed sternal closure: cause or coincidence

BACKGROUND

Infants who undergo major cardiac operations are at risk for developing bloodstream infections which contribute to the morbidity, mortality, and cost of treatment. Determining what factors are associated with this increased risk of infection may aid in prevention. We sought to evaluate the practice of delayed sternal closure after neonatal cardiac surgery to determine its role as a risk factor for postoperative bloodstream infection.

METHODS

We reviewed 110 consecutive patients with hypoplastic left heart syndrome after stage 1 Norwood procedure at Children's Healthcare of Atlanta. The rates of bloodstream infections were determined and risks analyzed with regard to postoperative status of sternal closure; primary versus delayed.

RESULTS

Delayed sternal closure was utilized in 67 of 110 patients (61%), while 43 patients had primary sternal closure in the operating room. Overall rate of bloodstream infection was 22% (24 of 110), with 83% (20 of 24) of infections occurring in the delayed closure group. Among infants with delayed closure, 30% developed bloodstream infection, as compared with 9% of patients with primary closure (p = 0.017). Patients with delayed closure had a fourfold increased risk (odds ratio 3.9, p = 0.03) of developing bloodstream infection in-hospital. Predominant organisms were coagulase negative Staphylococcus species; there was one case of mediastinitis.

CONCLUSIONS

Delayed sternal closure is associated with an increased likelihood of bloodstream infection and should be recognized as a risk factor after neonatal cardiac operations.

Impact of bloodstream infection on the outcome of children undergoing cardiac surgery

Bloodstream infections (BSIs) are a main cause of nosocomial infection in the critical care area. The development of BSI affects the surgical outcome and increases intensive care unit (ICU) morbidity and mortality. This prospective cohort study was undertaken to determine the incidence, etiology, risk factors, and outcome of BSI for postoperative pediatric cardiac patients in the pediatric cardiac ICU setup. All postoperative pediatric patients admitted to the pediatric cardiac ICU from January 2007 to December 2007 were included in the study. Data were prospectively collected using a standardized data collection form. Patients with BSI (group 1) were compared with non-BSI patients (group 2) in terms of age, weight, surgical complexity score, duration of central line, need to keep the chest open postoperatively, and the length of the pediatric cardiac ICU and hospital stay. Of the 311 patients who underwent cardiac surgery during the study period, 27 (8.6%) were identified as having BSI (group 1). The 311 patients included in the study had a total of 1,043 central line days and a catheter-related BSI incidence density rate of 25.8 per 1,000 central line days. According to univariate analysis, the main risk factors for the development of BSI after pediatric cardiac surgery were lower patient weight (p = 0.005), high surgical complexity score (p < 0.05), open sternum postoperatively (p < 0.05), longer duration of central lines (p < 0.0001), and prolonged pediatric cardiac ICU and hospital stay (p < 0.0001). Gram-negative organisms were responsible for 67% of the BSI in the pediatric cardiac ICU, with pseudomonas (28%) and enterobacter (22%) as the main causative organisms. The mortality rate in the BSI group was 11% compared with 2% in the non-BSI group. In our pediatric cardiac ICU, BSI developed in 8.6% of the children undergoing cardiac surgery, mainly caused by a Gram-negative organism. The main risk factors for BSI in the postoperative pediatric cardiac patient were high surgical complexity, open sternum, low body weight, longer duration of central line, and prolonged pediatric cardiac ICU stay.

Major infection after pediatric cardiac surgery: a risk estimation model

BACKGROUND

In pediatric cardiac surgery, infection is a leading cause of morbidity and mortality. We created a model to predict risk of major infection in this population.

METHODS

Using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we created a multivariable model in which the primary outcome was major infection (septicemia, mediastinitis, or endocarditis). Candidate-independent variables included demographic characteristics, comorbid conditions, preoperative factors, and cardiac surgical procedures. We created a reduced model by backward selection and then created an integer scoring system using a scaling factor with scores corresponding to percent risk of infection.

RESULTS

Of 30,078 children from 48 centers, 2.8% had major infection (2.6% septicemia, 0.3% mediastinitis, and 0.09% endocarditis). Mortality and postoperative length of stay were greater in those with major infection (mortality, 22.2% versus 3.0%; length of stay >21 days, 69.9% versus 10.7%). Young age, high complexity, previous cardiothoracic operation, preoperative length of stay more than 1 day, preoperative ventilator support, and presence of a genetic abnormality were associated with major infection after backward selection (p < 0.001). Estimated infection risk ranged from less than 0.1% to 13.3%; the model discrimination was good (c index, 0.79).

CONCLUSIONS

We created a simple bedside tool to identify children at high risk for major infection after cardiac surgery. These patients may be targeted for interventions to reduce the risk of infection and for inclusion in future clinical trials.

[Nosocomial infections in pediatric patients following cardiac surgery]

INTRODUCTION

Nosocomial infection (NI) is a possible complication in patients who undergo cardiac surgery, and represents an important cause of morbidity and mortality. This study was undertaken to determine the NI rate, main risk factors, and microbial spectrum in a paediatric intensive care unit (PICU) for this group of patients.

PATIENTS AND METHODS

A prospective review was performed, including all patients admitted to the PICU after cardiac surgery between December 2003 and November 2004. NI was defined according to Centers for Disease Control criteria.

RESULTS

Sixty-nine patients were included. Sixteen patients (23.2 %) acquired at least one episode of NI. The NI rate was 4.9 per 100 patient-days. The most common NI was pneumonia, followed by urinary tract infection. There were no episodes of sepsis. No patients died from infectious causes. The main aetiological organism was Haemophilus influenzae, associated with 41.6 % of pneumonias, and followed by Pseudomonas aeruginosa. No multiresistant organisms were isolated. There was a statistically significant association between the duration of use of external devices (mechanical ventilation, urinary and central venous catheterization) and development of NI.

CONCLUSIONS

Aggressive monitoring and support devices are the main risk factors for NI. Based on our data, we suggest early removal of these. Presumed NI should be diagnosed according standard criteria before starting antibiotic therapy, and treatment modified depending on culture results.

Medical errors affecting the pediatric intensive care patient: incidence, identification, and practical solutions

The complexity of patient care and the potential for medical error make the pediatric ICU environment a key target for improvement of outcomes in hospitalized children. This article describes several event-specific errors as well as proven and potential solutions. Analysis of pediatric intensive care staffing, education, and administration systems, although a less "traditional" manner of thinking about medical error, may reveal further opportunities for improved pediatric ICU outcome.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to: Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave., Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .