Defining pneumonia in critically ill infants and children

The Role of Mannose-Binding Lectin and Inflammatory Markers in Establishing the Course and Prognosis of Community-Acquired Pneumonia in Children

BACKGROUND

Community-acquired pneumonia (CAP) is one of the most significant childhood diseases worldwide and a leading infectious cause of death in children. This study aimed to evaluate the prognostic value of the inflammatory markers-C-reactive protein (CRP) and procalcitonin (PCT)-and the polymorphic glycoprotein mannose-binding lectin (MBL), deficiency of which is associated with severe infections, in the determination of the optimal type and timing of therapeutic intervention for CAP in childhood.

METHODS

Retrospective evaluation was conducted on a cohort of 204 children aged 4 months-17 years hospitalized with CAP. Their levels of CRP, PCT, and MBL were assessed for their association with a variety of outcomes, including the incidence of local and systemic complications, admission to the ICU, duration of antibiotic treatment and hospital stay, and death.

RESULTS

CRP and PCT proved to be better predictors of complications of CAP than MBL. The area under the curve (AUC) value was highest for PCT as a predictor of systemic complications (AUC = 0.931, 95%CI 0.895-0.967), while CRP (AUC = 0.674, 95%CI 0.586-0.761) performed best as a predictor of local complications (AUC = 0.674, 95%CI 0.586-0.761). Regarding admission to the ICU, CRP was the weakest predictor (AUC = 0.741), while PCT performed the best (AUC = 0.833), followed by MBL (AUC = 0.797). Sensitivity and specificity were calculated for the optimal threshold generated by receiver operating characteristic (ROC) curves, rendering sensitivity of 90% and specificity of 87% for PCT in assessing the risk of systemic complications, compared to sensitivity of 83% and specificity of 90% for CRP. MBL showed relatively high sensitivity (96%) but low specificity (25%) for predicting the need for ICU admission.

CONCLUSIONS

Early measurement of CRP, PCT, and MBL provides clinicians with important information regarding the course and prognosis of children diagnosed with CAP, thus ensuring prompt, optimal therapeutic management.

Mechanisms of Lung and Intestinal Microbiota and Innate Immune Changes Caused by Pathogenic Enterococcus Faecalis Promoting the Development of Pediatric Pneumonia

Bacterial pneumonia is the main cause of illness and death in children under 5 years old. We isolated and cultured pathogenic bacteria LE from the intestines of children with pneumonia and replicated the pediatric pneumonia model using an oral gavage bacterial animal model. Interestingly, based on 16srRNA sequencing, we found that the gut and lung microbiota showed the same imbalance trend, which weakened the natural resistance of this area. Further exploration of its mechanism revealed that the disruption of the intestinal mechanical barrier led to the activation of inflammatory factors IL-6 and IL-17, which promoted the recruitment of ILC-3 and the release of IL-17 and IL-22, leading to lung inflammation. The focus of this study is on the premise that the gut and lung microbiota exhibit similar destructive changes, mediating the innate immune response to promote the occurrence of pneumonia and providing a basis for the development and treatment of new drugs for pediatric pneumonia.

Granulocyte-macrophage colony-stimulating factor suppresses induction of type I interferon in infants with severe pneumonia

BACKGROUND

The underlying mechanisms for infantile bronchopneumonia development remain unknown.

METHODS

Peripheral blood mononuclear cell (PBMCs) and serum derived from severe and mild infantile bronchopneumonia were obtained, and the expression of various molecules was detected with enzyme-linked immunosorbent assay and quantitative PCR. Such molecules were also detected in granulocyte-macrophage colony-stimulating factor (GM-CSF)-induced bone marrow-derived NFκB2^-/- dendritic cells (DCs) or NIK SMI1 (NF-κB-inducing kinase inhibitor) administrated DCs.

RESULTS

The relative mRNA expression levels of type I interferons (IFNs) (IFN-α4, IFN-β), Th17 cell-associated markers (interleukin-17A, retinoic-acid-receptor-related orphan nuclear receptor gamma, and GM-CSF), and non-canonical NF-κB member (NFκB2) were significantly up-regulated in PBMCs and DCs derived from infantile bronchopneumonia compared with healthy controls. However, compared with Th17 cell-associated markers and non-canonical NF-κB molecules, the expression of IFN-α4 and IFN-β was significantly inhibited in severe infantile bronchopneumonia compared with mild infantile bronchopneumonia. The relative protein expression of the above molecules also showed a similar expression pattern in the PBMCs or serum. NF-κB2 knockout or NIK SMI1 administration could reverse the diminished expression of IFN-β in GM-CSF-induced bone marrow-derived DCs.

CONCLUSIONS

GM-CSF-dependent non-canonical NF-κB pathway-mediated inhibition of type I IFNs production in DCs contributes to the development of severe bronchopneumonia in infant.

IMPACT

Granulocyte-macrophage colony-stimulating factor-dependent non-canonical NF-κB pathway-mediated inhibition of type I IFNs production in dendritic cells is critical for the development of infantile bronchopneumonia. Our findings reveal a possible mechanism underlying the development of severe infantile bronchopneumonia. The results could provide therapeutic molecular target for the treatment of such disease.

HIV exposure and its association with paediatric ICU outcomes in children admitted with severe pneumonia at Chris Hani Baragwanath Academic Hospital, South Africa

Background. Pneumonia is one of the leading causes of under-5 death in South Africa and accounts for a substantial burden of paediatric intensive care unit (PICU) admissions. However, little is known about PICU outcomes in HIV-exposed uninfected (HIV-EU) children with pneumonia, despite the growing size of this vulnerable population.Objectives. To determine whether HIV exposure without infection is an independent risk factor for mortality and morbidity in childrenadmitted to PICU with pneumonia.Methods. This retrospective review included all patients with pneumonia admitted to the PICU at Chris Hani Baragwanath AcademicHospital between 1 January 2013 and 31 December 2014. Patients were classified as HIV-unexposed (HIV-U), HIV-EU and HIV-infected.Medical records were reviewed to determine survival to PICU discharge, duration of PICU admission and duration of mechanicalventilation. Survival analysis was used to determine the association between HIV infection/exposure with mortality, and linear regression was used to examine the association with length of stay and duration of mechanical ventilation. This study included 107 patients: 54 were HIV-U; 28 were HIV-EU; 23 HIV-positive; and 2 had an unknown HIV status.Results. Overall, 84% (n=90) survived to PICU discharge, with no difference in survival based on HIV infection or exposure. Both HIV-EUand HIV-U children had significantly shorter PICU admissions and fewer days of mechanical ventilation compared with HIV-infectedchildren (p=0.011 and p=0.004, respectively).Conclusion. HIV-EU children behaved similarly to HIV-U children in terms of mortality, duration of PICU admission and length ofmechanical ventilation. HIV infection was associated with prolonged length of mechanical ventilation and ICU stay but not increasedmortality

Oral mucosal mouthwash with chlorhexidine does not reduce the incidence of ventilator-associated pneumonia in critically ill children: A randomised controlled trial

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most frequently encountered causes of hospital-acquired infection and results in high morbidity among intubated patients. Few trials have investigated the efficacy of oral care with chlorhexidine (CHX) mouthwash for the prevention of VAP in the paediatric population.

OBJECTIVES

The objective of this study was to assess the efficacy of CHX mouthwash in the prevention of VAP and to determine risk factors for VAP in children aged 1 month to 18 years admitted to the paediatric intensive care unit (PICU).

METHODS

This was a prospective, randomised, controlled, double-blind trial performed in the PICU. Patients were randomised into two groups receiving CHX (0.12%) (n = 88) or placebo (0.9% NaCl) (n = 86) and were followed up for VAP development. The main outcome measures were incidence of VAP, duration of hospital stay, duration of PICU stay, duration of ventilation, mortality, and the characteristics of organisms isolated in cases with VAP.

RESULTS

No difference was observed in the incidence of VAP and the type and distribution of organisms in the two groups (p > 0.05). In the CHX and placebo groups, we identified 21 and 22 patients with VAP, respectively. Incidence per 1000 ventilation days was 29.5 events in the CHX group and 35.1 events in the placebo group. Gram-negative bacteria were most common (71.4% in CHX vs. 54.5% in placebo). The use of 0.12% CHX did not influence hospital stay, PICU stay, ventilation, and mortality (p > 0.05). Multivariate analysis identified duration of ventilation as the only independent risk factor for VAP (p = 0.001).

CONCLUSION

The use of 0.12% CHX did not reduce VAP frequency among critically ill children. The only factor that increased VAP frequency was longer duration on ventilation. It appears that low concentration of CHX is not effective for VAP prevention, especially in the presence of multiresistant bacteria. CLINICALTRIALS.

GOV IDENTIFIER

NCT04527276.

Assessing Severity in Pediatric Pneumonia: Predictors of the Need for Major Medical Interventions

OBJECTIVE

The aim of this study was to determine potential predictors of the need for major medical interventions in the context of assessing severity in pediatric pneumonia.

METHODS

This was a prospective, cohort study of previously healthy children and adolescents younger than 18 years presenting to the pediatric emergency room with clinically suspected pneumonia and examining both the full cohort and those with radiologically confirmed pneumonia. The presence of hypoxemia (peripheral oxygen saturation ≤92%), age-specific tachypnea, high temperature (≥38.5°C), chest retraction score, modified Pediatric Early Warning Score, age, C-reactive protein, white blood cell (WBC) count, and chest radiograph findings at first assessment were analyzed by univariate and multivariate analyses to examine their predictive ability for the need for major medical interventions: supplemental oxygen, supplemental fluid, respiratory support, intensive care, or treatment for complications during admission.

RESULTS

Fifty percent of the 394 cases of suspected pneumonia and 60% of the 265 cases of proven pneumonia were in need of 1 or more medical interventions. In multivariate logistic regression, only the presence of hypoxemia (odds ratios, 3.66 and 3.83 in suspected and proven pneumonia, respectively) and chest retraction score (odds ratios, 1.21 and 1.31, respectively for each 1-point increase in the score) significantly predicted the need for major medical interventions in both suspected and proven pneumonia. Specificity of 94% or greater, positive likelihood ratio of 6.4 or greater, and sensitivity of less than 40% were found for both hypoxemia and chest retraction score in predicting major medical interventions. C-reactive protein and white blood cell count were not associated with the need for these interventions, whereas multifocal radiographic changes were.

CONCLUSIONS

Hypoxemia and an assessment of chest retractions were the predictors significantly able to rule in more severe pneumonia, but with a limited clinical utility given their poor ability to rule out the need for major medical interventions. Future validation of these findings is needed.

Clinical characteristics and viral load of respiratory syncytial virus and human metapneumovirus in children hospitaled for acute lower respiratory tract infection

Respiratory syncytial virus (RSV) and human metapneumovirus (HMPV) are two common viral pathogens in acute lower respiratory tract infections (ALRTI). However, the association of viral load with clinical characteristics is not well‐defined in ALRTI. To explore the correlation between viral load and clinical characteristics of RSV and HMPV in children hospitalized for ALRTI in Lanzhou, China. Three hundred and eighty‐seven children hospitalized for ALRTI were enrolled. Nasopharyngeal aspirates (NPAs) were sampled from each children. Real‐time PCR was used to screen RSV, HMPV, and twelve additional respiratory viruses. Bronchiolitis was the leading diagnoses both in RSV and HMPV positive patients. A significantly greater frequency of wheezing (52% vs. 33.52%, P = 0.000) was noted in RSV positive and negative patients. The RSV viral load was significant higher in children aged <1 year (P = 0.003), children without fever and wheezing (P = 0.015 and P = 0.000), days of illness <14 days (P = 0.002), children with bronchiolitis (P = 0.012) and children with RSV single infections (P = 0.000). No difference was found in the clinical features of HMPV positive and negative patients. The HMPV viral load had no correlation with any clinical characteristics. The incidences of severe disease were similar between single infection and coinfection for the two viruses (RSV, P = 0.221; HMPV, P = 0.764) and there has no statistical significance between severity and viral load (P = 0.166 and P = 0.721). Bronchiolitis is the most common disease caused by RSV and HMPV. High viral load or co‐infection may be associated with some symptoms but neither has a significant impact on disease severity for the two viruses. J. Med. Virol. 89:589–597, 2017. © 2016 Wiley Periodicals, Inc.

Critically Ill Children Have Low Vitamin D-Binding Protein, Influencing Bioavailability of Vitamin D

RATIONALE

Vitamin D deficiency, often defined by total serum 25-hydroxyvitamin D (25[OH]D) <20 ng/ml, is common in critically ill patients, with associations with increased mortality and morbidity in the intensive care unit. Correction of vitamin D deficiency in critical illness has been recommended, and ongoing clinical trials are investigating the effect of repletion on patient outcome. The biologically active amount of 25(OH)D depends on the concentration and protein isoform of vitamin D-binding protein (VDBP), which is also an acute-phase reactant affected by inflammation and injury.

OBJECTIVES

We performed a secondary analysis of a cohort of critically ill children in which we reported a high rate of vitamin D deficiency, to examine how VDBP level and genotype would impact vitamin D status.

METHODS

We prospectively enrolled 511 children admitted to the pediatric intensive care unit over a 12-month period.

MEASUREMENTS AND MAIN RESULTS

We measured serum VDBP in 479 children. We genotyped single nucleotide polymorphisms rs7041 and rs4588 in the VDBP gene (GC) to determine haplotypes GC1F, GC1S, and GC2 in 178 subjects who consented, then calculated bioavailable 25(OH)D from serum 25(OH)D, VDBP, albumin, and GC haplotype. The median serum VDBP level was 159 μg/ml (interquartile range, 108-221), lower than has been reported in healthy children. Factors predicting lower levels in multivariate analysis included age <1 year, nonwhite race, being previously healthy, 25(OH)D <20 ng/ml and greater illness severity. In the subgroup that was genotyped, GC haplotype had the strongest association with VDBP level; carriage of one additional copy of GC1S was associated with a 37.5% higher level (95% confidence interval, 31.9-44.8; P < 0.001). Bioavailable 25(OH)D was also inversely associated with illness severity (r = -0.24, P < 0.001), and ratio to measured total 25(OH)D was variable and related to haplotype.

CONCLUSIONS

Physiologic deficiency of 25(OH)D in critical illness may be more difficult to diagnose, given that lower VDBP levels increase bioavailability. Treatment studies conducted on the basis of total 25(OH)D level, without consideration of VDBP concentration and genotype, may increase the risk of falsely negative results.

Risk Model of Bacterial Coinfection in Children with Severe Viral Bronchiolitis

Background Among children with respiratory failure from viral lower respiratory tract infection (LRTI), up to 39% will develop pulmonary bacterial coinfection, yet nearly all will receive antibiotics. We sought to identify patients with viral LRTI requiring mechanical ventilation at low risk of bacterial coinfection through the use of a risk prediction model. Methods We performed a retrospective cohort study identifying all patients admitted to the intensive care unit with laboratory-confirmed viral LRTI requiring invasive mechanical ventilation over a 2-year period and partitioned data in experimental and validation datasets. A multivariate probit regression model was constructed including variables associated with bacterial coinfection in the experimental dataset. Model was validated and recalibrated using the validation dataset. Model discrimination was assessed using receiver operating characteristic curve analysis. Results There were 126 patients included in the analysis. Variables associated with bacterial coinfection included tracheostomy in situ, Gram-stained smear white blood cells, and bacteria. The final recalibrated model discriminating between no coinfection and coinfection had an area under the curve of 0.8696. Conclusion Our prediction model identifies patients with viral LRTI requiring mechanical ventilation at very low risk of bacterial coinfection and has the potential to decrease antibiotic utilization without negatively impacting clinical outcome.

Optimizing the Use of Antibacterial Agents in the Neonatal Period

Antibiotics are invaluable in the management of neonatal infections. However, overuse or misuse of antibiotics in neonates has been associated with adverse outcomes, including increased risk for future infection, necrotizing enterocolitis, and mortality. Strategies to optimize the use of antibiotics in the neonatal intensive care unit include practicing effective infection prevention, improving the diagnostic evaluation and empiric therapy for suspected infections, timely adjustment of therapy as additional information becomes available, and treating proven infections with an effective, narrow-spectrum agent for the minimum effective duration. Antibiotic stewardship programs provide support for these strategies but require the participation and input of neonatologists as stakeholders to be most effective.

Value of clinical pulmonary infection score in critically ill children as a surrogate for diagnosis of ventilator-associated pneumonia

RATIONALE

Although the modified clinical pulmonary infection score (mCPIS) has been endorsed by national organizations, only a very few pediatric studies have assessed it for the diagnosis of ventilator-associated pneumonia (VAP).

METHODS

Seventy children were prospectively included if they fulfilled the diagnosis criteria for VAP referenced by the Centers for Disease Control and Prevention. The primary outcome was performance of mCPIS calculated on day 1 to accurately identify VAP as defined by microbiological data.

RESULTS

The data showed that an mCPIS of 6 or higher had a sensitivity of 94%, specificity of 50%, positive predictive value of 64%, negative predictive value of 90%, a positive likelihood ratio of 1.88, and a negative likelihood ratio of 0.11. The area under the receiver operating characteristic curve was 0.70. A positive posttest result increased the disease probability by 15.4%, whereas a negative test result reduced the probability by 38.6%. Patients with an mCPIS of 6 or higher had longer length of mechanical ventilation and pediatric intensive care unit stay compared with patients with an mCPIS lower than 6.

CONCLUSION

The mCPIS had a clinically acceptable performance, and it can be a helpful screening tool for VAP diagnosis. An mCPIS lower than 6 was highly able in distinguishing patients without VAP. Despite its high sensitivity and negative predictive value of this score, further studies are required to assess the use of mCPIS in guiding therapeutic decisions.

Defining sedation-related adverse events in the pediatric intensive care unit

BACKGROUND

Clinical trials exploring optimal sedation management in critically ill pediatric patients are urgently needed to improve both short- and long-term outcomes. Concise operational definitions that define and provide best-available estimates of sedation-related adverse events (AE) in the pediatric population are fundamental to this line of inquiry.

OBJECTIVES

To perform a multiphase systematic review of the literature to identify, define, and provide estimates of sedation-related AEs in the pediatric ICU setting for use in a multicenter clinical trial.

METHODS

In Phase One, we identified and operationally defined the AE. OVID-MEDLINE and CINAHL databases were searched from January 1998 to January 2012. Key terms included sedation, intensive and critical care. We limited our search to data-based clinical trials from neonatal to adult age. In Phase Two, we replicated the search strategy for all AEs and identified pediatric-specific AE rates.

RESULTS

We reviewed 20 articles identifying sedation-related adverse events and 64 articles on the pediatric-specific sedation-related AE. A total of eleven sedation-related AEs were identified, operationally defined and estimated pediatric event rates were derived. AEs included: inadequate sedation management, inadequate pain management, clinically significant iatrogenic withdrawal, unplanned endotracheal tube extubation, post-extubation stridor with chest-wall retractions at rest, extubation failure, unplanned removal of invasive tubes, ventilator-associated pneumonia, catheter-associated bloodstream infection, Stage II+ pressure ulcers and new tracheostomy.

CONCLUSIONS

Concise operational definitions that defined and provided best-available event rates of sedation-related AEs in the pediatric population are presented. Uniform reporting of adverse events will improve subject and patient safety.

A cross-sectional study of the clinical characteristics of hospitalized children with community-acquired pneumonia in eight eastern cities in China

BACKGROUND

Community-acquired pneumonia in children is common in China. To understand current clinical characteristics and practice, we conducted a cross-sectional study to analyze quality of care on childhood pneumonia in eight eastern cities in China.

METHODS

Consecutive hospital records between January 1, 2010 and December 31, 2010 were collected from 13 traditional Chinese medicine (TCM) and western medicine (WM) hospitals in February, May, August, and November (25 cases per season, 100 cases over the year), respectively. A predesigned case report form was used to extract data from the hospital medical records.

RESULTS

A total of 1298 cases were collected and analyzed. Symptoms and signs upon admission at TCM and WM hospitals were cough (99.3% vs. 98.6%), rales (84.8% vs. 75.0%), phlegm (83.3% vs. 49.1%), and fever (74.9% vs. 84.0%) in frequency. Patients admitted to WM hospitals had symptoms and signs for a longer period prior to admission than patients admitted to TCM hospitals. Testing to identify etiologic agents was performed in 1140 cases (88.4%). Intravenous antibiotics were administered in 99.3% (595/598) of cases in TCM hospitals and in 98.6% (699/700) of cases in WM hospitals. Besides, Chinese herbal extract injection was used more frequently in TCM hospitals (491 cases, 82.1%) than in WM hospitals (212 cases, 30.3%) (p < 0.01). At discharge, 818 cases (63.0%) were clinically cured, with a significant difference between the cure rates in TCM (87.6%) and WM hospitals (42.0%) (OR = 9.8, 95% confidence interval (CI): 7.3 ~ 12.9, p < 0.01). Pathogen and previous medical history were more likely associated with the disappearance of rales (OR = 7.2, 95% CI: 4.8 ~ 10.9). Adverse effects were not reported from the medical records.

CONCLUSIONS

Intravenous use of antibiotics is highly prevalent in children with community-acquired pneumonia regardless of aetiology. There was difference between TCM and WM hospitals with regard to symptom profile and the use of antibiotics. Intravenous use of herbal injection was higher in TCM hospitals than in WM hospitals. Most of the cases were diagnosed based on clinical signs and symptoms without sufficient confirmation of aetiology. Audit of current practice is urgently needed to improve care.

Outcome of infants with unrepaired heart disease admitted to the pediatric intensive care unit: single-center developing country perspective

OBJECTIVE

Congenital heart disease (CHD) has an incidence of ∼0.8-1%. Outcome of previously diagnosed CHD patients awaiting surgery (either correction or palliation) in a developing country setting is unknown. We strive to determine the outcome of patients with CHD awaiting surgery who present to pediatric intensive care unit (PICU) setting with an acute illness.

DESIGN

Retrospective cross-sectional chart review.

SETTING

Pediatric intensive care unit of The Aga Khan University Hospital, Karachi, Pakistan.

PATIENT

Medical records of infants (1-12 months) with CHD awaiting surgery presenting to the PICU with an acute illness between January 2009 and June 2012 were included. Newly diagnosed CHD patients, those not requiring PICU admission, and those transferred to another hospital were excluded.

RESULTS

A total of 34 infants met the inclusion criteria. Median age at presentation was 5 months. Seventy-four percent of the infants had CHD lesion characterized by increased pulmonary blood flow (shunt lesions). Though none of the patients met the strict criteria for sepsis or pneumonia, 74% were admitted with a diagnosis of pneumonia or sepsis. Only 15% of patient had congestive heart failure as an admitting diagnosis. Oxygen therapy was given to 94% of these patients. Fifty-nine percent of these patients expired during the admission, 95% of those expired had multiorgan dysfunction.

CONCLUSION

Patients with CHD awaiting surgery and who admitted to the PICU with acute illness are at high risk for mortality. Stringent criteria to diagnose pneumonia or sepsis should be used in these patients.

Approach to common bacterial infections: community-acquired pneumonia

Community-acquired pneumonia (CAP) occurs more often in early childhood than at almost any other age. Many microorganisms are associated with pneumonia, but individual pathogens are difficult to identify, which poses problems in antibiotic management. This article reviews the common as well as new, emerging pathogens, as well as the guidelines for management of pediatric CAP. Current guidelines for pediatric CAP continue to recommend the use of high-dose amoxicillin for bacterial CAP and azithromycin for suspected atypical CAP (usually caused by Mycoplasma pneumoniae) in children.

Prospective evaluation of sedation-related adverse events in pediatric patients ventilated for acute respiratory failure

OBJECTIVES

Sedation-related adverse events in critically ill pediatric patients lack reproducible operational definitions and reference standards. Understanding these adverse events is essential to improving the quality of patient care and for developing prevention strategies in critically ill children. The purpose of this study was to test operational definitions and estimate the rate and site-to-site heterogeneity of sedation-related adverse events.

DESIGN

Prospective cohort study.

SETTING

Twenty-two pediatric intensive care units in the United States enrolling baseline patients into a prerandomization phase of a multicenter trial on sedation management.

PATIENTS

Pediatric patients intubated and mechanically ventilated for acute respiratory failure.

DATA EXTRACTION

Analysis of adverse event data using consistent operational definitions from a Web-based data management system.

MEASUREMENTS AND MAIN RESULTS

There were 594 sedation-related adverse events reported in 308 subjects, for a rate of 1.9 adverse events per subject and 16.6 adverse events per 100 pediatric intensive care unit days. Fifty-four percent of subjects had at least one adverse event. Seven (1%) adverse events were classified as severe, 347 (58%) as moderate, and 240 (40%) as mild. Agitation (30% of subjects, 41% of events) and pain (27% of subjects, 29% of events) were the most frequently reported events. Eight percent of subjects (n = 24) experienced 54 episodes of clinically significant iatrogenic withdrawal. Unplanned endotracheal tube extubation occurred at a rate of 0.82 per 100 ventilator days, and 32 subjects experienced postextubation stridor. Adverse events with moderate intraclass correlation coefficients included: Inadequate sedation management (intraclass correlation coefficient = 0.130), clinically significant iatrogenic withdrawal (intraclass correlation coefficient = 0.088), inadequate pain management (intraclass correlation coefficient = 0.080), and postextubation stridor (intraclass correlation coefficient = 0.078).

CONCLUSIONS

Operational definitions for sedation-related adverse events were consistently applied across multiple pediatric intensive care units. Adverse event rates were different from what has been previously reported in single-center studies. Many adverse events have moderate intraclass correlation coefficients, signaling site-to-site heterogeneity.

Outcomes in children with refractory pneumonia supported with extracorporeal membrane oxygenation

PURPOSE

To review the use of extracorporeal membrane oxygenation (ECMO) in severe paediatric pneumonia and evaluate factors that may affect efficacy of this treatment.

METHODS

Retrospective study of the ECMO database of a tertiary paediatric intensive care unit and chart review of all patients who were managed with ECMO during their treatment for severe pneumonia over a 23-year period. The main outcome measures were survival to hospital discharge, and ICU and hospital length of stay. We compared the groups of culture-positive versus culture-negative pneumonia, venoarterial (VA) versus venovenous (VV) ECMO, community- versus hospital-acquired cases, and cases before and after 2005.

RESULTS

Fifty patients had 52 cases of pneumonia managed with ECMO. Community-acquired cases were sicker with higher oxygenation index (41.5 ± 20.5 versus 26.8 ± 17.8; p = 0.031) and higher inotrope score [20 (5-37.5) versus 7.5 (0-18.8); p = 0.07]. Use of VA compared with VV ECMO was associated with higher inotrope scores [20 (10-50) versus 5 (0-20); p = 0.012]. There was a trend towards improved survival in the VV ECMO group (82.4 versus 62.9 %; p = 0.15). Since 2005, patients have been older [4.7 (1-8) versus 1.25 (0.15-2.8) years; p = 0.008] and survival has improved (88.2 versus 60.0 %; p = 0.039).

CONCLUSIONS

Survival in children with pneumonia requiring ECMO has improved over time and is now 90 % in the modern era. Risk factors for death include performing a circuit change [odds ratio (OR) 5.0; 95 % confidence interval (CI) 1.02-24.41; p = 0.047] and use of continuous renal replacement therapy (OR 4.2; 95 % CI 1.13-15.59; p = 0.032).

Reducing VAP by instituting a care bundle using improvement methodology in a UK paediatric intensive care unit

Preventing ventilator-associated pneumonia (VAP) is one of the Department of Health Saving Lives initiatives. We describe the institution of a purpose-designed bundle of care in a tertiary paediatric ICU based on the available literature as part of our hospital's transformation project into reducing health-care-associated infection. A nurse-led VAP surveillance programme is in place, and we used this to compare VAP incidence before and after commencing a series of care measures aimed at reducing VAP as part of an overall drive for patient safety. The diagnostic criteria, surveillance methods and rates of VAP (5.6 per 1,000 ventilator days) have been previously reported. Nurse educators were added to the original core group, as a key feature is buy in from nursing staff. All nursing staff had multiple training opportunities, and VAP project education became a routine part of staff induction. The major features of the bundle of care were (1) elevation of bed to maximum (target, 45°; however, no beds currently permit this so achieved 20-30°), (2) mouth care using chlorhexidine or tooth brushing, (3) clean suctioning practice, (4) all patients not on full feeds commenced on ranitidine and (5) 4-hourly documentation. Compliance with these aspects was monitored. After the institution of the bundle, no paediatric case of VAP was recorded over a 12-month period, according to a priori definitions. One adult patient had a confirmed VAP over the same time interval. A paediatric VAP bundle was associated with reduced VAP on a UK PICU.

The impact of daily evaluation and spontaneous breathing test on the duration of pediatric mechanical ventilation: a randomized controlled trial

OBJECTIVES

To assess whether the combination of daily evaluation and use of a spontaneous breathing test could shorten the duration of mechanical ventilation as compared with weaning based on our standard of care. Secondary outcome measures included extubation failure rate and the need for noninvasive ventilation.

DESIGN

A prospective, randomized controlled trial.

SETTING

Two pediatric intensive care units at university hospitals in Brazil.

PATIENTS

The trial involved children between 28 days and 15 yrs of age who were receiving mechanical ventilation for at least 24 hrs.

INTERVENTIONS

Patients were randomly assigned to one of two weaning protocols. In the test group, the children underwent a daily evaluation to check readiness for weaning with a spontaneous breathing test with 10 cm H2O pressure support and a positive end-expiratory pressure of 5 cm H2O for 2 hrs. The spontaneous breathing test was repeated the next day for children who failed it. In the control group, weaning was performed according to standard care procedures.

MEASUREMENTS AND MAIN RESULTS

A total of 294 eligible children were randomized, with 155 to the test group and 139 to the control group. The time to extubation was shorter in the test group, where the median mechanical ventilation duration was 3.5 days (95% confidence interval, 3.0 to 4.0) as compared to 4.7 days (95% confidence interval, 4.1 to 5.3) in the control group (p = .0127). This significant reduction in the mechanical ventilation duration for the intervention group was not associated with increased rates of extubation failure or noninvasive ventilation. It represents a 30% reduction in the risk of remaining on mechanical ventilation (hazard ratio: 0.70).

CONCLUSIONS

A daily evaluation to check readiness for weaning combined with a spontaneous breathing test reduced the mechanical ventilation duration for children on mechanical ventilation for >24 hrs, without increasing the extubation failure rate or the need for noninvasive ventilation.

Effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia in children undergoing cardiac surgery

OBJECTIVE

To evaluate the effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial pneumonia and ventilator-associated pneumonia (VAP) in children undergoing cardiac surgery.

DESIGN

Prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Pediatric intensive care unit (PICU) at a tertiary care hospital.

PATIENTS

One hundred sixty children undergoing surgery for congenital heart disease, randomized into 2 groups: chlorhexidine (n = 87) and control (n = 73).

INTERVENTIONS

Oral hygiene with 0.12% chlorhexidine gluconate or placebo preoperatively and twice a day postoperatively until PICU discharge or death.

RESULTS

Patients in experimental and control groups had similar ages (median, 12.2 vs 10.8 months; P = .72) and risk adjustment for congenital heart surgery 1 score distribution (66% in category 1 or 2 in both groups; P = .17). The incidence of nosocomial pneumonia was 29.8% versus 24.6% (P = .46) and the incidence of VAP was 18.3% versus 15% (P = .57) in the chlorhexidine and the control group, respectively. There was no difference in intubation time (P = .34), need for reintubation (P = .37), time interval between hospitalization and nosocomial pneumonia diagnosis (P = .63), time interval between surgery and nosocomial pneumonia diagnosis (P = .10), and time on antibiotics (P = .77) and vasoactive drugs (P = .16) between groups. Median length of PICU stay (3 vs 4 days; P = .53), median length of hospital stay (12 vs 11 days; P = .67), and 28-day mortality (5.7% vs 6.8%; P = .77) were also similar in the chlorhexidine and the control group.

CONCLUSIONS

Oral hygiene with 0.12% chlorhexidine gluconate did not reduce the incidence of nosocomial pneumonia and VAP in children undergoing cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00829842 .

Procalcitonin as a marker of bacterial infection in children undergoing cardiac surgery with cardiopulmonary bypass

BACKGROUND

Owing to systemic inflammatory response syndrome, the diagnosis of post-operative infection after cardiopulmonary bypass is difficult to assess in children with the usual clinical and biological tools. Procalcitonin could be informative in this context.

METHODS

Retrospective study in a paediatric intensive care unit. Blood samples were collected as soon as infection was clinically suspected and a second assay was performed 24 hours later. Using referenced criteria, children were retrospectively classified into two groups: infected and non-infected.

RESULTS

Out of the 95 children included, 14 were infected. Before the third post-operative day, procalcitonin median concentration was significantly higher in the infected group than in the non-infected group - 20.24 nanograms per millilitre with a 25th and 75th interquartile of 15.52-35.71 versus 0.72 nanograms per millilitre with a 25th and 75th interquartile of 0.28 to 5.44 (p = 0.008). The area under the receiver operating characteristic curve was 0.89 with 95% confidence intervals from 0.80 to 0.97. The best cut-off value to differentiate infected children from healthy children was 13 nanograms per millilitre with 100% sensitivity - 95% confidence intervals from 51 to 100 - and 85% specificity - 95% confidence intervals from 72 to 91. After the third post-operative day, procalcitonin was not significantly higher in infected children - 2 nanograms per millilitre with a 25th and 75th interquartile of 0.18 to 12.42 versus 0.37 nanograms per millilitre with a 25th and 75th interquartile of 0.24 to 1.32 (p = 0.26). The area under the receiver operating characteristic curve was 0.62 with 95% confidence intervals from 0.47 to 0.77. A procalcitonin value of 0.38 nanograms per millilitre provided a sensitivity of 70% with 95% confidence intervals from 39 to 89 for a specificity of 52% with 95% confidence intervals from 34 to 68. After the third post-operative day, a second assay at a 24-hour interval can improve the sensitivity of the test.

CONCLUSIONS

Procalcitonin seems to be a discriminating marker of bacterial infection during the post-operative days following cardiopulmonary bypass in children.

Health Care–Associated Infection in the Pediatric Intensive Care Unit

•Handwashing is the most important means of preventing nosocomial infection. Each pediatric intensive care unit should develop programs to increase compliance with hand hygiene. •Nonessential invasive devices should be removed. Establish routines that require individual patient evaluation of device use daily. •Antimicrobial stewardship aims to minimize overexposure and unnecessary use of broad-spectrum antibiotics. Antibiotic-resistant bacteria are an increasing concern as a cause of hospital-acquired infection, requiring a multipronged approach to control that includes adherence to isolation procedures, appropriate use of antibiotics, educational interventions, prescribing guidelines, and restriction of the use of some antibiotics. •A comprehensive infection prevention and control program allied with organizational quality and patient safety programs is an essential strategy for minimizing hospital-acquired infections. Critical care teams should establish strong collaborative partnerships with the infection prevention and control service. •Parents and visitors should be made partners of the infection control team to help prevent infection in their children.

Risk factors for healthcare-associated infection in pediatric intensive care units: a systematic review

A systematic review of observational studies on risk factors for healthcare-associated infection in pediatric Intensive Care Units (ICU) was carried out. Studies indexed in MEDLINE, LILACS, Cochrane, BDENF, CAPES databases published in English, French, Spanish or Portuguese between 1987 and 2006 were included and cross references added. Key words for search were 'cross infection' and 'Pediatric Intensive Care Units' with others sub-terms included. 11 studies were selected from 419 originally found: four studies had healthcare-associated infection as the main outcome without a specific site; three articles identified factors associated with lower respiratory tract infection (pneumonia or tracheitis); three articles were concerned with laboratory-confirmed bloodstream infection; and a single retrospective study analyzed urinary tract infection. The production of evidence on risk factors Paediatric ICU has not kept up the same pace of that on adult - there are few studies with adequate design and statistical analysis. The methodological diversity of the studies did not allow for a summarized measurement of risk factors.

Clinical outcomes of seasonal influenza and pandemic influenza A (H1N1) in pediatric inpatients

BACKGROUND

In April 2009, a novel influenza A H1N1 (nH1N1) virus emerged and spread rapidly worldwide. News of the pandemic led to a heightened awareness of the consequences of influenza and generally resulted in enhanced infection control practices and strengthened vaccination efforts for both healthcare workers and the general population. Seasonal influenza (SI) illness in the pediatric population has been previously shown to result in significant morbidity, mortality, and substantial hospital resource utilization. Although influenza pandemics have the possibility of resulting in considerable illness, we must not ignore the impact that we can experience annually with SI.

METHODS

We compared the outcomes of pediatric patients ≤18 years of age at a large urban hospital with laboratory confirmed influenza and an influenza-like illness (ILI) during the 2009 pandemic and two prior influenza seasons. The primary outcome measure was hospital length of stay (LOS). All variables potentially associated with LOS based on univariable analysis, previous studies, or hypothesized relationships were included in the regression models to ensure adjustment for their effects.

RESULTS

There were 133 pediatric cases of nH1N1 admitted during 2009 and 133 cases of SI admitted during the prior 2 influenza seasons (2007-8 and 2008-9). Thirty-six percent of children with SI and 18% of children with nH1N1 had no preexisting medical conditions (p = 0.14). Children admitted with SI had 1.73 times longer adjusted LOS than children admitted for nH1N1 (95% CI 1.35 - 2.13). There was a trend towards more children with SI requiring mechanical ventilation compared with nH1N1 (16 vs.7, p = 0.08).

CONCLUSIONS

This study strengthens the growing body of evidence demonstrating that SI results in significant morbidity in the pediatric population. Pandemic H1N1 received considerable attention with strong media messages urging people to undergo vaccination and encouraging improved infection control efforts. We believe that this attention should become an annual effort for SI. Strong unified messages from health care providers and the media encouraging influenza vaccination will likely prove very useful in averting some of the morbidity related to influenza for future epidemics.

The critically ill child with novel H1N1 influenza A: a case series

OBJECTIVE

To describe the presentation, course, and outcome of critically ill children with novel H1N1 influenza disease.

DESIGN

Retrospective case series.

SETTING

Pediatric intensive care unit in an urban tertiary academic center.

PATIENTS

Thirteen consecutive patients admitted between June 2009 and August 2009 and known or subsequently found to be infected with novel H1N1 influenza A.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical, laboratory, and radiographic data were reviewed. The patients were predominantly male (62%), aged 5 months to 21 yrs, and most (92%) had known risk factors for severe disease. Direct fluorescent antibody testing had a high false-negative rate (62%) and delayed treatment in some cases. The respiratory illness presented clinically with both bronchoconstriction and alveolar consolidation to varying degrees. Bacterial superinfection occurred frequently (23%). Forty-six percent of patients required mechanical ventilation and 23% required inotropic support for hypotension. None of the patients in this series required extracorporeal membrane oxygenation. Intensive care unit length of stay did not differ between an early (within 48 hrs) oseltamivir treatment group (length of stay, 4.2 +/- 4.4 days) vs. a late treatment group (length of stay, 6.8 +/- 8.8 days). All patients survived to hospital discharge.

CONCLUSIONS

Underlying chronic illness (especially respiratory illness) seems associated with critical novel H1N1 influenza disease in children. Respiratory manifestations are highly variable among patients and within a single patient involving both bronchoconstriction and alveolar disease. Therapies must be individualized and rapidly adjusted. The duration of critical illness was not different between early and late treatment groups. Whether this is reflective of sample size or indicative of the importance of therapeutic intervention at any time early during infection in critically ill patients is unclear. Bacterial superinfection was more common than previously reported for seasonal influenza A. Moderate novel H1N1 influenza disease, including respiratory failure and hypotension, had 100% survival in our series.

Strategies to prevent bacterial and fungal infection in the neonatal intensive care unit

Hospital-acquired infections are one of the leading causes of preventable morbidity and mortality in neonatal intensive care units (NICUs). Device-related infections, such as catheter-associated blood stream infections (CABSIs) and ventilator-associated pneumonia (VAP), are the most common nosocomial infections. This review examines the pathogenesis of CABSIs and methods, widely accepted and novel, that can be used to help prevent them. Strategies to prevent fungal infections, which are often associated with the presence of a central venous catheter, are also reviewed. Finally, the dilemmas in the diagnosis and prevention of VAP in the NICU are discussed.

[Pneumococcal infection among community-acquired pneumonia. A retrospective study of 230 hospitalized children]

OBJECTIVES

To find arguments in favour of pneumococcal origin in community-acquired pneumonia.

POPULATION AND METHODS

A retrospective analysis of the files of 230 children hospitalized between January 1st 1999 and June 30th 2001 for community acquired pneumonia was performed. The files were classified into 3 subgroups: I (N=7), confirmed (positive blood culture); II (N=134), probable (biological arguments); III (N=89), possible pneumococcal infection. Age of the children was also taken into consideration.

RESULTS

All children in the subgroup I had fever>39 degrees C at admission and at least 1 of the 3 criteria (WBC> or=20.10(9)/l, neutrophils > or =10.10(9)/l, C-reactive protein level> or =60 mg/l). Dyspnea was more frequently asthmatiform in the subgroup III. Chest X-ray was not contributive. Before admission, 39% of the children were given one or several antibiotics, and so some of patients belonging to the subgroups II and III could have been infected by pneumococcus without possibility to confirm that.

CONCLUSION

Results of this analysis suggest that some criteria may be useful for selecting initial antibiotherapy even though systematic early specific antipneumococcal immunization should reduce the frequency of this infection.

Comparative study of levofloxacin in the treatment of children with community-acquired pneumonia

BACKGROUND

Levofloxacin has established efficacy and safety in the treatment of community-acquired pneumonia (CAP) in adults, and its use as an alternative therapy for children with CAP has been proposed.

OBJECTIVE

Assess the clinical efficacy and safety of levofloxacin compared with standard of care antibiotic therapy in the treatment of CAP in children aged 6 months to 16 years.

METHODS

In an open-label, multicenter, noninferiority trial, children with CAP were randomized 3:1 to receive levofloxacin or comparator antimicrobial therapy (0.5 to <5 years: amoxicillin/clavulanate or ceftriaxone; > or =5 years: clarithromycin or ceftriaxone with clarithromycin or erythromycin lactobinate) for 10 days. The primary outcome was cure rates at the test-of-cure visit (10-17 days after completing treatment) as determined by symptoms, physical examination, and chest radiography.

RESULTS

Seven hundred and thirty-eight children were enrolled and 539 (405 levofloxacin-treated, 134 comparator-treated) were clinically evaluable at test-of-cure visit. Clinical cure rates were 94.3% (382 of 405) in levofloxacin-treated and 94.0% (126 of 134) in comparator-treated children. Cure rates were also similar for levofloxacin and comparator for each age group (<5 years, 92.2% versus 90.8%; > or =5 years, 96.5% versus 97.1%; respectively) and for children categorized as being at higher risk for severe disease. Mycoplasma pneumoniae was the most frequently identified cause of pneumonia (230 children). Levofloxacin was as well tolerated as comparators, with similar type and incidence of adverse events.

CONCLUSIONS

Levofloxacin was as well tolerated and effective as standard-of-care antibiotics for the treatment of CAP in infants and children.

Can we apply the European surveillance program of nosocomial infections (HELICS) to pediatric intensive care units?

OBJECTIVE

To evaluate the applicability of the HELICS program [part of the "Improving Patient Safety in Europe" program aiming at controlling nosocomial infections (NI) through surveillance] in European pediatric ICUs.

DESIGN AND SETTING

A comparison of HELICS and pediatric definitions of the main NI was performed. The adaptability of the HELICS questionnaire for pediatric patients was examined. Then a European survey was carried out by e-mail questionnaire to analyze NI surveillance programs.

PARTICIPANTS

Units affiliated with the European Society of Paediatric and Neonatal Intensive Care or the French Groupe Francophone de Réanimation et Urgences Pédiatriques.

MEASUREMENTS AND RESULTS

The main differences between adult and pediatric ICUs were the definition of ICU-acquired pneumonia, severity scores at admission, and scores of risk for NI. A total of 65 answers from 23 countries were collected. Among them 56 had a NI surveillance program that was of local origin for 64%. The most frequently collected NI were blood stream infections (91% of the units), catheter-related infections (88%), acquired pneumonia (86%), and urinary tract infections (77%). Definitions of NI had a local-based origin in 18% of cases, a regional-based or nation-wide origin in 21%, came from the Centers for Disease Control and Prevention in 38% and had multiple origins in 20%. Seventy-five percent of the units declared an interest in joining a European pediatric working group on NI within the European Society of Paediatric and Neonatal Intensive Care.

CONCLUSIONS

The adaptation of the HELICS protocol for pediatric ICUs is necessary. Its application is largely wished and may be easily performed.

Children with pneumonia: how do they present and how are they managed?

OBJECTIVE

To describe the spectrum of clinical features and management of community acquired pneumonia in the UK.

DESIGN

Prospectively recorded clinical details for all children with possible pneumonia and chest x ray (CXR) changes in 13 hospitals in the North of England between 2001 and 2002.

RESULTS

89% of 711 children presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia and dyspnoea all correlated with each other and prompted appropriate interventions. Admission in children, not infants, was independently associated with RR, oxygen saturation, lobar CXR changes and pyrexia. Neither C-reactive protein, lobar CXR changes or pyrexia were associated with severity. Children over 1 year old with perihilar CXR changes more often had severe disease (p = 0.001). Initial intravenous antibiotics were associated with lobar CXR changes in infants and children and with dyspnoea, pyrexia and pleural effusion in children. The presence of pleural effusion increased duration of antibiotic treatment (p<0.001). Cefuroxime was the most often used intravenous antibiotic in 61%. Oral antibiotics included a penicillin in 258 (46%), a macrolide in 192 (34%) and a cephalosporin in 117 (21%). Infants stayed significantly longer (p<0.001) as did children with severe disease (p<0.01), effusions (p = 0.005) or lobar CXR changes (p< or =0.001).

CONCLUSIONS

There is a high rate of intravenous antibiotic administration in hospital admissions for pneumonia. Despite lobar CXR changes not being independently associated with severe disease, initial lobar CXR changes and clinical assessment in children independently influenced management decisions, including admission and route of antibiotics.

Use of computerized surveillance to detect nosocomial pneumonia in neonatal intensive care unit patients

BACKGROUND

Pneumonia surveillance is difficult and time-consuming. The definition is complicated, and there are many opportunities for subjectivity in determining infection status.

OBJECTIVE

To compare traditional infection control professional (ICP) surveillance for pneumonia among neonatal intensive care unit (NICU) patients with computerized surveillance of chest x-ray reports using an automated detection system based on a natural language processor.

METHODS

This system evaluated chest x-rays from 2 NICUs over a 2-year period. It flagged x-rays indicative of pneumonia according to rules derived from the National Nosocomial Infection Surveillance System definition as applied to radiology reports. Data from the automated system were compared with pneumonia data collected prospectively by an ICP.

RESULTS

Sensitivity of the computerized surveillance in NICU 1 was 71%, and specificity was 99.8%. The positive predictive value was 7.9%, and the negative predictive value (NPV) was >99%. Data from NICU 2 were incomplete.

CONCLUSIONS

Computer-assisted surveillance has the potential to decrease ICP workload and make pneumonia surveillance feasible. The high NPV means the system can safely screen out many chest x-rays of noninfected patients. However, all data must be available to the computer system and must be analyzed the same way for results to be comparable.