Defining urinary tract infection in the critically ill child

Evaluation of the relationship between vitamin D levels and prevalence of urinary tract infections in children

Urinary tract infection (UTI) is associated with increased health burden among paediatric patients. Vitamin D is known for its immunoregulatory effects, particularly antimicrobial activity. The aim of this study was to determine the relationship between vitamin D levels and UTIs in children referred to a hospital in Khorramabad, Iran. This case–control study was conducted on 258 children aged between 2 and 14 years; 44 children with UTI and 214 healthy children were enrolled. Patients were tested for UTI on the basis of signs and symptoms, and urine culture and analysis. Vitamin D levels were measured in children in both groups. According to the results, the two groups were significantly different in terms of sex (p 0.007). There was no significant difference between the mean vitamin D among the two groups. Vitamin D levels were not related to UTI by multivariate logistic regression. The relationship between the level of vitamin D and the incidence of UTI in children in accordance with age and sex had an odds ratio of 0.99, indicating that for a 1-unit increase in vitamin D, the odds of having a UTI decreased by 1, a correlation which was not statistically significant. According to the findings of this study, no significant correlation was found between UTI and vitamin D levels. However, the prevalence of UTI was higher in girls than boys.

The Effects of Bundles on Catheter-Associated Urinary Tract Infections in the Pediatric Intensive Care Unit

BACKGROUND

There are few studies in the literature from developing countries regarding the rates of catheter-associated urinary tract infection (CAUTI), which is frequently encountered in pediatric intensive care units (PICUs).

AIM

The aim of this study is to evaluate the 2-year rates of CAUTI in a PICU where a CAUTI Prevention Bundle was implemented.

DESIGN

This was an interventional prospective study.

METHODS

The study was conducted with 390 patients in the PICU of Istanbul Faculty of Medicine, Turkey, from July 2013 to July 2015. The patients were selected based on the diagnostic criteria of the Centers for Disease Control and Prevention.

RESULTS

Urinary colonization occurred in 8 (2.2%) patients in the prebundle group and 3 (0.8%) patients in the postbundle group, and contamination occurred in 10 (2.8%) patients in the prebundle group and 6 (1.5%) patients in the postbundle group. The CAUTI incidence and rates were 5.8% and 6.1 per 1000 urinary catheter days and 1.5% and 1.8 per 1000 urinary catheter days prebundle and postbundle, respectively. There was a statistically significant difference between the prebundle and postbundle CAUTI rates.

CONCLUSION

Our findings support that clinical nurse specialists in developing countries should consider the use of CAUTI bundles to prevent CAUTIs.

Infections in Children Receiving Extracorporeal Life Support

Objective.

To describe risk factors for and the outcome of infections in children receiving extracorporeal life support (ECLS) and to determine the need for removal of foreign bodies with bloodstream infections (BSIs) in children receiving ECLS.

Design.

Retrospective cohort study.

Setting.

Tertiary care children's hospital.

Patients.

Children receiving ECLS from May 1997 through May 2007.

Methods.

For patients with documented infections, medical records were examined for demographic, clinical, and laboratory details. Patients with and without documented infections were compared with regard to demographic characteristics and ECLS course.

Results.

One hundred seventeen patients underwent ECLS for a total of 878 days (median, 5.12 days). Thirty-five patients (29.9%) developed 55 infections, including 21 BSIs (38.2%), 20 urinary tract infections (36.4%), 6 ventilator-associated pneumonia episodes (10.9%), 2 viral infections (3.6%), and 6 miscellaneous infections (10.9%). The rates (in cases per 1,000 ECLS-days) were 23.9 for BSI, 22.8 for urinary tract infection, and 6.8 for ventilator-associated pneumonia. There were no significant differences in the demographic characteristics, indications for ECLS, or ECLS course between infected and uninfected patients, except for the median duration of ECLS (10.1 vs 3.8 days; P < .001). One death was attributed to infection. Resolution of BSI occurred without removal of foreign bodies in 18 (85.7%) of 21 children.

Conclusions.

Longer duration of ECLS was the only identified risk factor for infection. Mortality was not statistically significantly different between infected and uninfected patients. Most BSIs that occurred during ECLS cleared without removal of foreign bodies.

Study of nosocomial urinary tract infections in a pediatric intensive care unit

Nosocomial urinary tract infections (NUTI) are one of the commonest infections in a Pediatric Intensive Care Unit (PICU). This prospective study was conducted in PICU between January and December 2008 to study the incidence, organisms and risk factors for NUTI. A total of 287 consecutive patients with >48 h PICU stay and sterile admission urine culture, were enrolled and monitored for NUTI (defined as per CDC criteria 1988) till discharge or death. Patients with and without NUTI were compared with respect to demographics, PRISM scores, primary diagnosis, nutritional status and device utilization to identify risk factors. Outcome was defined as length of PICU stay and survival or death. There were 69 episodes of UTI in 60 (20.9%) patients; incidence being 18 episodes/1000 patient days. Candida (52.1%) and Enterococcus (13%) were commonest followed by Escherichia coli (11.6%) and Klebsiella pneumoniae (10.1%). Catheterization and duration of catheterization were the risk factors for NUTI (p < 0.001). The median length of PICU stay was significantly longer in NUTI group compared to non-NUTI group (19 vs. 8 days, p = 0.001). Mortality rates in both the groups were similar.

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.

[Nosocomial urinary tract infection in critical pediatric patients]

OBJECTIVE

To determine the incidence, etiology and risk factors of nosocomial urinary tract infections (nUTI) in a second level Pediatric Intensive Care Unit (PICU).

PATIENTS AND METHODS

A prospective study of 104 patients admitted to the PICU with a length of stay of more than 48 hours was carried out over a one year period (January to December 2009) to study the incidence and risk factors of nUTI. Urine samples were collected and cultured in all patients admitted for more than 48 hours to our PICU. Those needing indwelling urinary catheters had urine samples collected upon admission and every 24 hours until catheter retrieval, while those who did not need catheters had samples collected upon admission and every 48 hours until discharge from the PICU.

RESULTS

Six patients (5.8% of those admitted) were diagnosed of nUTI, with an incidence density of 5/1000 patients/day and 12.2/1000 catheterization days. Four of these were caused by E. coli (including a multiresistant strain), and two by C. albicans. Patients suffering nUTIs had significantly more relevant medical antecedents and a longer period of admittance than patients without nUTI. A statistically nonsignificant tendency towards increased infection risk was also found in younger patients and in those who needed an indwelling catheter for longer periods.

CONCLUSIONS

We found a higher incidence density of catheter associated nUTI than in other reports. This at least partially could be due to the characteristics of our patients, and to the exhaustive methodology used for detection.

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.

Characteristics and outcome of infants with candiduria in neonatal intensive care - a Paediatric Investigators Collaborative Network on Infections in Canada (PICNIC) study

BACKGROUND

There is limited information in the literature on the presentation and prognosis of candidal urinary tract infection (UTI) in infants in the neonatal intensive care unit (NICU).

METHODS

This was a prospective cohort study performed in 13 Canadian NICUs. Infants with candidal UTI without extra-renal candidal infection at presentation were enrolled.

RESULTS

Thirty infants fit the study criteria. Median birth weight and gestational age were 2595 grams (range 575-4255) and 35 weeks (range 24-41) with 10 infants being < 30 weeks gestation. The most common primary underlying diagnosis was congenital heart disease (n = 10). The median age at initial diagnosis was 16 days (range 6-84 days). Renal ultrasonography findings were compatible with possible fungal disease in 15 of the 26 infants (58%) in whom it was performed. Treatment was variable, but fluconazole and either amphotericin B deoxycholate or lipid-based amphotericin B in combination or sequentially were used most frequently. Extra-renal candidiasis subsequently developed in 4 infants. In 2 of these 4 infants, dissemination happened during prolonged courses of anti-fungal therapy. Three of 9 deaths were considered to be related to candidal infection. No recurrences of candiduria or episodes of invasive candidiasis following treatment were documented.

CONCLUSION

Candidal UTI in the NICU population occurs both in term infants with congenital abnormalities and in preterm infants, and is associated with renal parenchymal disease and extra-renal dissemination. A wide variation in clinical approach was documented in this multicenter study. The overall mortality rate in these infants was significant (30%). In one third of the deaths, Candida infection was deemed to be a contributing factor, suggesting the need for antifungal therapy with repeat evaluation for dissemination in infants who are slow to respond to therapy.

Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome

OBJECTIVE

To define the most common types of nosocomial infections in critically ill children and to summarize the effect of methods to reduce their prevalence.

DESIGN

Review of published literature.

RESULTS

While in the pediatric intensive care unit, 16% of children develop a nosocomial infection. Processes affecting modifiable factors of care can reduce the prevalence of hospital-acquired infections.

CONCLUSIONS

The occurrence of a nosocomial infection represents failure and is not an acceptable outcome of treating critically ill children. Evidence-based process improvement can lead to significant reductions in hospital-acquired infections in children. Most of the processes and practices discussed are not novel or intriguing but, when performed routinely and appropriately, can lead to reductions in hospital-acquired infections.