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García-Boyano M, Climent Alcalá FJ, Rodríguez Alonso A, García Fernández de Villalta M, Zubiaur Alonso O, Rabanal Retolaza I, Quiles Melero I, Calvo C, Escosa García L. Pneumonia in Children With Complex Chronic Conditions With Tracheostomy: An Emerging Challenge. Pediatr Infect Dis J 2024; 43:919-923. [PMID: 38753990 DOI: 10.1097/inf.0000000000004395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Despite respiratory infections being a leading cause of hospitalization in children with tracheostomy tubes, there are no published guidelines for their diagnosis and management. This study aims to outline the clinical, laboratory and microbiological aspects of pneumonia in these children, along with the antibiotics used and outcomes. Additionally, it seeks to determine pneumonia incidence and associated risk factors. METHODS We conducted a retrospective study using the medical records of tracheostomized children at La Paz University Hospital in Madrid from 2010 to 2021. RESULTS Thirty-three pneumonia cases were observed in 25 tracheostomized children. Pseudomonas aeruginosa was the predominant bacterium (52%), followed by Escherichia coli , Staphylococcus aureus and Serratia marcescens . The same microorganism isolated in the tracheal aspirate culture during pneumonia was previously isolated in 83% of cases that had a similar culture, with some growth obtained within 7-30 days prior. Multiplex respiratory PCR detected respiratory viruses in 73% of cases tested. Antibiotic treatment was administered in all cases except 1, mostly intravenously (81%), with piperacillin/tazobactam and meropenem being commonly used. Only 1 of the described episodes had a fatal outcome. CONCLUSIONS It is advisable to include coverage for P. aeruginosa , E. coli , S. aureus , and S. marcescens in the empirical antibiotic treatment for pneumonia in tracheostomized children, along with the microorganisms identified in tracheal cultures obtained within 7-30 days prior, if available. A positive PCR for respiratory viruses is often discovered in bacterial pneumonia in tracheostomized children.
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Affiliation(s)
| | | | | | | | | | | | | | - Cristina Calvo
- From the Pediatric Infectious and Tropical Diseases Department
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
- Institute for Health Research IdiPAZ, Madrid, Spain
- Pediatric Department, Autonomous University, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Escosa García
- Department of Pediatric Internal Medicine
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
- Institute for Health Research IdiPAZ, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Miller AL, Hart CK, Kao DD, Bellew LE, Hysinger EB. Patient factors associated with positive respiratory cultures following tracheostomy in pediatric patients. Int J Pediatr Otorhinolaryngol 2024; 184:112075. [PMID: 39186881 DOI: 10.1016/j.ijporl.2024.112075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 08/06/2024] [Accepted: 08/16/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVES An increasing number of pediatric patients undergo tracheostomy placement annually. Despite advances in care, these patients remain at high risk for postoperative complications, including respiratory infections. The risk factors for positive respiratory cultures and the impact of culture positivity on overall morbidity and mortality in this population is not fully characterized. STUDY DESIGN AND SETTING Retrospective cross-sectional analysis of all patients within a single tertiary care institution who underwent tracheostomy placement from January 1, 2019 to 12/31/2021. METHODS We collected patient demographic information, comorbidities, primary indication for tracheostomy placement, and respiratory culture information preoperatively and postoperatively. The primary outcome measure was positive bacterial respiratory culture with speciation within 1, 3, or 6 months of tracheostomy placement. The secondary outcome measure was all-cause mortality within the study period. RESULTS A total of 180 patients with median (IQR) age of 5.2 (3.4-31.0) months at time of tracheostomy placement were included in the study. Nearly half of patients had a positive culture within 1 month (n = 81,47.4 %) while 63.7 % of patients were positive within 6 months of tracheostomy placement (n = 109). Risk factors included respiratory and/or cardiac comorbidities. Positive respiratory cultures within 6 months of surgery and cardiac and/or neurologic comorbidities were associated with increased all-cause mortality following tracheostomy placement. CONCLUSIONS Positive respiratory cultures are common following tracheostomy placement, more so in patients with cardiac and pulmonary comorbid conditions. Positive cultures are associated with increased all-cause mortality. More work is necessary to determine optimal screening frequency and treatment protocols for positive cultures in this population.
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Affiliation(s)
- Ashley L Miller
- Department of Otolaryngology - Head & Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA; Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Catherine K Hart
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Derek D Kao
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Laura E Bellew
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Erik B Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Tomatis-Souverbielle C, Lyman E, Thomas T, May A, Erdem G. Ventilator-associated respiratory infections in children on home invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2141-2144. [PMID: 38837868 DOI: 10.1002/ppul.27114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 05/14/2024] [Accepted: 05/28/2024] [Indexed: 06/07/2024]
Abstract
Ventilator-associated respiratory tract infections (VARTI) are among the most common indications for hospitalization among children with chronic respiratory failure requiring at-home ventilation. This review aims to provide an overview of the key clinical features, diagnostic approaches, and management strategies for home VARTIs while highlighting the challenges in diagnosis and management.
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Affiliation(s)
- Cristina Tomatis-Souverbielle
- Division of Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Terace Thomas
- Division of Pulmonary Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anne May
- Division of Pulmonary Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Guliz Erdem
- Division of Infectious Diseases, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Lyon E, Goldman J, Lee B, Campbell M, Selvarangan R, Monsees E. Repeat tracheal aspirate cultures in pediatric intensive care patients: Frequency, resistance, and antimicrobial use. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38818881 DOI: 10.1017/ice.2024.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To evaluate the clinical impact and features associated with repeat tracheal aspirate (TA) cultures in children admitted to the intensive care unit. DESIGN Retrospective cohort study. SETTING A 338-bed freestanding, tertiary pediatric academic medical center with pediatric medical intensive care unit (PICU) and cardiac intensive care units (CICU). PATIENTS Children ≤18 years of age who were admitted to either the PICU or CICU who had ≥2 TA cultures in a single intensive care admission. METHODS Patients with ≥2 TA cultures between 2018 and 2019 were included in this study. The following information was collected: patient demographics, clinical data summarizing patient condition at the time of culture collection, number of TA cultures per patient, antibiotic usage, and microbiologic data. Descriptive statistics established the frequency of TA collection, time between culturing, clinical reasoning for collection, antibiotic exposure, and development of multidrug-resistant organisms (MDRO). RESULTS Sixty-three patients had repeat TA cultures and accounted for 252 TA cultures during the study period. Most patients with repeat TA cultures were admitted to the PICU (71%) and were male (65%). A median of 3 TA cultures per patient were obtained with 50% of repeat cultures occurring within 7 days from the previous culture. Sixty-six percent of patients had the same organism cultured on ≥2 TA cultures. Most antibiotics were not modified or continued to treat the results of the TA culture. CONCLUSIONS Repeat TA cultures frequently show the same pathogens, and results do not often influence antibiotic selection or usage. Repeat TA cultures did demonstrate the development of MDROs.
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Affiliation(s)
- Edward Lyon
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jennifer Goldman
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, University of Missouri, Kansas City, MO, USA
| | - Brian Lee
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO, USA
| | - Margaret Campbell
- Department of Graduate Medical Education, Children's Mercy Hospital, Kansas City, MO, USA
| | - Rangaraj Selvarangan
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Department of Pathology and Laboratory Medicine, Children's Mercy Hospital, Kansas City, MO, USA
| | - Elizabeth Monsees
- School of Medicine, University of Missouri, Kansas City, MO, USA
- Department of Service and Performance Excellence, Children's Mercy Hospital, Kansas City, MO, USA
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Sick-Samuels AC, Koontz DW, Xie A, Kelly D, Woods-Hill CZ, Aneja A, Xiao S, Colantuoni EA, Marsteller J, Milstone AM. A Survey of PICU Clinician Practices and Perceptions regarding Respiratory Cultures in the Evaluation of Ventilator-Associated Infections in the BrighT STAR Collaborative. Pediatr Crit Care Med 2024; 25:e20-e30. [PMID: 37812030 PMCID: PMC10756695 DOI: 10.1097/pcc.0000000000003379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
OBJECTIVES To characterize respiratory culture practices for mechanically ventilated patients, and to identify drivers of culture use and potential barriers to changing practices across PICUs. DESIGN Cross-sectional survey conducted May 2021-January 2022. SETTING Sixteen academic pediatric hospitals across the United States participating in the BrighT STAR Collaborative. SUBJECTS Pediatric critical care medicine physicians, advanced practice providers, respiratory therapists, and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We summarized the proportion of positive responses for each question within a hospital and calculated the median proportion and IQR across hospitals. We correlated responses with culture rates and compared responses by role. Sixteen invited institutions participated (100%). Five hundred sixty-eight of 1,301 (44%) e-mailed individuals completed the survey (median hospital response rate 60%). Saline lavage was common, but no PICUs had a standardized approach. There was the highest variability in perceived likelihood (median, IQR) to obtain cultures for isolated fever (49%, 38-61%), isolated laboratory changes (49%, 38-57%), fever and laboratory changes without respiratory symptoms (68%, 54-79%), isolated change in secretion characteristics (67%, 54-78%), and isolated increased secretions (55%, 40-65%). Respiratory cultures were likely to be obtained as a "pan culture" (75%, 70-86%). There was a significant correlation between higher culture rates and likelihood to obtain cultures for isolated fever, persistent fever, isolated hypotension, fever, and laboratory changes without respiratory symptoms, and "pan cultures." Respondents across hospitals would find clinical decision support (CDS) helpful (79%) and thought that CDS would help align ICU and/or consulting teams (82%). Anticipated barriers to change included reluctance to change (70%), opinion of consultants (64%), and concern for missing a diagnosis of ventilator-associated infections (62%). CONCLUSIONS Respiratory culture collection and ordering practices were inconsistent, revealing opportunities for diagnostic stewardship. CDS would be generally well received; however, anticipated conceptual and psychologic barriers to change must be considered.
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Affiliation(s)
- Anna C Sick-Samuels
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
| | - Danielle W Koontz
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Kelly
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Anushree Aneja
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shaoming Xiao
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Elizabeth A Colantuoni
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Jill Marsteller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute of Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Aaron M Milstone
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, MD
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García-Boyano M, Alcalá FJC, Alonso AR, de Villalta MGF, Alonso OZ, Retolaza IR, Melero IQ, Calvo C, García LE. Microbiological patterns of bacterial infections in tracheostomized children: Reducing uncertainty in continuous care. Pediatr Pulmonol 2023; 58:3507-3515. [PMID: 37701951 DOI: 10.1002/ppul.26684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Respiratory infections are the most frequent cause of hospitalization in tracheostomized children. However, there is a lack of publications to guide their management. The primary objective was to describe the microbiological isolates and their antibiotic susceptibilities of bacterial respiratory infections in a population of tracheostomized children. METHODS Retrospective follow-up study of children with tracheostomy seen at a tertiary hospital. Respiratory infection episodes in patients under 18 years of age who had a tracheostomy and bacterial isolation with a count ≥104 Colony Forming Units/mL in tracheal aspirate were included. RESULTS The study analyzed 328 respiratory infection episodes: 164 tracheobronchitis (50%), 112 nonspecific respiratory episodes (34.1%), and 52 pneumonias (15.9%). The most commonly isolated microorganisms were Pseudomonas aeruginosa, Serratia marcescens, and Staphylococcus aureus. The antibiotics that exhibited the highest effectiveness were meropenem (92%), imipenem (87%), and levofloxacin (86%). When hospitalization exceeded 7 days, there was a higher chance of isolating Escherichia coli and Klebsiella pneumoniae (p < 0.001 and p = 0.001, respectively), as well as an increased rate of multidrug resistance (27% vs. 7%, p = 0.035). In 75.3% of cases, the microorganism had been previously isolated in a sample taken 7-30 days before the current one, with a higher frequency observed in the case of P. aeruginosa (95.2%) compared to other microorganisms (65.3%, p < 0.001). CONCLUSIONS Meropenem, imipenem, and levofloxacin provided the most effective coverage for these infections. The risk of multidrug resistance increased with longer hospital stays, especially for E. coli and K. pneumoniae. Recent isolation of P. aeruginosa may justify empirical coverage.
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Affiliation(s)
| | | | - Aroa Rodríguez Alonso
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
| | | | - Oihane Zubiaur Alonso
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
| | | | | | - Cristina Calvo
- Infectious Diseases Department, La Paz University Hospital, Madrid, Spain
- RITIP (Red de Investigación Translacional en Infectología Pediátrica), Spain
- Área de Enfermedades Infecciosas del Centro de Investigación Biomédica en Red del Instituto de Salud Carlos III (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Escosa García
- Department of Pediatric Internal Medicine, La Paz University Hospital, Madrid, Spain
- RITIP (Red de Investigación Translacional en Infectología Pediátrica), Spain
- Área de Enfermedades Infecciosas del Centro de Investigación Biomédica en Red del Instituto de Salud Carlos III (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Prinzi AM, Baker CD. So tell me… does this tracheal aspirate culture indicate "infection" or "colonization"? Pediatr Pulmonol 2023; 58:2439-2441. [PMID: 37278550 DOI: 10.1002/ppul.26534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/02/2023] [Accepted: 05/27/2023] [Indexed: 06/07/2023]
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Steuart R, Ale GB, Woolums A, Xia N, Benscoter D, Russell CJ, Shah SS, Thomson J. Respiratory culture organism isolation and test characteristics in children with tracheostomies with and without acute respiratory infection. Pediatr Pulmonol 2023; 58:1481-1491. [PMID: 36751142 DOI: 10.1002/ppul.26349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/26/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Among children with tracheostomies, little is known about how respiratory culture results differ between states with and without acute respiratory infections (ARI), or the overall test performance of respiratory cultures. OBJECTIVE To determine the association of respiratory culture organism isolation with diagnosis of ARI in children with tracheostomies, and assess test characteristics of respiratory cultures in the diagnosis of bacterial ARI (bARI). METHODS This single-center, retrospective cohort study included respiratory cultures of children with tracheostomies obtained between 2010 and 2018. The primary predictor was ARI diagnosis code at the time of culture; the primary outcomes were respiratory culture organism isolation and species identified. Generalized estimating equations were used to assess for association between ARI diagnosis and isolation of any organism while controlling for potential confounders and accounting for within-patient clustering. A multinomial logistic regression equation assessed for association with specific species. Test characteristics were calculated using bARI diagnosis as the reference standard. RESULTS Among 3578 respiratory cultures from 533 children (median 4 cultures/child, interquartile range (IQR): 1-9), 25.9% were obtained during ARI and 17.2% had ≥1 organism. Children with ARI diagnosis had higher odds of organism identification (adjusted odds ratio 1.29, 95% confidence interval [CI] 1.16-1.44). When controlling for covariates, ARI was associated with isolation of Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pneumoniae, and Streptococcus pyogenes. Test characteristics revealed a 24.3% sensitivity, 85.2% specificity, 36.5% positive predictive value, and 76.3% negative predictive value in screening for bARI. CONCLUSION The utility of respiratory culture testing to screen for, diagnose, and direct treatment of ARI in children with tracheostomies is limited.
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Affiliation(s)
- Rebecca Steuart
- Department of Pediatrics, Section of Special Needs, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Complex Care Program, Children's Wisconsin, Milwaukee, Wisconsin, USA
| | - Guillermo B Ale
- Department of Pediatrics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Pulmonary and Sleep Medicine, Children's of Alabama, Birmingham, Alabama, USA
| | - Abigail Woolums
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicole Xia
- Department of Pediatrics, Section of Special Needs, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Dan Benscoter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christopher J Russell
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Samir S Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Gipsman A, Prero M, Toltzis P, Craven D. Inhaled antibiotics in children with tracheostomy tubes: A descriptive study. Pediatr Pulmonol 2023; 58:1028-1033. [PMID: 36541025 DOI: 10.1002/ppul.26288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/07/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Respiratory tract infections (RTIs) are common in children with tracheostomy tubes. Anecdotally, inhaled antibiotics are commonly prescribed, although to date there are no studies describing their use in this patient population. The objective of this study was to assess the variability of this practice at a single tertiary care children's hospital. METHODS All children admitted to our hospital with a tracheostomy tube who were prescribed inhaled antibiotics between 2013 and 2020 were included. Patient characteristics and data regarding inhaled antibiotic use were obtained retrospectively from the electronic medical record. RESULTS A total of 424 courses of inhaled antibiotics were prescribed during the study period. 296 (69.8%) courses were prescribed to treat an acute RTI, whereas 128 (30.2%) were prescribed prophylactically to prevent RTIs. 58.9% of children with tracheostomy tubes hospitalized during the study period received at least one course of inhaled antibiotics. The most common antibiotics prescribed were tobramycin and gentamicin; several different doses were used. In 53.2% of treatment courses, inhaled antibiotics were co-prescribed with systemic antibiotics. Therapy duration for treatment varied from 3 to 28 days. Respiratory cultures were used variably and antimicrobial susceptibility was often not taken into account when prescribing inhaled antibiotics. CONCLUSIONS Inhaled antibiotics were frequently prescribed as treatment and prophylaxis in children with tracheostomy tubes at our center, with significant variation in the prescribed antibiotic type, dose, frequency, duration, and co-prescription with systemic antibiotics. Prospective studies are needed to define best practice regarding inhaled antibiotics in this patient population.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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Scarselli A, Smarrazzo A, De Sanctis F, Ravà L, Carletti M, Ciofi Degli Atti M, Aversa M, Drago R, Crocoli A, Geremia C, Guerricchio A, Lucignano B, Campana A, De Ioris MA, Perrotta D. The burden of central line-associated bloodstream infections in children with medical complexity. J Vasc Access 2023; 24:198-204. [PMID: 34148383 DOI: 10.1177/11297298211027468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are significant cause of complications in pediatric intensive care units (PICUs). An emerging challenge are CLABSIs in children with medical complexity (CMC) admitted to PICU. CMC are patients with chronic conditions with or without neurological impairment needing for tracheostomy and/or home mechanical or non-invasive ventilation and/or gastrostomy/jejunostomy. We evaluate CLABSI incidence in a PICU with high prevalence of CMC. METHODS This was a retrospective study in the PICU of the Bambino Gesù Children Hospital from January 2017 to December 2020. The medical records were reviewed and demographic, clinical and microbiological data were extracted. CLABSI were defined according to the Center for Disease Control and Prevention's National Healthcare Safety Networks (NHSN) surveillance. RESULTS A total of 101 children with 125 central lines (CLs) were included; 79/101 (78%) patients were CMC and 50/101 (50%) had a thracheostomy. CLABSI incidence was 2.75/1000 CL-days (9 cases/3269 CL-days); incidence was 0 in patients without underling conditions and 3.14/1000 in CMC (p < 0.001). CLABSI were due to gram negative bacteria in five patients, Candida spp in three and Staphylococcus hominis in one. CLs were removed in eight cases while in the later one, with CLABSI due to Pseudomonas aeruginosa, a conservative strategy was adopted cause of unavailable alternative venous access and removed at discharge with negative culture. All patients recovered. CONCLUSIONS A target 0% CLABSI was possible in critically ill children without underling condition while a high incidence was reported in CMC and sustained by a peculiar CLABSI ecology. This ecology should be considered when a CLABSI was suspected in CMC for prompt antibiotics stewardship.
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Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention. Infect Control Hosp Epidemiol 2023; 44:191-199. [PMID: 36594433 DOI: 10.1017/ice.2022.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. DESIGN Mixed-methods study. SETTING Tertiary-care pediatric intensive care unit (PICU). PARTICIPANTS Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. METHODS This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. RESULTS The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. CONCLUSIONS We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.
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Impact of Organism Reporting from Endotracheal Aspirate Cultures on Antimicrobial Prescribing Practices in Mechanically Ventilated Pediatric Patients. J Clin Microbiol 2022; 60:e0093022. [PMID: 36218349 DOI: 10.1128/jcm.00930-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Endotracheal aspirate cultures (EACs) help diagnose lower respiratory tract infections in mechanically ventilated patients but are limited by contamination with normal microbiota and variation in laboratory reporting. Increased use of EACs is associated with increased antimicrobial prescribing, but the impact of microbiology reporting on prescribing practices is unclear. This study was a retrospective analysis of EACs from mechanically ventilated patients at Children's Hospital Colorado (CHCO) admitted between 1 January 2019 and 31 December 2019. Chart review was performed to collect all culture and Gram stain components, as well as antibiotic use directed to organisms in culture. Reporting concordance was determined for each organism using American Society for Microbiology guidelines. Days of therapy were calculated for overreported and guideline-concordant organisms. A multivariable model was used to assess the relationship between organism reporting and total days of therapy. Overall, 448 patients with 827 EACs were included in this study. Among patients with tracheostomy, 25 (8%) organisms reported from EACs were overreported and contributed 48 days of excess therapy, while 227 (29%) organisms from the EACs of endotracheally intubated patients were overreported, contributing 472 excess days of therapy. After adjustment, organism overreporting was associated with a >2-fold-higher rate of antimicrobial therapy than guideline-concordant reporting (incident rate ratio [IRR], 2.83; 95% confidence interval [CI], 1.23, 6.53; P < 0.05). Overreported organisms from respiratory cultures contribute to excess antimicrobial therapy exposure in mechanically ventilated patients. Microbiology laboratories have an opportunity to mitigate antimicrobial overuse through standardized reporting practices.
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Tsukahara K, Johnson B, Klimowich K, Chiotos K, Jensen EA, Planet P, Phinizy P, Piccione J. Comparison of tracheal aspirate and bronchoalveolar lavage samples in the microbiological diagnosis of lower respiratory tract infection in pediatric patients. Pediatr Pulmonol 2022; 57:2405-2410. [PMID: 35781810 PMCID: PMC9489655 DOI: 10.1002/ppul.26049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/01/2022] [Accepted: 06/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bacterial cultures from tracheal aspirates (TA) and bronchoalveolar lavage (BAL) specimens can be used to assess patients with artificial airways for lower respiratory tract infections (LRTI). TA collection may be advantageous in situations of limited resources or critical illness. Literature comparing these diagnostic modalities in pediatric populations is scarce. METHODS Single-center, retrospective analysis of 52 pediatric patients with an artificial airway undergoing evaluation for LRTI. All patients had a TA specimen collected for semiquantitative Gram stain and culture followed by BAL within 48 h. Microbiologic diagnosis of LRTI was defined as a BAL sample with >25% neutrophils and growth of >104 colony-forming units/ml of one or more bacterial species. The test characteristics of TA were compared with these BAL results as the reference standard. Concordance in microorganism identification was also assessed. RESULTS Overall, 24 patients (47%) met criteria for LRTI using BAL as the diagnostic standard. TA samples positive for an isolated organism had poor sensitivity for acute LRTI when compared with BAL, regardless of semiquantitative white blood cell (WBC) count by Gram stain. Using a TA diagnostic threshold of organism growth and at least "moderate" WBC yielded a specificity of 93%. Positive predictive value was highest when an organism was identified by TA. Negative predictive value was >70% for TA samples with no WBC by semiquantitative analysis, with or without growth of an organism. Complete concordance of cultured species was 58% for all patients, with a higher rate seen among those with endotracheal tubes. CONCLUSIONS The role of cultures obtained by TA remains limited for the diagnosis of acute LRTI as demonstrated by the poor correlation to BAL results within our cohort. Optimal strategies for diagnosing LRTI across patient populations and airway types remain elusive.
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Affiliation(s)
- Katharine Tsukahara
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brandy Johnson
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katelyn Klimowich
- Department of Urologic Surgery, Jefferson Health NJ,
Stratford, New Jersey
| | - Kathleen Chiotos
- Division of Critical Care Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital
of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A. Jensen
- Division of Neonatology, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul Planet
- Division of Infectious Diseases, Children’s Hospital
of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pelton Phinizy
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph Piccione
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Wasserman MG, Graham RJ, Mansbach JM. Airway Bacterial Colonization, Biofilms and Blooms, and Acute Respiratory Infection. Pediatr Crit Care Med 2022; 23:e476-e482. [PMID: 35767569 PMCID: PMC9529803 DOI: 10.1097/pcc.0000000000003017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Mollie G Wasserman
- Department of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA
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15
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Ingolfsland EC, Gonzalez-Villamizar JD, Moore J, Kubly J, Ali HM, Kvant A, Smith B, Norton L. Improving management of ventilator associated tracheitis in a level IV NICU. J Perinatol 2022; 42:1260-1265. [PMID: 35449445 DOI: 10.1038/s41372-022-01399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 03/18/2022] [Accepted: 04/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are no published guidelines regarding the diagnosis and treatment of ventilator-associated tracheitis (VAT) in the neonatal intensive care unit (NICU). VAT is likely over-diagnosed and over-treated, increasing antibiotic burden and cost. LOCAL PROBLEM Diagnosis and treatment of VAT were entirely NICU provider dependent. METHODS Retrospective pre- and post-intervention chart reviews were performed. INTERVENTIONS A VAT diagnosis and treatment algorithm was created for use in the care of intubated patients without tracheostomies. 3 plan-do-study-act (PDSA) cycles were used to implement change. RESULTS Intubated patients treated for VAT with <25 PMNs on Gram stain decreased from 79% to 35% following the quality improvement (QI) initiative. Treatment of VAT with >7 days of antibiotic therapy decreased from 42% to 10%. CONCLUSION Implementing a QI initiative to improve the diagnosis and treatment of VAT in the NICU decreased the percent of patients treated inappropriately for VAT.
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Affiliation(s)
| | | | - Jeanne Moore
- M Health Fairview, Minneapolis, MN, United States
| | - Janet Kubly
- M Health Fairview, Minneapolis, MN, United States
| | - Hawa M Ali
- University of Minnesota Medical School, Minneapolis, MN, United States
| | - Ann Kvant
- M Health Fairview, Minneapolis, MN, United States
| | - Betsy Smith
- M Health Fairview, Minneapolis, MN, United States
| | - Laura Norton
- Division of Pediatric Infectious Diseases, Medical School, University of Minnesota, Minneapolis, MN, United States
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16
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Roncin C, Vanel N, Morand A, Belghiti Alaoui M, Michel F. Systematic Endotracheal Aspiration in the Pediatric Intensive Care Unit Reduces Broad-spectrum Antibiotic Use for Ventilator-associated Pneumonia. Pediatr Infect Dis J 2022; 41:544-548. [PMID: 35363654 DOI: 10.1097/inf.0000000000003529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM To determine the impact of a systematic endotracheal aspiration (ETA) sampling program for mechanically ventilated patients on initial antibiotic therapy for ventilator-acquired pneumonia (VAP). DESIGN Retrospective cohort study; before-after study design. SETTING Pediatric intensive care unit (PICU) with 16 medical and surgical beds in a tertiary teaching hospital. SUBJECTS Patients <16 years of age hospitalized in the PICU who fulfilled VAP criteria. INTERVENTION Biweekly systematic ETA sampling was conducted in mechanically ventilated patients. MEASUREMENTS We retrospectively studied patients who received antibiotic therapy for suspected VAP 12 months before and after the initiation of systematic ETA (periods 1 and 2, respectively), evaluating the initial antibiotic therapy spectrum in both periods. RESULTS During period 1, 56 patients developed VAP and 47 developed VAP during period 2. The incidence was 17 cases of VAP/1000 days of mechanical ventilation in both periods. Ideal antibiotic therapy was prescribed in 19.6% of cases for period 1 and 55.2% for period 2 (P = 0.001). Initial antibiotic therapy for VAP during period 2 had a significantly lower proportion of broad-spectrum antibiotics than therapy during period 1 (P = 0.01). CONCLUSION In our PICU, knowledge of bronchial colonization reduced initial broad-spectrum antibiotic use for VAP.
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Affiliation(s)
- César Roncin
- From the Anesthesia and Intensive Care Unit, Timone Children's Hospital, Hôpitaux Universitaires de Marseille, France
| | - Noémie Vanel
- From the Anesthesia and Intensive Care Unit, Timone Children's Hospital, Hôpitaux Universitaires de Marseille, France
| | - Aurelie Morand
- Pédiatrie spécialisée et médecine infantile Marseille, Timone Children's Hospital, Hôpitaux Universitaires de Marseille, France
| | - Myriem Belghiti Alaoui
- From the Anesthesia and Intensive Care Unit, Timone Children's Hospital, Hôpitaux Universitaires de Marseille, France
| | - Fabrice Michel
- From the Anesthesia and Intensive Care Unit, Timone Children's Hospital, Hôpitaux Universitaires de Marseille, France
- Aix Marseille University CNRS, EFS, ADES, UMR 7268, Marseille, France
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17
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Gipsman A, Prero M, Toltzis P, Craven D. Tracheobronchitis in children with tracheostomy tubes: Overview of a challenging problem. Pediatr Pulmonol 2022; 57:814-821. [PMID: 34981895 DOI: 10.1002/ppul.25814] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/16/2021] [Accepted: 12/30/2021] [Indexed: 12/21/2022]
Abstract
Tracheobronchitis is common in children with tracheostomy tubes. These children are predisposed to respiratory infections due to the bypassing of normal upper airway defense mechanisms by the tracheostomy, bacterial colonization of the tracheostomy tube itself, and underlying medical conditions. Diagnosis of bacterial tracheobronchitis is challenging due to the difficulty in differentiating between bacterial colonization and infection, as well as between viral and bacterial etiologies. Difficulty in diagnosis complicates management decisions, and there are currently no consensus guidelines to assist clinicians in the treatment of these patients. Frequent administration of systemic antibiotics causes adverse effects and leads to the emergence of resistant organisms. Topical administration of antibiotics via nebulization or direct instillation may lead to a significantly higher concentration of drug in the upper and lower airways without causing systemic side effects, although therapeutic trials in children with tracheostomy tubes are lacking. Several preventative measures such as regular airway clearance and the use of a speaking valve may mitigate the risk of developing respiratory infections.
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Affiliation(s)
- Alexander Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Moshe Prero
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Philip Toltzis
- Department of Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Daniel Craven
- Department of Pulmonology, Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
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18
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Sick-Samuels AC, Woods-Hill C. Diagnostic Stewardship in the Pediatric Intensive Care Unit. Infect Dis Clin North Am 2022; 36:203-218. [PMID: 35168711 PMCID: PMC8865365 DOI: 10.1016/j.idc.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?
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Affiliation(s)
- Anna C. Sick-Samuels
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD,The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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19
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Ting JY, Autmizguine J, Dunn MS, Choudhury J, Blackburn J, Gupta-Bhatnagar S, Assen K, Emberley J, Khan S, Leung J, Lin GJ, Lu-Cleary D, Morin F, Richter LL, Viel-Thériault I, Roberts A, Lee KS, Skarsgard ED, Robinson J, Shah PS. Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective. Front Pediatr 2022; 10:894005. [PMID: 35874568 PMCID: PMC9304938 DOI: 10.3389/fped.2022.894005] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.
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Affiliation(s)
- Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Autmizguine
- Division of Infectious Diseases, Department of Pediatrics, Université de Montreal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada
| | - Michael S Dunn
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julie Choudhury
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montreal, Montreal, QC, Canada
| | - Shikha Gupta-Bhatnagar
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Katrin Assen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Julie Emberley
- Division of Neonatology, Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Khan
- Department of Microbiology, McMaster University, Hamilton, ON, Canada
| | - Jessica Leung
- Department of Pediatrics, University of Massachusetts, Worcester, MA, United States
| | - Grace J Lin
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | - Frances Morin
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay L Richter
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Erik D Skarsgard
- Division of Pediatric Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joan Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Prakesh S Shah
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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20
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Prinzi A, Parker SK, Thurm C, Birkholz M, Sick-Samuels A. Association of Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients. JAMA Netw Open 2021; 4:e2140378. [PMID: 34935920 PMCID: PMC8696566 DOI: 10.1001/jamanetworkopen.2021.40378] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Endotracheal aspirate cultures are commonly collected from patients with mechanical ventilation to evaluate for ventilator-associated pneumonia or tracheitis. However, the respiratory tract is not sterile, making differentiating between colonization from bacterial infection challenging, and results may be unreliable owing to variable specimen quality and sample processing across laboratories. Despite these limitations, clinicians routinely interpret bacterial growth in endotracheal aspirate cultures as evidence of infection, sometimes regardless of organism significance, prompting antibiotic treatment. OBJECTIVE To assess the variability in endotracheal aspirate culture rates and the association between culture rates and antibiotic prescribing among patients with mechanical ventilation across children's hospitals in the US. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective analysis of data obtained from the Children's Hospital Association Pediatric Health Information System database between January 1, 2016, through December 31, 2019. Participants were all patients hospitalized with mechanical ventilation aged less than 18 years. EXPOSURES A charge for an endotracheal aspirate culture on a ventilated day. MAIN OUTCOMES AND MEASURES Endotracheal aspirate culture rate and antibiotic days of therapy per ventilated days. For mechanical ventilation, clinical transaction classification codes for mechanical ventilation other unspecified ventilator assistance were used. To identify respiratory cultures, the laboratory test code for aerobic culture was used and relevant keywords (ie, respiratory tract, sputum) were used to identify sources in the hospital charge description master. RESULTS A total of 152 132 patients were identified among 31 hospitals. Among these patients, 79 691 endotracheal aspirate cultures were collected on a ventilator-day (patients aged less than 1 year, 44%; 1-4 years, 27%, 5-11 years. 16%, and 12-18 years, 13%; 3% were Asian; 17% Hispanic; 21% non-Hispanic Black; 45% Non-Hispanic White patients; 14% were other; 56% of patients were male, 44% were female). The overall median rate of culture use was 46 per 1000 ventilator-days (IQR, 32-73 cultures per 1000 ventilator-days). The endotracheal aspirate culture rate was positively correlated with the hospital's antibiotic days of therapy rate (R = 0.46; P = .009). In a multivariable model adjusting for patient-level and hospital-level characteristics and among patients with mechanical ventilation, each additional endotracheal aspirate culture was associated with 2.87 (95% CI, 2.74-3.01) higher odds of receiving additional days of therapy compared with patients who did not receive and endotracheal aspirate culture. CONCLUSIONS AND RELEVANCE In this study, notable variability was found in endotracheal aspirate culture rates across US pediatric hospitals and pediatric intensive care units, and endotracheal aspirate culture use was associated with increased antibiotic use. These findings suggest an opportunity for diagnostic and antibiotic stewardship to standardize testing and treatment of suspected ventilator-associated infections in pediatric patients with mechanical ventilation pediatric patients.
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Affiliation(s)
- Andrea Prinzi
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
- University of Colorado Anschutz Medical Campus Graduate School, Denver
| | - Sarah K. Parker
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
- Department of Pediatrics, University of Colorado School of Medicine, Denver
| | - Cary Thurm
- Children’s Hospital Association, Lenexa, Kansas
| | - Meghan Birkholz
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
| | - Anna Sick-Samuels
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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21
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Kalm B, Lai K, Darro N. Care of children with home mechanical ventilation in the healthcare continuum. Hosp Pract (1995) 2021; 49:456-466. [PMID: 34605728 DOI: 10.1080/21548331.2021.1988608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction:The care of children with invasive home mechanical ventilation (HMV) is challenging and insufficiently described in the literature. Objectives:Our objective regarding this unique and growing population is to describe our institution's pediatric chronic HMV program and discuss our current understanding of best care practices. Methods: In addition to characterizing the clinical landscape of our program, we describe demographics for our roughly 223 current HMV patients with comparisons to available national data. We discuss evidence and expert opinion regarding various elements of care including initiation of HMV, caregiver education, equipment concerns, inpatient care, and longitudinal care.Results: Data was collected but not statistically analyzed for our roughly 223 current patients and historical cohort. Descriptive data included demographic information, patient medical characteristics and complexity, and reasons for rehospitalizations.Conclusions:While we have provided institutional expertise regarding the care of this complex population, the evidence base remains insufficient and there are many areas which need future research to develop standardized care practice guidelines for children with HMV.
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Affiliation(s)
- Benjamin Kalm
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Khanh Lai
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Natalie Darro
- Division of Pediatric Complex Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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22
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Karsies T, Tarquinio K, Shein SL, Beardsley AL, Prentice E, Karam O, Fontela P, Moore-Clingenpeel M, Willson DF. Compliance With an Antibiotic Guideline for Suspected Ventilator-Associated Infection: The Ventilator-Associated INfection (VAIN2) Study. Pediatr Crit Care Med 2021; 22:859-869. [PMID: 33965989 DOI: 10.1097/pcc.0000000000002761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate a guideline for antibiotic decisions in children with suspected ventilator-associated infection. DESIGN Prospective, observational cohort study conducted in 22 PICUs in the United States and Canada. SETTING PICUs in 22 hospitals from April 2017 to January 2019. SUBJECTS Children less than 3 years old on mechanical ventilation greater than 48 hours who had respiratory secretions cultured and antibiotics initiated for suspected ventilator-associated infection. INTERVENTIONS After baseline data collection in children with suspected ventilator-associated infection (Phase 1), a consensus guideline was developed for advising antibiotic continuation or stopping at 48-72 hours (Phase 2) and implemented (Phase 3). Guideline-based antibiotic recommendations were provided to the treating clinicians once clinical and microbiologic data were available. Demographic and outcome data were collected, and guideline compliance and antibiotic utilization evaluated for Phase 1 and Phase 3. MEASUREMENTS AND MAIN RESULTS Despite education and implementation efforts, guideline-concordant antibiotic management occurred in 158 of 227 (70%) Phase 3 subjects compared with 213 of 281 (76%) in Phase 1. Illness severity and positive respiratory cultures were the primary determinants of antibiotic continuation. For subjects with a positive respiratory culture but a score for which antibiotic discontinuation was recommended (score ≤ 2), only 27% of Phase 3 subjects had antibiotics discontinued. Antibiotic continuation was not associated with improved outcomes in these subjects and was associated with significantly longer duration of ventilation (median 5.5 d longer) and PICU stay (5 d longer) in the overall study population. Positive respiratory cultures were not associated with outcomes irrespective of antibiotic treatment. CONCLUSIONS Antibiotic guideline efficacy and safety remain uncertain due to clinician failure to follow the guideline, instead primarily relying on respiratory culture results. Strategies to overcome clinician perceptions of respiratory cultures and other barriers will be vital for improving guideline adherence and antibiotic use in suspected ventilator-associated infection in future studies.
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Affiliation(s)
- Todd Karsies
- Division of Pediatric Critical Care, Nationwide Children's Hospital, Columbus, OH
| | - Keiko Tarquinio
- Division of Pediatric Critical Care, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Steven L Shein
- Division of Pediatric Critical Care, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Andrew L Beardsley
- Division of Pediatric Critical Care, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Elizabeth Prentice
- Division of Pediatric Critical Care, Helen DeVos Children's Hospital, Grand Rapids, MI
| | - Oliver Karam
- Division of Pediatric Critical Care, Children's Hospital of Richmond at VCU, Richmond, VA
| | - Patricia Fontela
- Division of Pediatric Critical Care, McGill University Children's Hospital, Montreal, QC, Canada
| | - Melissa Moore-Clingenpeel
- Biostatistics Resource at Nationwide Children's Hospital and Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Douglas F Willson
- Division of Pediatric Critical Care, Children's Hospital of Richmond at VCU, Richmond, VA
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23
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Sick-Samuels AC, Linz M, Bergmann J, Fackler JC, Berenholtz SM, Ralston SL, Hoops K, Dwyer J, Colantuoni E, Milstone AM. Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU. Pediatrics 2021; 147:peds.2020-1634. [PMID: 33827937 PMCID: PMC8086005 DOI: 10.1542/peds.2020-1634] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. METHODS We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. RESULTS In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. CONCLUSIONS A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.
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Affiliation(s)
- Anna C. Sick-Samuels
- Departments of Pediatrics and,Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Matthew Linz
- New Jersey Medical School, Rutgers University, Newark, New Jersey; and
| | - Jules Bergmann
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - James C. Fackler
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - Sean M. Berenholtz
- Anesthesiology and Critical Care Medicine, School of Medicine, and,Departments of Health Policy and Management and,Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Katherine Hoops
- Anesthesiology and Critical Care Medicine, School of Medicine, and
| | - Joe Dwyer
- Extra-Corporeal Membrane Oxygenation Services, Division of Respiratory Care, Departments of Pediatrics and
| | - Elizabeth Colantuoni
- Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Aaron M. Milstone
- Departments of Pediatrics and,Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
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The Pediatric Endotracheal Aspirate Culture Survey (PETACS): Examining Practice Variation across Pediatric Microbiology Laboratories in the United States. J Clin Microbiol 2021; 59:JCM.02232-20. [PMID: 33298605 DOI: 10.1128/jcm.02232-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/25/2020] [Indexed: 11/20/2022] Open
Abstract
In the absence of evidence-based laboratory guidelines, the workup and interpretation of tracheal aspirate (TA) cultures remains controversial and confusing within the fields of clinical microbiology, infectious diseases, and critical care. Between 22 January and 24 February 2020, we conducted a national, web-based survey of microbiology laboratory personnel in free-standing pediatric hospitals and adult hospitals containing pediatric facilities regarding the laboratory practices used for TA specimens. We hypothesized there would be substantial center-level variability in laboratory processing of TA cultures. The response rate for the survey was 48% (73/153). There was a high level of variability in the criteria used for all processes, including specimen receipt, Gram staining, and culture reporting. Most respondents (77%) reported they do not reject TA specimens based on Gram stain criteria, and 44% of labs do not require that a minimum number of Gram stain fields be reviewed prior to reporting results. Overall, nonacademic hospital laboratories and pediatric-only laboratories are more likely to identify, report, and perform susceptibility testing on organisms from TA cultures, regardless of organism quantity or predominance. There is a substantial amount of process variability among pediatric microbiology laboratories that affects TA culture reporting, and which guides treatment decisions. This variation within and among labs makes clinical outcome studies related to TA cultures difficult to interpret. This study serves as a pragmatic step in informing the development of robust clinical guidelines. Clinical outcome and implementation studies are necessary to determine the effectiveness of guidelines for TA cultures.
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Understanding reasons clinicians obtained endotracheal aspirate cultures and impact on patient management to inform diagnostic stewardship initiatives. Infect Control Hosp Epidemiol 2021; 41:240-242. [PMID: 31813405 DOI: 10.1017/ice.2019.347] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Willems J, Hermans E, Schelstraete P, Depuydt P, De Cock P. Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review. Paediatr Drugs 2021; 23:39-53. [PMID: 33174101 PMCID: PMC7654352 DOI: 10.1007/s40272-020-00426-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 02/08/2023]
Abstract
Antibiotics are one of the most prescribed drug classes in the pediatric intensive care unit, yet the incidence of inappropriate antibiotic prescribing remains high in critically ill children. Optimizing the use of antibiotics in this population is imperative to guarantee adequate treatment, avoid toxicity and the occurrence of antibiotic resistance, both on a patient level and on a population level. Antibiotic stewardship encompasses all initiatives to promote responsible antibiotic usage and the PICU represents a major target environment for antibiotic stewardship programs. This narrative review provides a summary of the available knowledge on the optimal selection, duration, dosage, and route of administration of antibiotic treatment in critically ill children. Overall, more scientific evidence on how to optimize antibiotic treatment is warranted in this population. We also give our personal expert opinion on research priorities.
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Affiliation(s)
- Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Eline Hermans
- Department of Pediatrics, Ghent University Hospital, Gent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology, Ghent University Hospital, Gent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Pieter De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium.
- Department of Pharmacy, Ghent University Hospital, Gent, Belgium.
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Practice Improvement for Standardized Evaluation and Management of Acute Tracheitis in Mechanically Ventilated Children. Pediatr Qual Saf 2020; 6:e368. [PMID: 33403314 PMCID: PMC7775031 DOI: 10.1097/pq9.0000000000000368] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023] Open
Abstract
There is no consensus definition for ventilator-associated tracheitis and limited evidence to guide diagnosis and treatment. To improve acute tracheitis evaluation and management, this quality improvement project aimed to (1) improve the appropriateness of tracheal aspirate cultures while decreasing the number of unnecessary cultures by 20% and (2) decrease antibiotic use for acute tracheitis not consistent with local guidelines by 20% over 12 months among pediatric patients requiring mechanical ventilation.
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Abstract
The tracheal aspirate (TA) culture is commonly ordered in the NICU, but it has low sensitivity and specificity, limited by contamination. Interpretation of a TA culture out of context can lead to antibiotic overuse, which should be avoided. Clinicians should practice caution in the diagnosis of congenital pneumonia and use newer, published approaches to the diagnosis of ventilator-associated pneumonia in neonates. A subset of neonatal patients with risk factors of maternal fever or chorioamnionitis requiring intubation may benefit from TA culture performed within 12 hours after birth, to help identify an organism when blood culture may be negative, and tailor antimicrobial therapies. The more invasive, but more sensitive, technique of nonbronchoscopic bronchoalveolar lavage should be considered in older infants when bacterial isolation from the lower respiratory tract is necessary, because TA culture cannot distinguish between colonization and infection in that population.
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Affiliation(s)
- Colleen C Claassen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, St Louis, MO
| | - William J Keenan
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, St Louis, MO
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Ericson JE, McGuire J, Michaels MG, Schwarz A, Frenck R, Deville JG, Agarwal S, Bressler AM, Gao J, Spears T, Benjamin DK, Smith PB, Bradley JS. Hospital-acquired Pneumonia and Ventilator-associated Pneumonia in Children: A Prospective Natural History and Case-Control Study. Pediatr Infect Dis J 2020; 39:658-664. [PMID: 32150005 PMCID: PMC8293907 DOI: 10.1097/inf.0000000000002642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Clinical trials for antibiotics designed to treat hospital-acquired and ventilator-associated bacterial pneumonias (HABP/VABP) are hampered by making these diagnoses in a way that is acceptable to the United States Food and Drug Administration and consistent with standards of care. We examined laboratory and clinical features that might improve pediatric HABP/VABP trial efficiency by identifying risk factors predisposing children to HABP/VABP and describing the epidemiology of pediatric HABP/VABP. METHODS We prospectively reviewed the electronic medical records of patients <18 years of age admitted to intensive and intermediate care units (ICUs) if they received qualifying respiratory support or were started on antibiotics for a lower respiratory tract infection or undifferentiated sepsis. Subjects were followed until HABP/VABP was diagnosed or they were discharged from the ICU. Clinical, laboratory and imaging data were abstracted using structured chart review. We calculated HABP/VABP incidence and used a stepwise backward selection multivariable model to identify risk factors associated with development of HABP/VABP. RESULTS A total of 862 neonates, infants and children were evaluated for development of HABP/VABP; 10% (82/800) of those receiving respiratory support and 12% (103/862) overall developed HABP/VABP. Increasing age, shorter height/length, longer ICU length of stay, aspiration risk, blood product transfusion in the prior 7 days and frequent suctioning were associated with increased odds of HABP/VABP. The use of noninvasive ventilation and gastric acid suppression were both associated with decreased odds of HABP/VABP. CONCLUSIONS Food and Drug Administration-defined HABP/VABP occurred in 10%-12% of pediatric patients admitted to ICUs. Risk factors vary by age group.
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Affiliation(s)
| | | | | | - Adam Schwarz
- Children’s Hospital of Orange County, Orange, CA, USA
| | - Robert Frenck
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC, USA
| | - Tracy Spears
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC USA
| | - John S. Bradley
- University of California, San Diego School of Medicine and Rady Children’s Hospital San Diego, San Diego, CA USA
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30
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Klatte JM. Pediatric Antimicrobial Stewardship Programs: Current Perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2020; 11:245-255. [PMID: 32801990 PMCID: PMC7383043 DOI: 10.2147/phmt.s224774] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022]
Abstract
With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.
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Affiliation(s)
- J Michael Klatte
- Division of Infectious Disease, Dayton Children's Hospital, Dayton, OH, USA
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31
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Gertz SJ, McArthur J, Hsing DD, Nitu ME, Smith LS, Loomis A, Fitzgerald JC, Duncan CN, Mahadeo KM, Moffet J, Hall MW, Pinos EL, Cheifetz IM, Rowan CM. Respiratory pathogens associated with intubated pediatric patients following hematopoietic cell transplant. Transpl Infect Dis 2020; 22:e13297. [PMID: 32306533 DOI: 10.1111/tid.13297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 03/23/2020] [Accepted: 03/31/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND We describe organisms found in the respiratory tracts of a multicenter cohort of pediatric hematopoietic cell transplant (HCT) recipients with respiratory failure. METHODS Twelve centers contributed up to 25 pediatric allogeneic HCT recipients requiring mechanical ventilation for respiratory failure to a retrospective database. Positive respiratory pathogens and method of obtaining sample were recorded. Outcomes were assessed using Mann-Whitney U test or chi-squared analysis. RESULTS Of the 222 patients in the database, ages 1 month through 21 years, 34.6% had a positive respiratory culture. 105 pathogens were identified in 77 patients; of those, 48.6% were viral, 34.3% bacterial, 16.2% fungal, and 1% parasitic. PICU mortality with a respiratory pathogen was 68.8% compared to 54.9% for those without a respiratory pathogen (P = .045). Those with a positive respiratory pathogen had longer PICU length of stay, 20 days (IQR 14.0, 36.8) vs 15 (IQR 6.5, 32.0), P = .002, and a longer course of mechanical ventilation, 17 days (IQR 10, 29.5) vs 8 (3, 17), P < .0001. Method of pathogen identification, type of pathogen, and the presence of multiple pathogens were not associated with changes in PICU outcomes. CONCLUSIONS In this multicenter retrospective cohort of intubated pediatric post-HCT patients, there was high variability in the respiratory pathogens identified. Type of pathogen and method of detection did not affect PICU mortality. The presence of any organism leads to increased PICU mortality, longer PICU stay, and increased duration of mechanical ventilation suggesting that early detection and treatment of pathogens may be beneficial in this population.
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Affiliation(s)
- Shira J Gertz
- Department of Pediatrics, Saint Barnabas Medical Center, Livingston, New Jersey, USA
| | - Jennifer McArthur
- Division of Critical Care, Department of Pediatrics, St. Jude's Children's Research Hospital, Memphis, Tennessee, USA.,Division of Critical Care Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Deyin D Hsing
- Division of Critical Care, Department of Pediatrics, Weil Cornell Medical College, New York Presbyterian Hospital, New York City, New York, USA
| | - Mara E Nitu
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Ashley Loomis
- Division of Critical Care, Department of Pediatrics, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota, USA
| | - Julie C Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine N Duncan
- Department of Pediatrics, Pediatric Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, Massachusetts, USA
| | - Kris M Mahadeo
- Division of Pediatric Stem Cell Transplant and Cellular Therapy, Department of Pediatrics, University of Texas at MD Anderson Cancer Center, Houston, Texas, USA
| | - Jerelyn Moffet
- Division of Blood and Marrow Transplant, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, North Carolina, USA
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Emily L Pinos
- Pennsylvania State University College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Ira M Cheifetz
- Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, North Carolina, USA
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Acinetobacter baumannii Is a Risk Factor for Lower Respiratory Tract Infections in Children and Adolescents With a Tracheostomy. Pediatr Infect Dis J 2019; 38:1005-1009. [PMID: 31568139 DOI: 10.1097/inf.0000000000002421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lower respiratory tract infections (LRIs) are a major cause of hospitalization for children and adolescents with a tracheostomy. The aim of this study was to identify risk factors for LRI. METHODS In this retrospective study, we assessed the number of LRI and hospitalizations for LRI from 2004 to 2014 at the University Hospital Muenster Pediatric Department. We analyzed associations between LRI and clinical findings, and we cultured pathogens in tracheal aspirates (TAs) during noninfection periods. Univariable and multivariable negative, binomial regression analyses were applied to identify associations between possible risk factors and LRI. RESULTS Seventy-eight patients had 148 LRI, of which 99 were treated in hospital. The median number of LRI per year was 0.4. Six-hundred thirteen pathogens were detected in 315 specimens; Staphylococcus aureus (22.5%), Pseudomonas aeruginosa (14.8%) and Haemophilus influenzae (6.2%) were most frequently detected. Acinetobacter baumannii is an independent risk factor for LRI (rate ratio, 1.792; P = 0.030) and hospital admissions for LRI (rate ratio, 1.917; P = 0.011). CONCLUSIONS Children with a tracheostomy have frequent LRI. A. baumannii but not P. aeruginosa or S. aureus in TA is a risk factor for LRI in children with a long-term tracheostomy. This supports repetitive culture of TA for microbiologic workup to identify children and adolescents with an increased risk for LRI.
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Shen L, Wang F, Shi J, Xu W, Jiang T, Tang H, Yu X, Yin H, Hu S, Wu X, Chan SK, Sun J, Chang Q. Microbiological analysis of endotracheal aspirate and endotracheal tube cultures in mechanically ventilated patients. BMC Pulm Med 2019; 19:162. [PMID: 31455270 PMCID: PMC6712863 DOI: 10.1186/s12890-019-0926-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 08/19/2019] [Indexed: 11/18/2022] Open
Abstract
Background To compare the microbiological culture within endotracheal aspirate specimens (ETAs) and endotracheal tube specimens (ETTs) in patients undergoing mechanical ventilation (MV) by statistical tools. Method ETAs and ETTs from a total number of 81 patients, who were undergoing MV at the intensive care unit (ICU) of Jiading Central Hospital Affiliated Shanghai University of Medicine & Health Sciences from September 1st, 2017 to August 31st, 2018, were collected for microbiological culture analysis. Correlation of ETAs and ETTs cultures were obtained by Spear-men correlation analysis, while the consistency of the two specimens was determined by Kappa analysis and principal component analysis (PCA). Results Microbiological culture from both ETAs and ETTs showed that Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae were the main pathogens, with Spear-man correlation coefficients of 0.676, 0.951, 0.730 and 0.687 respectively (all P < 0.01), and the overall Spear-man correlation coefficient is 0.757 (P < 0.01). This result shows that two samples were positively correlated. Kappa analysis also revealed high consistency of the microbial culture results from the ETAs and the ETTs (overall κ = 0.751, P < 0.01). The κ values for the four bacteria detected were 0.670, 0.949, 0.723, and 0.687, respectively (all P < 0.001). PCA also revealed high similarity. Conclusion Combining microbiological culture and statistical analysis of samples collected from 81 patients who were undergoing MV in ICU, we showed that microbe found in the ETAs had high similarity with that found in the ETTs which collected at the end of the catheters. In clinical practice, ETAs analysis is easily accessible meanwhile provides a valuable information for MV patients. Electronic supplementary material The online version of this article (10.1186/s12890-019-0926-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lijuan Shen
- Department of Clinical Laboratory, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, No.1, Chengbei Rd, Jiading District, Shanghai, 201800, China
| | - Fei Wang
- Department of Critical Care Medicine, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Junfeng Shi
- Shanghai Key Laboratory for Molecular Imaging, Shanghai University of Medicine & Health Sciences, Shanghai, 301318, China
| | - Weixin Xu
- Department of Clinical Laboratory, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, No.1, Chengbei Rd, Jiading District, Shanghai, 201800, China
| | - Tingting Jiang
- Department of Critical Care Medicine, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Huifang Tang
- Department of Pharmacology, Zhejiang University, School of Basic Medical Sciences, Hangzhou, 310058, China
| | - Xiuwen Yu
- Department of Clinical Laboratory, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, No.1, Chengbei Rd, Jiading District, Shanghai, 201800, China
| | - Hao Yin
- Department of Critical Care Medicine, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Shanyou Hu
- Department of Critical Care Medicine, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Xiao Wu
- Emergency Department, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai, 201800, China
| | - Siu Kit Chan
- Shanghai Key Laboratory for Molecular Imaging, Shanghai University of Medicine & Health Sciences, Shanghai, 301318, China
| | - Jie Sun
- Department of Clinical Laboratory, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, No.1, Chengbei Rd, Jiading District, Shanghai, 201800, China.
| | - Qing Chang
- Clinical Research Center, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, No.1, Chengbei Rd, Jiading District, Shanghai, 201800, China.
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Decision-Making Around Positive Tracheal Aspirate Cultures: The Role of Neutrophil Semiquantification in Antibiotic Prescribing. Pediatr Crit Care Med 2019; 20:e380-e385. [PMID: 31232849 DOI: 10.1097/pcc.0000000000002014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Ventilator-associated infections are a major contributor to antibiotic use in the PICU. Quantitative or semiquantitative assessment of neutrophils (microscopic purulence) is routinely reported in positive cultures from tracheal aspirates. The role of microscopic purulence in guiding antibiotic therapy or its association with symptoms of ventilator-associated infections is less described in children. We examine microscopic purulence as an independent predictor of antibiotic use for positive tracheal aspirate cultures in the PICU. DESIGN Retrospective cohort study. SETTING Tertiary care pediatric hospital. PATIENTS Children admitted to the PICU, neuro-PICU, or cardiac PICU with a positive tracheal aspirate culture from January 1, 2016, to December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Positive tracheal aspirate cultures were reviewed. The outcome variable was antibiotic treatment that targeted the positive tracheal aspirate culture. The predictor variable was microscopic purulence, defined as moderate or many neutrophils on Gram stain report. Competing predictors included demographics, comorbidities, vital signs changes, respiratory support, and laboratory values. Of 361 positive cultures in the cohort, 81 (22%) were treated with antibiotics. Positive cultures with microscopic purulence were targeted for therapy more frequently (30% vs 11%). Microscopic purulence was the strongest predictor for antibiotic therapy (odds ratio, 3.3; 95% CI, 1.6-6.8) compared with fever (odds ratio, 2.0; 95% CI, 1.0-4.1) or increased respiratory support (odds ratio, 2.3; 95% CI, 1.2-4.3). There was no significant variation in symptomatology between microscopic purulence reported as moderate or many versus other (e.g., fever -24% vs 22%, increased respiratory support -36% vs 28%). Microscopic purulence was less prevalent with longer ventilator durations at the time of sampling. CONCLUSIONS Microscopic purulence was an independent predictor of antibiotic therapy for positive tracheal aspirate cultures in our PICUs. However, microscopic purulence was not associated with clinical symptomatology.
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Development of an Antibiotic Guideline for Children With Suspected Ventilator-Associated Infections. Pediatr Crit Care Med 2019; 20:697-706. [PMID: 30985606 DOI: 10.1097/pcc.0000000000001942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To develop a guideline for the decision to continue or stop antibiotics at 48-72 hours after their initiation in children with suspected ventilator-associated infection. DESIGN Prospective, multicenter observational data collection and subsequent development of an antibiotic guideline. SETTING Twenty-two PICUs. PATIENTS Children less than 3 years old receiving mechanical ventilation who underwent clinical testing and initiation of antibiotics for suspected ventilator-associated infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Phase 1 was a prospective data collection in 281 invasively ventilated children with suspected ventilator-associated infection. The median age was 8 months (interquartile range, 4-16 mo) and 75% had at least one comorbidity. Phase 2 was development of the guideline scoring system by an expert panel employing consensus conferences, literature search, discussions with institutional colleagues, and refinement using phase 1 data. Guideline scores were then applied retrospectively to the phase 1 data. Higher scores correlated with duration of antibiotics (p < 0.001) and higher PEdiatric Logistic Organ Dysfunction 2 scores (p < 0.001) but not mortality, PICU-free days or ventilator-free days. Considering safety and outcomes based on the phase 1 data and aiming for a 25% reduction in antibiotic use, the panel recommended stopping antibiotics at 48-72 hours for guideline scores less than or equal to 2, continuing antibiotics for scores greater than or equal to 6, and offered no recommendation for scores 3, 4, and 5. The acceptability and effect of these recommendations on antibiotic use and outcomes will be prospectively tested in phase 3 of the study. CONCLUSIONS We developed a scoring system with recommendations to guide the decision to stop or continue antibiotics at 48-72 hours in children with suspected ventilator-associated infection. The safety and efficacy of the recommendations will be prospectively tested in the planned phase 3 of the study.
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Antibiotic Prescription in Young Children With Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes. Pediatr Crit Care Med 2019; 20:101-109. [PMID: 30720644 DOI: 10.1097/pcc.0000000000001839] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To describe antibiotic prescribing practices during the first 2 days of mechanical ventilation among previously healthy young children with respiratory syncytial virus-associated lower respiratory tract infection and evaluate associations between the prescription of antibiotics at onset of mechanical ventilation with clinical outcomes. DESIGN Retrospective cohort study. SETTING Forty-six children's hospitals in the United States. PATIENTS Children less than 2 years old discharged between 2012 and 2016 with an International Classification of Diseases diagnosis of respiratory syncytial virus-associated lower respiratory tract infection, no identified comorbid conditions, and receipt of mechanical ventilation. INTERVENTIONS Antibiotic prescription during the first 2 days of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS We compared duration of mechanical ventilation and hospital length of stay between children prescribed antibiotics on both of the first 2 days of mechanical ventilation and children not prescribed antibiotics during the first 2 days of mechanical ventilation. We included 2,107 PICU children with respiratory syncytial virus-associated lower respiratory tract infection (60% male, median age of 1 mo [interquartile range, 1-4 mo]). The overall proportion of antibiotic prescription on both of the first 2 days of mechanical ventilation was 82%, decreasing over the study period (p = 0.004) and varying from 36% to 100% across centers. In the bivariate analysis, antibiotic prescription was associated with a shorter duration of mechanical ventilation (6 d [4-9 d] vs 8 d [6-11 d]; p < 0.001) and a shorter hospital length of stay (11 d [8-16 d] vs 13 d [10-18 d]; p < 0.001). After adjustment for center, demographics, and vasoactive medication prescription, antibiotic prescription was associated with a 1.21-day shorter duration of mechanical ventilation and a 2.07-day shorter length of stay. Ultimately, 95% of children were prescribed antibiotics sometime during hospitalization, but timing, duration, and antibiotic choice varied markedly. CONCLUSIONS Although highly variable across centers and decreasing over time, the practice of instituting antibiotics after intubation in young children with respiratory syncytial virus-associated lower respiratory tract infection was associated with a shortened clinical course after adjustment for the limited available covariates. A prudent approach to identify and optimally treat bacterial coinfection is needed.
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Abstract
A wide variety of microorganisms are potential respiratory pathogens, and the spectrum of known pathogens for each respiratory infection syndrome has not changed markers over recent years. Detection of likely etiologic agents of respiratory infections can help direct management and can also play an important role in disease surveillance. For this purpose, we are still reliant on many traditional diagnostic tools that have been used for decades in order to determine the microbial etiology of respiratory infections. However, these tools have been increasingly supplemented by newer methods, particular molecular diagnostic techniques, which have enabled the more rapid detection of many pathogens that were previously difficult to detect. These advances have particularly lead to improvements in the ability to detect respiratory viruses and also other microorganisms that do not normally colonize the respiratory tract. Recognition of the existence of the lung microbiome has challenged the traditional views of pneumonia pathogenesis and may provide the opportunity for new diagnostic tools that are focused on more than just detection of specific known pathogens. Continued liaison between clinicians and laboratory staff is vital in order to facilitate the most cost-effective use of laboratory diagnostics.
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Variability in antimicrobial use in pediatric ventilator-associated events. Infect Control Hosp Epidemiol 2018; 40:32-39. [PMID: 30409233 DOI: 10.1017/ice.2018.264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs). DESIGN Descriptive retrospective cohort with nested case-control study. SETTING Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.PatientsChildren≤18 years ventilated for≥1 calendar day. METHODS We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria. RESULTS Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20-67%; PICU, 0-70%; and NICU, 0-43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test. CONCLUSIONS Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
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Karsies T, Moore-Clingenpeel M, Hall M. Development and Validation of a Model to Predict Growth of Potentially Antibiotic-Resistant Gram-Negative Bacilli in Critically Ill Children With Suspected Infection. Open Forum Infect Dis 2018; 5:ofy278. [PMID: 30488040 PMCID: PMC6247662 DOI: 10.1093/ofid/ofy278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/23/2018] [Indexed: 12/23/2022] Open
Abstract
Background Risk-based guidelines aid empiric antibiotic selection for critically ill adults with suspected infection with Gram-negative bacilli with high potential for antibiotic resistance (termed high-risk GNRs). Neither evidence-based guidelines for empiric antibiotic selection nor validated risk factors predicting high-risk GNR growth exist for critically ill children. We developed and validated a model for predicting high-risk GNR growth in critically ill children with suspected infection. Methods This is a retrospective cohort study involving 2 pediatric cohorts admitted to a pediatric intensive care unit (ICU) with suspected infection. We developed a risk model predicting growth of high-risk GNRs using multivariable regression analysis in 1 cohort and validated it in a separate cohort. Results In our derivation cohort (556 infectious episodes involving 489 patients), we identified the following independent predictors of high-risk GNR growth: hospitalization >48 hours before suspected infection, hospitalization within the past 4 weeks, recent systemic antibiotics, chronic lung disease, residence in a chronic care facility, and prior high-risk GNR growth. The model sensitivity was 96%, the specificity was 48%, performance using the Brier score was good, and the area under the receiver operator characteristic curve (AUROC) was 0.722, indicating good model performance. In our validation cohort (525 episodes in 447 patients), model performance was similar (AUROC, 0.733), indicating stable model performance. Conclusions Our model predicting high-risk GNR growth in critically ill children demonstrates the high sensitivity needed for ICU antibiotic decisions, good overall predictive capability, and stable performance in 2 separate cohorts. This model could be used to develop risk-based empiric antibiotic guidelines for the pediatric ICU.
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Affiliation(s)
- Todd Karsies
- Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Mark Hall
- Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Leroue MK, Harris JK, Burgess KM, Stevens MJ, Miller JI, Sontag MK, Sierra YL, Wagner BD, Mourani PM. Molecular analysis of endotracheal tube biofilms and tracheal aspirates in the pediatric intensive care unit. ADVANCES IN PEDIATRIC RESEARCH 2017; 4:14. [PMID: 29963643 PMCID: PMC6023549 DOI: 10.12715/apr.2017.4.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a known complication of mechanically ventilated children in the pediatric intensive care unit (PICU). Endotracheal tube (ETT) biofilms are often implicated in the development of VAP by providing a conduit for pathogens to the lower respiratory tract. METHODS A prospective cohort study from April 2010-March 2011 of children 4 weeks to 18 years of age ventilated for greater than 72 hours to determine the microbiota of ETT biofilms and tracheal aspirates. RESULTS Thirty-three patients were included with a mean age of 6.1 years (SD ± 5.1 years) and average length of intubation of 8.8 days (SD ± 5.0 days). Bacterial communities from tracheal aspirates and the proximal and distal ends of ETTs were determined using 16S rRNA gene libraries. Statistical analysis utilized two-part statistics and the Wilcoxon signed rank sum test for comparison of bacterial communities. Sequencing revealed a predominance of oropharyngeal microbiota including Prevotella and Streptococcus spp. Pathogenic bacterial genera including Staphylococcus, Burkholderia, Moraxella, and Haemophilus were also represented. Bacterial load was greatest at the proximal aspect of the ETT. Duration of intubation did not significantly impact bacterial load. Morisita Horn analysis across sites showed similar communities in 24/33 (72%) of patients. CONCLUSIONS ETT biofilms and tracheal aspirates of intubated patients in the PICU primarily consisted of oropharyngeal microbiota, but had a significant representation of potentially pathogenic genera. While the majority of patients had similar microbiota when comparing their ETT biofilms and tracheal aspirates, a subset of patients showed a divergence between communities that requires further investigation.
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Affiliation(s)
- Matthew K. Leroue
- Department of Pediatrics, Section of Emergency Medicine, University
of Colorado School of Medicine, Anschutz Medical Center, and Children’s
Hospital Colorado, Aurora, CO, USA
| | - J. Kirk Harris
- Department of Pediatrics, Section of Pulmonary Medicine, University
of Colorado School of Medicine, Anschutz Medical Center, and Children’s
Hospital Colorado, Aurora, CO, USA
| | - Katherine M. Burgess
- Department of Epidemiology, Colorado School of Public Health,
Anschutz Medical Center, Colorado School of Public Health, Aurora, CO, USA
| | - Mark J. Stevens
- Department of Pediatrics, Section of Pulmonary Medicine, University
of Colorado School of Medicine, Anschutz Medical Center, and Children’s
Hospital Colorado, Aurora, CO, USA
| | - Joshua I. Miller
- Department of Epidemiology, Colorado School of Public Health,
Anschutz Medical Center, Colorado School of Public Health, Aurora, CO, USA
| | - Marci K. Sontag
- Department of Epidemiology, Colorado School of Public Health,
Anschutz Medical Center, Colorado School of Public Health, Aurora, CO, USA
| | | | - Brandie D. Wagner
- Department of Biostatistics and Informatics, Colorado School of
Public Health, Aurora, CO, USA
| | - Peter M. Mourani
- Department of Pediatrics, Section of Critical Care, University of
Colorado School of Medicine, Anschutz Medical Center, and Children’s
Hospital Colorado, Aurora, CO, USA
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Mourani PM, Sontag MK. Ventilator-Associated Pneumonia in Critically Ill Children: A New Paradigm. Pediatr Clin North Am 2017; 64:1039-1056. [PMID: 28941534 DOI: 10.1016/j.pcl.2017.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Ventilator-associated pneumonia (VAP) is a serious complication of critical illness. Surveillance definitions have undergone revisions for more objective and consistent reporting. The 1 organism-1 disease paradigm for microbial involvement may not adequately apply to many cases of VAP, in which pathogens are introduced to a pre-existing and often complex microbial community that facilitates or hinders the potential pathogen, consequently determining whether progression to VAP occurs. As omics technology is applied to VAP, a paradigm is emerging incorporating simultaneous assessments of microbial populations and their activity, as well as the host response, to personalize prevention and treatment.
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Affiliation(s)
- Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Colorado Denver, School of Medicine, Children's Hospital Colorado, 13121 East 17th Avenue, MS8414, Aurora, CO 80045, USA.
| | - Marci K Sontag
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver Anschutz Medical Campus, 13001 East 17th, B119, Aurora, CO 80045, USA
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Renk H, Stoll L, Neunhoeffer F, Hölzl F, Kumpf M, Hofbeck M, Hartl D. Suspicion of respiratory tract infection with multidrug-resistant Enterobacteriaceae: epidemiology and risk factors from a Paediatric Intensive Care Unit. BMC Infect Dis 2017; 17:163. [PMID: 28222699 PMCID: PMC5320655 DOI: 10.1186/s12879-017-2251-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 02/07/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Multidrug-resistant (MDR) infections are a serious concern for children admitted to the Paediatric Intensive Care Unit (PICU). Tracheal colonization with MDR Enterobacteriaceae predisposes to respiratory infection, but underlying risk factors are poorly understood. This study aims to determine the incidence of children with suspected infection during mechanical ventilation and analyses risk factors for the finding of MDR Enterobacteriaceae in tracheal aspirates. METHODS A retrospective single-centre analysis of Enterobacteriaceae isolates from the lower respiratory tract of ventilated PICU patients from 2005 to 2014 was performed. Resistance status was determined and clinical records were reviewed for potential risk factors. A classification and regression tree (CRT) to predict risk factors for infection with MDR Enterobacteriaceae was employed. The model was validated by simple and multivariable logistic regression. RESULTS One hundred sixty-seven Enterobacteriaceae isolates in 123 children were identified. The most frequent isolates were Enterobacter spp., Klebsiella spp. and E.coli. Among these, 116 (69%) isolates were susceptible and 51 (31%) were MDR. In the CRT analysis, antibiotic exposure for ≥ 7 days and presence of gastrointestinal comorbidity were the most relevant predictors for an MDR isolate. Antibiotic exposure for ≥ 7 days was confirmed as a significant risk factor for infection with MDR Enterobacteriaceae by a multivariable logistic regression model. CONCLUSIONS This study shows that critically-ill children with tracheal Enterobacteriaceae infection are at risk of carrying MDR isolates. Prior use of antibiotics for ≥ 7 days significantly increased the risk of finding MDR organisms in ventilated PICU patients with suspected infection. Our results imply that early identification of patients at risk, rapid microbiological diagnostics and tailored antibiotic therapy are essential to improve management of critically ill children infected with Enterobacteriaceae.
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Affiliation(s)
- Hanna Renk
- Dept. of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
| | - Lenja Stoll
- Dept. of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
| | - Felix Neunhoeffer
- Dept. of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
| | - Florian Hölzl
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Elfriede-Aulhorn-Str.6, Tübingen, 72076 Germany
| | - Matthias Kumpf
- Dept. of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
| | - Michael Hofbeck
- Dept. of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
| | - Dominik Hartl
- Dept. of Paediatrics, Pediatric Infectious Diseases, Immunology & Pneumology/Cystic fibrosis, University Children’s Hospital Tübingen, Hoppe-Seyler Str. 1, Tübingen, 72076 Germany
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Nonbronchoscopic Methods [Nonbronchoscopic Bronchoalveolar Lavage (BAL), Mini-BAL, Blinded Bronchial Sampling, Blinded Protected Specimen Brush] to Investigate for Pulmonary Infections, Inflammation, and Cellular and Molecular Markers: A Narrative Review. ACTA ACUST UNITED AC 2017. [DOI: 10.1097/cpm.0000000000000185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
OBJECTIVE Suspected ventilator-associated infection is the most common reason for antibiotics in the PICU. We sought to characterize the clinical variables associated with continuing antibiotics after initial evaluation for suspected ventilator-associated infection and to determine whether clinical variables or antibiotic treatment influenced outcomes. DESIGN Prospective, observational cohort study conducted in 47 PICUs in the United States, Canada, and Australia. Two hundred twenty-nine pediatric patients ventilated more than 48 hours undergoing respiratory secretion cultures were enrolled as "suspected ventilator-associated infection" in a prospective cohort study, those receiving antibiotics of less than or equal to 3 days were categorized as "evaluation only," and greater than 3 days as "treated." Demographics, diagnoses, comorbidities, culture results, and clinical data were compared between evaluation only and treated subjects and between subjects with positive versus negative cultures. SETTING PICUs in 47 hospitals in the United States, Canada, and Australia. SUBJECTS All patients undergoing respiratory secretion cultures during the 6 study periods. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Treated subjects differed from evaluation-only subjects only in frequency of positive cultures (79% vs 36%; p < 0.0001). Subjects with positive cultures were more likely to have chronic lung disease, tracheostomy, and shorter PICU stay, but there were no differences in ventilator days or mortality. Outcomes were similar in subjects with positive or negative cultures irrespective of antibiotic treatment. Immunocompromise and higher Pediatric Logistic Organ Dysfunction scores were the only variables associated with mortality in the overall population, but treated subjects with endotracheal tubes had significantly lower mortality. CONCLUSIONS Positive respiratory cultures were the primary determinant of continued antibiotic treatment in children with suspected ventilator-associated infection. Positive cultures were not associated with worse outcomes irrespective of antibiotic treatment although the lower mortality in treated subjects with endotracheal tubes is notable. The necessity of continuing antibiotics for a positive respiratory culture in suspected ventilator-associated infection requires further study.
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Willson DF, Webster A, Heidemann S, Meert KL. Diagnosis and Treatment of Ventilator-Associated Infection: Review of the Critical Illness Stress-Induced Immune Suppression Prevention Trial Data. Pediatr Crit Care Med 2016; 17:287-93. [PMID: 26890200 PMCID: PMC5116373 DOI: 10.1097/pcc.0000000000000664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The Critical Illness Stress-Induced Immune Suppression prevention trial was a randomized, masked trial of zinc, selenium, glutamine, and metoclopramide compared with whey protein in delaying nosocomial infection in PICU patients. One fourth of study subjects were diagnosed with nosocomial lower respiratory infection, which contributed to subjects receiving antibiotics 74% of all patient days in the PICU. We analyzed diagnostic and treatment variability among the participating institutions and compared outcomes between nosocomial lower respiratory infection subjects (n = 74) and intubated subjects without nosocomial infection (n = 1 55). DESIGN Post hoc analysis. SETTING Eight hospitals in the Collaborative Pediatric Critical Care Research Network. PATIENTS Critical Illness Stress-Induced Immune Suppression study subjects. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Variability across institutions existed in the frequency and manner by which respiratory secretion cultures were obtained, processed, and results reported. Most results were reported semiquantitatively, and both Gram stains and antibiotic sensitivities were frequently omitted. The nosocomial lower respiratory infection diagnosis was associated with increased PICU lengths of stay compared with those who were intubated without nosocomial infection (24 ± 19 vs 9 ± 6 d; p < 0.001) and antibiotic use (38 ± 29 vs 15 ± 20 antibiotics days; p < 0.001). Despite antibiotic treatment, the same bacteria persisted in 45% of follow-up cultures. CONCLUSIONS The Critical Illness Stress-Induced Immune Suppression data demonstrate that the nosocomial lower respiratory infection diagnosis is associated with longer lengths of stay and increased antibiotic use, but there is considerable diagnostic and treatment variability across institutions. More rigorous standards for when and how respiratory cultures are obtained, processed, and reported are necessary. Bacterial persistence also complicates the interpretation of follow-up cultures.
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Affiliation(s)
- Douglas F Willson
- 1Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA. 2University of Utah, Salt Lake City, UT. 3Children's Hospital of Michigan, Detroit, MI
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Ventilator-Associated Respiratory Infections: Choosing Between Scylla and Charybdis. Pediatr Crit Care Med 2016; 17:361-3. [PMID: 27043899 DOI: 10.1097/pcc.0000000000000692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Joseph B Cantey
- Division of Neonatal/Perinatal Medicine, Division of Infectious Diseases, Texas A&M Health Science Center College of Medicine, Baylor Scott & White Health, Temple, TX, USA.
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Comparison of the New Adult Ventilator-Associated Event Criteria to the Centers for Disease Control and Prevention Pediatric Ventilator-Associated Pneumonia Definition (PNU2) in a Population of Pediatric Traumatic Brain Injury Patients. Pediatr Crit Care Med 2016; 17:157-64. [PMID: 26673842 PMCID: PMC4740240 DOI: 10.1097/pcc.0000000000000590] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The new Centers for Disease Control and Prevention paradigm for ventilator-associated events is intended to simplify surveillance of infectious and noninfectious complications of mechanical ventilation in adults. We assessed the ventilator-associated events algorithm in pediatric patients. DESIGN A retrospective observational cohort study. SETTING This single-center study took place in a PICU at an urban academic medical facility. PATIENTS Pediatric (ages 0-18 yr old) trauma patients with moderate-to-severe traumatic brain injury ventilated for greater than or equal to 2 days. MEASUREMENTS AND MAIN RESULTS We assessed for pediatric ventilator-associated pneumonia (as defined by current Centers for Disease Control and Prevention PNU2 guidelines), adult ventilator-associated events, and an experimental ventilator-associated events definition modified for pediatric patients. We compared ventilator-associated events to ventilator-associated pneumonia to calculate the test characteristics. Thirty-nine of 119 patients (33%) developed ventilator-associated pneumonia. Sensitivity of the adult ventilator-associated condition definition was 23% (95% CI, 11-39%), which increased to 56% (95% CI, 40-72%) using the modified pediatric ventilator-associated pneumonia criterion. Specificity reached 100% for both original and modified pediatric probable ventilator-associated pneumonia using ventilator-associated events criteria. Children who developed ventilator-associated pneumonia or ventilator-associated condition had similar baseline characteristics: age, mechanism of injury, injury severity scores, and use of an intracranial pressure monitor. Diagnosis of ventilator-associated pneumonia and ventilator-associated condition portended similarly unfavorable outcomes: longer median duration of ventilation, ICU and hospital length of stay, and more discharges to rehabilitation, home health, or nursing care compared with patients with no pulmonary complication. CONCLUSIONS Both current and modified ventilator-associated events criteria have poor sensitivity but good specificity in identifying pediatric ventilator-associated pneumonia. Despite poor sensitivity, the high specificity of the ventilator-associated events diagnoses does provide a useful and objective metric for interinstitution ICU comparison. Ventilator-associated pneumonia and ventilator-associated condition were both associated with excess morbidity in pediatric traumatic brain injury patients.
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