Ventilator-Associated Pneumonia and Events in Pediatric Intensive Care: A Single Center Study

Outcomes associated with ventilator-associated events (VAE), respiratory infections (VARI), pneumonia (VAP) and tracheobronchitis (VAT) in ventilated pediatric ICU patients: A multicentre prospective cohort study

OBJECTIVES

An objective categorization of respiratory infections based on outcomes is an unmet clinical need. Ventilator-associated pneumonia and tracheobronchitis remain used in clinical practice, whereas ventilator-associated events (VAE) are limited to surveillance purposes.

RESEARCH METHODOLOGY/DESIGN

This was a secondary analysis from a multicentre observational prospective cohort study. VAE were defined as a sustained increase in minimum Oxygen inspired fraction (FiO2) and/or Positive end-expiratory pressures (PEEP) of ≥ 0.2/2 cm H2O respectively, or an increase of 0.15 FiO2 + 1 cm H20 positive end-expiratory pressures for ≥ 1 calendar-day.

SETTING

15 Paediatric Intensive Care Units.

MAIN OUTCOME MEASURES

Mechanical ventilation duration, intensive care and hospital length of stay; (LOS) and mortality.

RESULTS

A cohort of 391 ventilated children with an age (median, [Interquartile Ranges]) of 1 year[0.2-5.3] and 7 days[5-10] of mechanical ventilation were included. Intensive care and hospital stays were 11 [7-19] and 21 [14-39] days, respectively. Mortality was 5.9 %. Fifty-eight ventilator-associated respiratory infections were documented among 57 patients: Seventeen (29.3 %) qualified as ventilator-associated pneumonia (VAP) and 41 (70.7 %) as ventilator-associated tracheobronchitis (VAT). Eight pneumonias and 16 tracheobronchitis (47 % vs 39 %,P = 0.571) required positive end-expiratory pressure or oxygen increases consistent with ventilator-associated criteria. Pneumonias did not significantly impact on outcomes when compared to tracheobronchitis. In contrast, infections (pneumonia or tracheobronchitis) following VAEs criteria were associated with > 6, 8 and 15 extra-days of ventilation (16 vs 9.5, P = 0.001), intensive care stay (23.5 vs 15; P = 0.004) and hospital stay (39 vs 24; P = 0.015), respectively.

CONCLUSION

When assessing ventilated children with respiratory infections, VAE apparently is associated with higher ventilator-dependency and LOS compared with pneumonia or tracheobronchitis.

IMPLICATIONS FOR PRACTICE

Incorporating the modification of ventilatory settings for further categorization of the respiratory infections may facilitate therapeutic management among ventilated patients.

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis

CONTEXT

Indwelling invasive devices inserted into the body for extended are associated with infections.

OBJECTIVE

This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) postinsertion infection complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported.

RESULTS

A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58).

CONCLUSIONS

Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

Prevalence of Ventilator-Associated Pneumonia in Children Admitted to Pediatric ‎Intensive Care Units in the Middle East: A Systematic Review

Ventilator-associated pneumonia (VAP) is a common healthcare-associated disease in intensive care units, leading to significant morbidity and mortality. This systematic review aims to investigate the prevalence, risk factors, and prevention strategies for VAP in the Middle East. PubMed, SCOPUS, Web of Science, Science Direct, and Google Scholar were systematically searched to include the relevant literature. Rayyan QCRI was used throughout this systematic approach. Ten studies, involving a total of 6295 patients diagnosed with VAP, were included in this review. Among these patients, 336 (5.3%) developed VAP. The prevalence of VAP in children and neonates in the Middle East was relatively low. Risk factors associated with VAP development included prematurity, low birth weight, prolonged mechanical ventilation, enteral feeding, intrusive devices such as umbilical catheters, and cardiac operations. All reviewed studies emphasized the importance of infection control measures in reducing the risk of VAP.

Clinical Decision Support System to Detect the Occurrence of Ventilator-Associated Pneumonia in Pediatric Intensive Care

OBJECTIVES

Ventilator-associated pneumonia (VAP) is a severe care-related disease. The Centers for Disease Control defined the diagnosis criteria; however, the pediatric criteria are mainly subjective and retrospective. Clinical decision support systems have recently been developed in healthcare to help the physician to be more accurate for the early detection of severe pathology. We aimed at developing a predictive model to provide early diagnosis of VAP at the bedside in a pediatric intensive care unit (PICU).

METHODS

We performed a retrospective single-center study at a tertiary-care pediatric teaching hospital. All patients treated by invasive mechanical ventilation between September 2013 and October 2019 were included. Data were collected in the PICU electronic medical record and high-resolution research database. Development of the clinical decision support was then performed using open-access R software (Version 3.6.1®).

MEASUREMENTS AND MAIN RESULTS

In total, 2077 children were mechanically ventilated. We identified 827 episodes with almost 48 h of mechanical invasive ventilation and 77 patients who suffered from at least one VAP event. We split our database at the patient level in a training set of 461 patients free of VAP and 45 patients with VAP and in a testing set of 199 patients free of VAP and 20 patients with VAP. The Imbalanced Random Forest model was considered as the best fit with an area under the ROC curve from fitting the Imbalanced Random Forest model on the testing set being 0.82 (95% CI: (0.71, 0.93)). An optimal threshold of 0.41 gave a sensitivity of 79.7% and a specificity of 72.7%, with a positive predictive value (PPV) of 9% and a negative predictive value of 99%, and with an accuracy of 79.5% (95% CI: (0.77, 0.82)).

CONCLUSIONS

Using machine learning, we developed a clinical predictive algorithm based on clinical data stored prospectively in a database. The next step will be to implement the algorithm in PICUs to provide early, automatic detection of ventilator-associated pneumonia.

Cost of pediatric laryngotracheal reconstruction: Differences between single-versus double-stage procedures

OBJECTIVE

Examine differences in cost between single stage (ss) versus double stage (ds) laryngotracheal reconstruction (LTR) for pediatric subglottic stenosis.

STUDY DESIGN

Retrospective chart review of children who underwent ssLTR or dsLTR from 2014 to 2018 at a single institution.

METHODS

Costs related to LTR and post-operative care up to one year after tracheostomy decannulation were extrapolated from charges billed to the patient. Charges were obtained from the hospital finance department and the local medical supplies company. Patient demographics including baseline severity of subglottic stenosis and co-morbidities were noted. Variables assessed include duration of hospital admission, number of ancillary procedures, duration of sedation wean, cost of tracheostomy maintenance, and time to tracheostomy decannulation.

RESULTS

Fifteen children underwent LTR for subglottic stenosis. D Ten patients underwent ssLTR, while five underwent dsLTR. Grade 3 subglottic stenosis was more prevalent in patients who underwent dsLTR (100%) than ssLTR (50%). The average per-patient hospital charges for ssLTR was $314,383 versus $183,638 for dsLTR. When estimated mean cost of tracheostomy supplies and nursing care until tracheostomy decannulation was included, the mean total charges associated with dsLTR patients was $269,456. Average hospital stay after initial surgery was 22 days for ssLTR versus 6 days for dsLTR. Average time to tracheostomy decannulation for dsLTR was 297 days. Average number of ancillary procedures needed was 3 versus 8 for ssLTR versus dsLTR.

CONCLUSION

For pediatric patients with subglottic stenosis, dsLTR may have a lower cost than ssLTR. Although ssLTR has the benefit of immediate decannulation, it is associated with higher patient charges, as well as longer initial hospitalization and sedation. For both patient groups, fees associated with nursing care comprised the majority of charges. Recognizing the factors that contribute to cost differences between ssLTR and dsLTR may be useful when performing cost-benefit analyses and assessing value in health care delivery.

Proton Pump Inhibitor Use and Associated Infectious Complications in the PICU: Propensity Score Matching Analysis

OBJECTIVES

We aimed to evaluate the association between proton pump inhibitor (PPI) exposure and nosocomial infection (NI) during PICU stay.

DESIGN

Propensity score matched analysis of a single-center retrospective cohort from January 1, 2017, to December 31, 2018.

SETTING

Tertiary medical and surgical PICU in France.

PATIENTS

Patients younger than 18 years old, admitted to the PICU with a stay greater than 48 hours.

INTERVENTION

Patients were retrospectively allocated into two groups and compared depending on whether they received a PPI or not.

MEASUREMENTS AND MAIN RESULTS

Seven-hundred fifty-four patients were included of which 231 received a PPI (31%). PPIs were mostly used for stress ulcer prophylaxis (174/231; 75%), but upper gastrointestinal bleed risk factors were rarely present (18%). In the unadjusted analyses, the rate of NI was 8% in the PPI exposed group versus 2% in the nonexposed group. After propensity score matching ( n = 184 per group), we failed to identify an association between PPI exposure and greater odds of NI (adjusted odds ratio 2.9 [95% CI, 0.9-9.3]; p = 0.082). However, these data have not excluded the possibility that there is up to nine-fold greater odds of NI.

CONCLUSIONS

This study highlights the prevalent use of PPIs in the PICU, and the potential association between PPIs and nine-fold greater odds of NI is not excluded.

The Impact of Improved Oral Care Methods on the Oral Health of Patients Undergoing Transoral Mechanical Ventilation

Objective

To explore the effects of improved oral care on the number of oropharyngeal bacteria and the incidence of ventilator-associated pneumonia in patients undergoing mechanical ventilation through oral endotracheal intubation by improving conventional oral care methods and operating procedures and to evaluate the quality of improved oral care and effect.

Methods

A total of 100 cases of mechanically ventilated patients with oral endotracheal intubation who met the inclusion criteria were randomly divided into the observation group and control group with 50 cases each. The control group took routine oral care, that is, scrubbing 3 times per day, and the oral care solution was selected as physiological brine. The observation group improved the conventional oral care method, namely, oral scrubbing before intubation, brushing and washing after intubation, 3 times per day, and 0.1% povidone-iodine in oral care solution. Analysis and comparison of the oral bacterial flora, oral cleanliness, and incidence of ventilator-associated pneumonia, mechanical ventilation time, ICU hospitalization time, and mortality rate of the two groups of patients were analyzed and compared. The relevant data were collected and processed for statistical processing.

Results

The oral bacterial flora of the two groups of patients before oral care after mechanical ventilation after oral tracheal intubation was compared, and there was no significant statistical difference (P > 0.05). After nursing, the oral bacterial flora of the observation group at 8 h, 16 h, and 24 h after intubation was significantly lower than that of the control group. Statistics showed that the difference was statistically significant (P < 0.05). After nursing, the number of patients with oral cleanliness in the observation group was significantly higher than that of the control group, while the incidence of ventilator-associated pneumonia in the observation group was 8% significantly lower than that of the control group 14%. Statistics show that this difference is statistically significant (P < 0.05). After nursing, the observation group's oral cleanliness score, mechanical ventilation time, ICU hospitalization time, and GCS score were better than those of the control group. Statistics showed that the difference was statistically significant (P < 0.05). The mortality of the observation group was significantly lower than that of the control group, which was not statistically significant (P > 0.05).

Conclusion

Oral care can effectively reduce the number of oropharyngeal bacteria in patients who are mechanically ventilated through orotracheal intubation and significantly reduce the incidence of ventilator-associated pneumonia.

Ventilator-associated pneumonia is linked to a worse prognosis than community-acquired pneumonia in children

BACKGROUND

Around 12-20% of patients with community-acquired pneumonia (CAP) require critical care. Ventilator-associated pneumonia (VAP) is the second cause of nosocomial infection in Paediatric Intensive Care Units (PICU). As far as we know, there are no studies comparing both types of pneumonia in children, thus it remains unclear if there are differences between them in terms of severity and outcomes.

OBJECTIVE

The aim was to compare clinical and microbiological characteristics and outcomes of patients with severe CAP and VAP.

METHODS

A retrospective descriptive study, including patients diagnosed of VAP and CAP, with a positive respiratory culture and under mechanical ventilation, admitted to the PICU from 2015 to 2019.

RESULTS

238 patients were included; 163 (68.4%) with CAP, and 75 (31.5%) with VAP. Patients with VAP needed longer mechanical ventilation (14 vs. 7 days, p<0.001) and more inotropic support (49.3 vs. 30.7%, p = 0.006). Patients with VAP had higher mortality (12 vs. 2.5%, p = 0.005). Enterobacterales were more involved with VAP than with CAP (48 vs. 9%, p<0.001). Taking into account only the non-drug sensitive microorganisms, patients with VAP tended to have more multidrug-resistant bacteria (30 vs. 10.8%, p = 0.141) than patients with CAP.

CONCLUSION

Patients with VAP had worse prognosis than patients with CAP, needing longer mechanical ventilation, more inotropic support and had higher mortality. Patients with VAP were mainly infected by Enterobacterales and had more multidrug resistant microorganisms than patients with CAP.

RISK score for developing ventilator-associated pneumonia in children: The RISVAP study

OBJECTIVES

Ventilator-associated pneumonia (VAP) is the second most common healthcare-associated infection in children. The aim of this study was to determine the risk factors for VAP in children and to create a risk score for developing VAP (RISVAP score).

STUDY DESIGN

It was a prospective observational study, including children who required mechanical ventilation (MV), registered in the multicentre ENVIN-HELICS database from 2014 to 2019. The regression coefficients of each independent risk factor for VAP were used to create the RISVAP score. Each factor scored 0 if it was absent, or, if it was present, an assigned value from 1 to 7, according to the regression coefficient.

RESULTS

A total of 3798 patients were included, 97(2.5%) developing VAP. The independent risk factors for VAP were: female (odds ratio [OR]: 1.642, p = 0.024), MV > 4 days (OR: 26.79, p < 0.001), length in pediatric intensive care unit > 7 days (OR: 11.74, p < 0.001), and previous colonisation (OR: 4.18, p < 0.001). The RISVAP was calculated for each patient as the sum of all the independent risk factors. Three risk groups were obtained: low (0-5 points), intermediate (6-12 points), and high risk for VAP (13-16 points). The area under the curve for the final score was 0.905 (95%confidence interval: 0.888-0.923, p < 0.001).

CONCLUSIONS

The RISVAP is the first risk score for VAP in pediatric populations. Using this predictive score, might be helpful to detect vulnerable patients and therefore implement preventative strategies.

Ventilator-associated events in children: A multicentre prospective cohort study

BACKGROUND

The Centres for Disease Control and Prevention (CDC) broadened the focus of surveillance from ventilator-associated pneumonia to ventilator-associated event (VAE) for quality purposes. No paediatric definition of VAE (PaedVAE) has been accurately validated. We aimed to analyse the incidence and impact on patient outcomes resulting from the application of the adult and two paediatric VAE (PaedVAE) criteria.

SECONDARY OBJECTIVE

to evaluate VAE/PaedVAE as factors associated with increased duration of mechanical ventilation (MV) and Paediatric Intensive Care Unit (PICU) stay.

METHODS

Multicentre observational prospective cohort study in 15 PICUs in Spain. VAEs were assessed using the 2013/2015 CDC classification. PaedVAE were assessed using the CDC definition based on mean airway pressure (MAP-PaedVAE) versus a paediatric definition based on positive end-expiratory pressure (PEEP-PaedVAE). Children who underwent MV ≥ 48 h were included.

RESULTS

A total of 3626 ventilator-days in 391 patients were analysed. The incidence of VAE, MAP-PaedVAE and PEEP-PaedVAE was 8.55, 5.24 and 20.96 per 1000 ventilator-days, respectively. The median time [IQR] for VAE, MAP-PaedVAE and PEEP-PaedVAE development from the MV onset was 4 [3-12.5], 4 [3-14], and 5 [3-7.75] days, respectively. Among survivors, all three were associated with increased MV duration (> 7 days) and PICU stay (> 10 days) at univariate analysis. Multivariate analysis showed that PEEP-PaedVAE was the only definition independently associated with MV above 7 days [OR = 4.86, 95% CI (2.41-10.11)] and PICU stay [OR = 3.49, 95% CI (1.68-7.80)] above ten days, respectively.

CONCLUSIONS

A VAE definition based on slight PEEP increases should be preferred for VAE surveillance in children.

Evaluation of the applicability of the current CDC pediatric ventilator-associated events (PedVAE) surveillance definition in the neonatal intensive care unit population

Background

There is limited data on pediatric ventilator-associated events (PedVAE) in the neonatal intensive care unit (NICU) setting, since the CDC mandated state reporting of these events in January 2019. This study sought to describe PedVAE rates and characteristics in the NICU population.

Methods

Single-center case-control study of infants requiring mechanical ventilation in a 39-bed level IV NICU between January 1, 2018 and December 31, 2020. Baseline infant demographic, respiratory support and antibiotic use data was obtained and comparisons were performed between patients with potential PedVAEs and those without events.

Result

Two hundred and nine infants were mechanically ventilated. Two of the 126 patients ventilated for ≥4 days met CDC criteria for PedVAEs with a total of 3 events, and 32 (25%) received antibiotics with escalation of respiratory support, primarily for tracheitis.

Conclusion

NICU-specific data on PedVAE is limited. Only 2 infants in the study period met the current CDC criteria for PedVAE with a rate of 0.9 events per 1000 ventilator days. The current CDC PedVAE definition might be inadequate to identify actionable VAEs to inform prevention efforts in the NICU population, and alternate indices could better characterize these events.

Risk Factors and Nursing Countermeasures of Ventilator-Associated Pneumonia in Children in the Intensive Care Unit

Objective

This study discussed and analyzed the risk factors and nursing countermeasures of ventilator-associated pneumonia (VAP) in the children intensive care unit (ICU).

Methods

In this study, 155 children with mechanical ventilation in the pediatric intensive care unit from Oct. 2018 to Oct. 2020 were chosen as research objects. We retrospectively analyzed the clinical data of children and divided them into VAP groups and non-VAP groups according to the occurrence of VAP. Subsequently, we adopted a univariate and multivariate logistic regression model to analyze and clarify the risk factors of VAP and formulated the corresponding nursing countermeasures.

Results

49 cases of total research objects had occurred VAP, with an infection rate of 31.62%. The primary pathogenic bacteria were Gram-negative bacteria (43/70, 61.43%). According to multivariate logistic regression analysis, the duration of mechanical ventilation, invasive procedures, and application of hormones and antacids are all independent risk factors for VAP in pediatric ICU. The VPA group had longer hospital stay than the non-VAP group, and the difference was statistically significant ((20.92 ± 4.16)d, (15.24 ± 3.77)d, t = 8.4383, P ≤ 0.001). The hospitalization cost of the VPA group was substantially higher than that of the non-VAP Group ((45.8 ± 10.4) thousand Yuan, (33.2 ± 4.3) thousand Yuan, t = 10.6822, P ≤ 0.001).

Conclusion

Children admitted to the pediatric ICU have a high VAP incidence. The primary pathogenic bacteria are Gram-negative bacteria. As the occurrence of VAP is closely related to a variety of factors, we should take targeted nursing countermeasures to reduce the duration of mechanical ventilation and the frequency of invasive operations and use the hormone and antacids rationally to reduce the risk of VAP and improve the prognosis.

Association of monocyte HLA-DR expression over time with secondary infection in critically ill children: a prospective observational study

An impaired immune response could play a role in the acquisition of secondary infections in critically ill children. Human leukocyte antigen-DR expression on monocytes (mHLA-DR) has been proposed as marker to detect immunosuppression, but its potential to predict secondary infections in critically ill children is unclear. We aimed to assess the association between mHLA-DR expression at several timepoints and the change of mHLA-DR expression over time with the acquisition of secondary infections in critically ill children. In this prospective observational study, children < 18 years with fever and/or suspected infection (community-acquired or hospital-acquired) were included at a paediatric intensive care unit in the Netherlands. mHLA-DR expression was determined by flow cytometry on day 1, day 2-3 and day 4-7. The association between delta-mHLA-DR expression (difference between last and first measurement) and secondary infection was assessed by multivariable regression analysis, adjusted for age and Paediatric Logistic Organ Dysfunction-2 score. We included 104 patients at the PICU (median age 1.2 years [IQR 0.3-4.2]), of whom 28 patients (27%) developed a secondary infection. Compared to 93 healthy controls, mHLA-DR expression of critically ill children was significantly lower at all timepoints. mHLA-DR expression did not differ at any of the time points between patients with and without secondary infection. In addition, delta-mHLA-DR expression was not associated with secondary infection (aOR 1.00 [95% CI 0.96-1.04]).Conclusions: Our results confirm that infectious critically ill children have significantly lower mHLA-DR expression than controls. mHLA-DR expression was not associated with the acquisition of secondary infections. What is Known: • An impaired immune response, estimated by mHLA-DR expression, could play an essential role in the acquisition of secondary infections in critically ill children. • In critically ill children, large studies on the association of mHLA-DR expression with secondary infections are scarce. What is New: • Our study confirms that critically ill children have lower mHLA-DR expression than healthy controls. • mHLA-DR expression and change in mHLA-DR was not associated with the acquisition of secondary infection.

The Correlation Between Mechanical Ventilation Duration, Pediatric Sequential Organ Failure Assessment Score, and Blood Lactate Level in Children in Pediatric Intensive Care

OBJECTIVE

This study aimed to investigate whether the ventilation duration for children undergoing invasive mechanical ventilation (IMV) in pediatric intensive care unit (PICU) is correlated with pediatric sequential organ failure (pSOFA) score, white blood cell (WBC) count, blood lactate level, and duration of fever.

METHODS

Retrospectively reviewed that the medical records of patients who received IMV in the PICU of Jingzhou Central Hospital between January 2018 and December 2020. According to the duration of IMV in diagnosis-related groups, these patients were divided into two groups: group A, ventilation duration <96 h, and group B, ventilation duration ≥96 h. Each group's pSOFA scores, WBC counts, blood lactate levels, and durations of fever were compared. Logistic regression analysis was used to analyze the clinical risk factors of ventilation duration ≥96 h, and the receiver operator characteristic (ROC) curve was drawn.

RESULTS

A total of 42 patients were included, including 23 in group A and 19 in group B. The difference in pSOFA score between group A and group B was statistically significant (P < 0.05), while the differences in blood lactate level, duration of fever, and WBC count between the two groups were not statistically significant (P > 0.05). Logistic regression analysis was conducted to analyze the influencing factors of mechanical ventilation duration ≥96 h. An ROC curve was drawn with pSOFA score as a test variable and duration of mechanical ventilation ≥96 h as a state variable, revealing that the area under the curve was 0.76 (SE = 0.075, 95% CI: 0.614-0.906, P = 0.005). The sensitivity and specificity were 68.4 and 73.9%, respectively, and the corresponding pSOFA score was 7.5.

CONCLUSION

When the pSOFA score ≥8, the risk of mechanical ventilation duration ≥96 h increases.

Device-related infections in a pediatric intensive care unit: The Jordan University of Science and Technology experience

To estimate the prevalence of the most frequent infections related to device utilization and their antimicrobial sensitivity panel, and to investigate the overall incidence of device associated infection rates per 1000 device days, at the pediatric intensive care unit of the Jordan University of Science and Technology.This is a retrospective study from a single pediatric intensive care unit. Data were collected in relation to bloodstream infections associated with central venous catheters, pneumonia associated with ventilator endotracheal tubes, and urinary tract infections associated with Foley catheters, between January 2013 and December 2018, according to the center of disease control and prevention protocols.During the 5-year study, 3195 patients were admitted to the pediatric intensive care unit for a total of 16,487 days. Forty-six patients (1.4%) developed 55 infections, with a median incidence rate of 7.4, 3.7, and 0.7 per 1000 days for central line associated infections, ventilator associated pneumonia, and catheter associated infections, respectively. The commonest isolated microorganisms were gram-negative bacteria in 89.1% of cases, and fungi in 10.9% of cases. Among the resistant bacterial isolates, 59.2% were multidrug resistant, and 32.6% were extended spectrum beta lactamase producers Klebsiella pneumoniae and Eschericia coli. High infection rates were related to Acinetobacter baumannii and K pneumoniae, associated with high resistance to cephalosporins. Susceptibility was highest to tigecycline and imipenem at 42.9% and 32.7% respectively.Microbial isolates are commonly associated with healthcare device insertions in pediatric intensive care unit, invasive bacterial infections associated with critical morbidity and mortality. Further studies on device associated infections are recommended for regional profiling purposes.

Estimated Pao2: A Continuous and Noninvasive Method to Estimate Pao2 and Oxygenation Index

Supplemental Digital Content is available in the text.

Pao₂ is the gold standard to assess acute hypoxic respiratory failure, but it is only routinely available by intermittent spot checks, precluding any automatic continuous analysis for bedside tools.

A Phase 3, Randomized, Investigator-blinded Trial Comparing Ceftobiprole With a Standard-of-care Cephalosporin, With or Without Vancomycin, for the Treatment of Pneumonia in Pediatric Patients

BACKGROUND

The advanced-generation, broad-spectrum, intravenous (IV) cephalosporin, ceftobiprole, is an effective and well-tolerated treatment for adults with hospital-acquired pneumonia (HAP) or community-acquired pneumonia (CAP), but its effects in pediatric patients have not been established.

METHODS

In this multicenter, investigator-blinded, active-controlled, phase 3 study, patients 3 months to <18 years old with HAP or CAP requiring hospitalization were randomized (2:1) to ceftobiprole versus standard-of-care (SoC) IV cephalosporin treatments (ceftazidime or ceftriaxone), with or without vancomycin. After at least 3 days' IV treatment, patients demonstrating clinical improvement could be switched to an oral antibiotic, to complete a minimum of 7 days' treatment.

RESULTS

Overall, 138 patients were randomized to ceftobiprole (n = 94) or a SoC cephalosporin (n = 44). Median time to oral switch was 6.0 days in the ceftobiprole group and 8.0 days in the SoC cephalosporin group. While on IV therapy, adverse events and treatment-related adverse events were reported by 20.2% and 8.5% of ceftobiprole-treated patients and 18.2% and 0% of SoC cephalosporin-treated patients. Early clinical response rates at day 4 in the intention-to-treat population were 95.7% and 93.2% (between-group difference, 2.6%; 95% confidence interval, -5.5% to 14.7%) in the ceftobiprole and comparator groups, and clinical cure rates at the test-of-cure visit were 90.4% and 97.7% (between-group difference, -7.3%; 95% confidence interval, -15.7% to 3.6%), respectively.

CONCLUSIONS

Ceftobiprole was well tolerated and, in this small phase 3 study, demonstrated similar efficacy to SoC cephalosporins in pediatric patients with HAP or CAP requiring hospitalization.

Frequency of ventilator circuit changes to prevent ventilator-associated pneumonia in neonates and children-A systematic review and meta-analysis

OBJECTIVE

To assess the effect of different frequencies of ventilator circuit changes in neonates and children through a systematic review and meta-analysis.

INTERVENTIONS

(1) "No routine change of ventilator circuit (unless visibly soiled)" versus "routine change at any fixed interval"; (2) routine change of circuit at "less frequent" versus "more frequent" intervals.

OUTCOMES

Primary outcomes were VAP rate (number of VAP episodes per 1000 ventilator-days) and all-cause mortality before discharge.

METHODS

MEDLINE, CENTRAL, EMBASE, and CINAHL were systematically searched from inception till November 3, 2020. Two authors assessed trial eligibility and risk of bias, and independently extracted data. Data were synthesized using fixed effects model. GRADE was used to assess certainty of evidence (CoE).

RESULTS

We identified six studies enrolling 768 participants evaluating circuit changes at two fixed intervals. Meta-analysis of studies on circuit changes "once in less than 7 days" versus "once weekly" showed no difference in VAP rate (risk ratio: 0.83 [0.38-1.81]; one randomized controlled trial (RCT) and 0.94 [0.49-1.81]; two before-after studies) or mortality before discharge (0.67 [0.34-1.3]; one RCT and 1.01 [0.63-1.64]; two before-after studies). CoE was very low. Less frequent circuit changes reduced health-care costs. No study evaluating "circuit changes only when visibly soiled" versus "circuit changes at a fixed interval" was identified.

CONCLUSION

There is no evidence to suggest that ventilator circuits can be safely left unchanged until visibly soiled in neonates and children. Extending circuit changes interval to "once weekly" may not increase VAP rate (CoE-very low) and reduces healthcare costs.

Trauma patients in the pediatric ICU: rational use of a limited resource

PURPOSE OF REVIEW

Traumatic injuries are a leading cause of pediatric mortality; pediatric ICUs (PICUs) are an important but potentially limited resource associated with high costs. In an era of rising healthcare costs, appropriate resource utilization is important. Here, we examine evidence-based guidelines supporting the management of pediatric traumatic injury outside of the PICU.

RECENT FINDINGS

Historical management of solid organ injury and traumatic brain injury was focused on operative management. However, over the past four decades, management of solid organ injury has shifted from invasive management to nonsurgical management with a growing body of evidence supporting the safety and efficacy of this trend. The management of traumatic brain injury (TBI) has had a similar evolution to that of solid organ injury with regard to nonoperative management and management outside the critical care setting.

SUMMARY

The use of evidence-based guidelines to support expectant management in the setting of pediatric trauma has the potential to reduce unnecessary resource utilization of the PICU. In this review, we present findings that support nonoperative management and management of pediatric trauma outside of the PICU setting. In resource-poor areas, this approach may facilitate care for pediatric trauma patients. The implications are also important in resource-rich settings because of the unintended risks associated with PICU.

Impacts of Multidrug-Resistant Pathogens and Inappropriate Initial Antibiotic Therapy on the Outcomes of Neonates with Ventilator-Associated Pneumonia

It is unknown whether neonatal ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) pathogens and inappropriate initial antibiotic treatment is associated with poor outcomes after adjusting for confounders. Methods: We prospectively observed all neonates with a definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and March 2020. All clinical features, therapeutic interventions, and outcomes were compared between the MDR–VAP and non-MDR–VAP groups. Multivariate regression analyses were used to investigate independent risk factors for treatment failure. Results: Of 720 neonates who were intubated for more than 2 days, 184 had a total of 245 VAP episodes. The incidence rate of neonatal VAP was 10.1 episodes/per 1000 ventilator days. Ninety-six cases (39.2%) were caused by MDR pathogens. Neonates with MDR–VAP were more likely to receive inadequate initial antibiotic therapy (51.0% versus 4.7%; p < 0.001) and had delayed resolution of clinical symptoms (38.5% versus 25.5%; p = 0.034), although final treatment outcomes were comparable with the non-MDR–VAP group. Inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. The VAP-attributable mortality rate and overall mortality rate of this cohort were 3.7% and 12.0%, respectively. Independent risk factors for treatment failure included presence of concurrent bacteremia (OR 4.83; 95% CI 2.03–11.51; p < 0.001), septic shock (OR 3.06; 95% CI 1.07–8.72; p = 0.037), neonates on high-frequency oscillatory ventilator (OR 4.10; 95% CI 1.70–9.88; p = 0.002), and underlying neurological sequelae (OR 3.35; 95% CI 1.47–7.67; p = 0.004). Conclusions: MDR–VAP accounted for 39.2% of all neonatal VAP in the neonatal intensive care unit (NICU), but neither inappropriate initial antibiotics nor MDR pathogens were associated with treatment failure. Neonatal VAP with concurrent bacteremia, septic shock, and underlying neurological sequelae were independently associated with final worse outcomes.

Machine Learning Predicts Prolonged Acute Hypoxemic Respiratory Failure in Pediatric Severe Influenza

Supplemental Digital Content is available in the text.

Influenza virus is a major cause of acute hypoxemic respiratory failure. Early identification of patients who will suffer severe complications can help stratify patients for clinical trials and plan for resource use in case of pandemic.

Application of the New Centers for Disease Control and Prevention Surveillance Criteria for Ventilator-Associated Events to a Cohort of PICU Patients Identifies Different Patients Compared With the Previous Definition and Physician Diagnosis

OBJECTIVES

We sought to compare the performance of the 2008 Centers for Disease Control and Prevention Pediatric criteria for ventilator-associated pneumonia, the 2013 Adult Ventilator-Associated Condition criteria, the new Draft Pediatric Ventilator-Associated Condition criteria, and physician-diagnosed ventilator-associated pneumonia in a cohort of PICU patients.

DESIGN

Secondary analysis of a previously conducted prospective observational study.

SETTING

PICU within a tertiary care children's hospital between April 1, 2010, and April 1, 2011.

PATIENTS

Patients between 31 days and 18 years old, mechanically ventilated via endotracheal tube for more than 72 hours and no limitations of care.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Ventilator-associated pneumonia criteria applied in real time and ventilator-associated condition criteria applied retrospectively. Outcomes assessed between cases and noncases within criteria. Of the 133 eligible participants, 24 (18%) had ventilator-associated pneumonia by 2008 Pediatric criteria and 27 (20%) by physician diagnosis. Sixteen (12%) and 10 (8%) had ventilator-associated condition by 2013 Adult and Draft Pediatric criteria, respectively. We found significant overlap between cases identified with 2008 Pediatric criteria and physician diagnosis (p = 0.549), but comparisons between the other definitions revealed that the newer criteria identify different patients than previous Centers for Disease Control and Prevention ventilator-associated pneumonia criteria and physician diagnosis (p < 0.01). Although 20 participants were diagnosed with ventilator-associated pneumonia by 2008 Pediatric criteria and physician diagnosis, only three participants were identified by all four criteria. Three subjects uniquely identified by the Draft Pediatric criteria were noninfectious in etiology. Cases identified by all criteria except Draft Pediatric had higher ratios of actual ICU length of stay to Pediatric Risk of Mortality III-adjusted expected length of stay compared with noncases.

CONCLUSIONS

The Draft Pediatric criteria identify fewer and different patients than previous ventilator-associated pneumonia criteria or physician diagnosis, potentially missing patients with preventable harms, but also identified patients with potentially preventable noninfectious respiratory deteriorations. Further investigations are required to maximize the identification of patients with preventable harms from mechanical ventilation.