Risk factors for healthcare-associated infection in a pediatric intensive care unit

Device Exposure and Patient Risk Factors’ Impact on the Healthcare-Associated Infection Rates in PICUs

Healthcare-associated infections related to device use (DA-HAIs) are a serious public health problem since they increase mortality, length of hospital stay and healthcare costs. We performed a multicenter, prospective study analyzing critically ill pediatric patients admitted to 26 Spanish pediatric intensive care units (PICUs) over a 3-month period each year from 2014 to 2019. To make comparisons and evaluate the influence of HAI Zero Bundles (care bundles that intend to reduce the DA-HAI rates to zero) on PICU HAI rates, the analysis was divided into two periods: 2014–2016 and 2017–2019 (once most of the units had incorporated all the Zero Bundles). A total of 11,260 pediatric patients were included. There were 390 episodes of HAIs in 317 patients and the overall rate of HAIs was 6.3 per 1000 patient days. The DA-HAI distribution was: 2.46/1000 CVC days for central-line-associated bloodstream infections (CLABSIs), 5.75/1000 MV days for ventilator-associated pneumonia (VAP) and 3.6/1000 UC days for catheter-associated urinary tract infections (CAUTIs). Comparing the two periods, the HAI rate decreased (p = 0.061) as well as HAI episodes (p = 0.011). The results demonstrate that exposure to devices constitutes an extrinsic risk factor for acquiring HAIs. The multivariate analysis highlights previous bacterial colonization by multidrug-resistant (MDR) bacteria as the most important extrinsic risk factor for HAIs (OR 20.4; 95%CI 14.3–29.1). In conclusion, HAI Zero Bundles have been shown to decrease HAI rates, and the focus should be on the prompt removal of devices, especially in children with important intrinsic risk factors.

Risk factors for healthcare-associated infection among children in a low-and middle-income country

BACKGROUND

Healthcare-associated infections (HAI) are one of significant causes of morbidity and mortality. Evaluating risk factors associated with HAI are important to improve clinical outcomes. We aimed to evaluate the risk factors of HAI in children in a low-to middle-income country.

METHODS

A prospective cohort study was conducted during 43 months at a teaching hospital in Yogyakarta, Indonesia. All consecutive patients admitted to pediatric ICU and pediatric wards > 48 h were eligible. Those eligible patients were observed daily to identify the presence of HAI based on CDC criteria. The risk factors of HAI were identified. Multivariable logistic regression was used to identify independent risk factors.

RESULTS

Total of 2612 patients were recruited. Of 467 were diagnosed as HAI. The cumulative incidence of HAI was 17.9%. In the multivariable analysis; length of stay > 7 days, severe sepsis, use of urine catheter, central venous catheter (CVC), non-standardized antibiotics, and aged < 1 year were independently associated with increased risk of HAI with adjusted OR (95%CI): 5.6 (4.3-7.3), 1.9 (1.3-2.9), 1.9 (1.3-2.6), 1.8 (1.1-2.9), 1.6 (1.2-2.0), and 1.4 (1.1-1.8), respectively.

CONCLUSIONS

This study found that length of stay > 7 days, use of urine catheter and CVC, non-standardized antibiotic use, aged < 1 year, and had a diagnosis of severe sepsis increased risk of HAI.

Actigraphy in mechanically ventilated pediatric ICU patients: comparison to PSG and evaluation of behavioral circadian rhythmicity

Sleep disruption is common in pediatric intensive care unit (PICU) patients, but measuring sleep in this population is challenging. We aimed to evaluate the utility of actigraphy for estimating circadian rhythmicity in mechanically ventilated PICU patients and its accuracy for measuring sleep by comparing it to polysomnogram (PSG). We conducted a single-center prospective observational study of children 6 months - 17 years of age receiving mechanical ventilation and standard, protocolized sedation for acute respiratory failure, excluding children with acute or historical neurologic injury. We enrolled 16 children and monitored them with up to 14 days of actigraphy and 24 hours of simultaneous limited (10 channel) PSG. Daily actigraphy-based activity profiles demonstrated that patients had a high level of nighttime activity (30-41% of total activity), suggesting disrupted circadian activity cycles. Among n = 12 patients with sufficient actigraphy and PSG data overlap, actigraphy-based sleep estimation showed poor agreement with PSG-identified sleep states, with good sensitivity (94%) but poor specificity (28%), low accuracy (70%,) and low agreement (Cohen's kappa = 0.2, 95% CI = 0.08-0.31). Using univariate linear regression, we identified that Cornell Assessment of Pediatric Delirium scores were associated with accuracy of actigraphy but that other clinical factors including sedative medication doses, activity levels, and restraint use were not. In this population, actigraphy did not reliably discern between sleep and wake states. However, in select patients, actigraphy was able to distinguish diurnal variation in activity patterns, and therefore may be useful for evaluating patients' response to circadian-oriented interventions.

Epidemiologic profile of nosocomial infections among paediatric patients in a referral hospital in Hamadan, west of Iran

Healthcare-associated infections (HC-AI) are major health problem with high financial impact. HC-AIs are one of the main causes of morbidity and mortality in paediatric hospitals. This study was performed to determine the epidemiology of HC-AIs in children admitted to medical wards of Besat Hospital in Hamadan, west of Iran. Data on cases of HC-AIs in paediatrics were collected from March 2017 to February 2018 in Besat Hospital. The medical records of eligible cases were extracted from Iranian Nosocomial Infections Surveillance Software. During the study period, a total of 355 HC-AIs in children were detected, 213 (60%) in boys and 214 (60.3%) in the 0-4-year age group. Of these, bloodstream infection was the most frequent infection in both age groups (37.38% in 0-4 years and 34.75% in 5-14 years). Escherichia coli was the common detected microorganism in girls (25.84% in those aged 0-4 years and 24.53% in 5-14 years), whereas Staphylococcus was more prevalent in boys (33.6% in those aged 0-4 years and 29.55% in 5-14 years). HC-AIs were more prevalent in burn, haematology and intensive care unit wards. In Besat Hospital, bloodstream infection and urinary tract infection were the most frequent infections among paediatric patients, and E. coli and Staphylococcus were the commonest detected microorganism in girls and boys respectively. Preventive activities should be targeted to reduce the rate of HC-AIs in wards associated with more contamination.

Sleep Architecture in Mechanically Ventilated Pediatric ICU Patients Receiving Goal-Directed, Dexmedetomidine- and Opioid-based Sedation

This single-center prospective observational study aimed to evaluate sleep architecture in mechanically ventilated pediatric intensive care unit (PICU) patients receiving protocolized light sedation. We enrolled 18 children, 6 months to 17 years of age, receiving mechanical ventilation and standard, protocolized sedation for acute respiratory failure, and monitored them with 24 hours of limited (10 channels) polysomnogram (PSG). The PSG was scored by a sleep technician and reviewed by a pediatric sleep medicine physician. Sixteen children had adequate PSG data for sleep stage scoring. All received continuous opioid infusions, 15 (94%) received dexmedetomidine, and 7 (44%) received intermittent benzodiazepines. Total sleep time was above the age-matched normal reference range (median 867 vs. 641 minutes, p = 0.002), attributable to increased stage N1 and N2 sleep. Diurnal variation was absent, with a median of 47% of sleep occurring during night-time hours. Rapid eye movement (REM) sleep was observed as absent in most patients (n = 12, 75%). Sleep was substantially disrupted, with more awakenings per hour than normal for age (median 2.2 vs. 1.1, p = 0.008), resulting in a median average sleep period duration (sleep before awakening) of only 25 minutes (interquartile range [IQR]: 14–36) versus normal 72 minutes (IQR: 65–86, p = 0.001). Higher ketamine and propofol doses were associated with increased sleep disruption. Children receiving targeted, opioid-, and dexmedetomidine-based sedation to facilitate mechanical ventilation for acute respiratory failure have substantial sleep disruption and abnormal sleep architecture, achieving little to no REM sleep. Dexmedetomidine-based sedation does not ensure quality sleep in this population.

Profile of hospitalizations in Pediatric Intensive Care Units of the Brazilian Unified Health System in the state of Pernambuco, Brazil

In Brazil, the distribution of pediatric intensive care units (PICUs), causes of admission, costs incurred and how care is provided are still poorly understood. The objective was to describe the profile of hospitalizations in the PICUs of the Brazilian Unified Health System in the state of Pernambuco, in 2010. A cross-sectional study was performed, with 1,915 hospitalizations in the six PICUs, collected in the Hospital Information System. The variables were compared by age group. There was a predominance of male hospitalizations (58.1%), an age range of between one and four years old (32.5%), the use of philanthropic units (64.1%) and type III PICUs (59.2%) and admissions due to neoplasms (28.9%). The mean hospital stay was 14.4 days, and the mean cost was BRL 6,674.80. The mean distance between the municipality of residence and the PICU ranged from 8.7 to 486.5 km. There were 207 deaths (10.8/100 admissions), of which 30% were due to infectious and parasitic diseases. Differences were identified between the age groups (p < 0.05), except regarding gender. In conclusion, admissions to PICUs in Pernambuco show differences in geographical access and sociodemographic characteristics, admissions, and causes of hospitalization and death among age groups.

Development and Validation of a Model to Predict Growth of Potentially Antibiotic-Resistant Gram-Negative Bacilli in Critically Ill Children With Suspected Infection

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.

Prevention of healthcare-associated infections in paediatric intensive care unit

INTRODUCTION

Healthcare-associated infections put a tremendous burden on health services around. In the last few decades, there has been a tremendous advancement in foetal and maternal care, and it has led to premature babies born as early as 25 weeks of gestation being nursed and cared for in neonatal and paediatric intensive care units. However, these children can pick up a number of uncommon and rare hospital-acquired infections including central nervous system (CNS) infections.

METHODS

The authors have given their own insight as to the prevention of healthcare-associated infections in paediatric intensive care settings and reviewed the current literature on the topic.

CONCLUSIONS

Healthcare-associated infections are largely preventable provided adequate prevention and protective measures are put in place and prevention guidelines are stritctly followed.

Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies

OBJECTIVE

To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015).

DATA SOURCES

Literature review, research data, and expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

DATA SYNTHESIS

Summary of presentations and discussion supported and supplemented by relevant literature.

CONCLUSIONS

Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.

Suspicion of respiratory tract infection with multidrug-resistant Enterobacteriaceae: epidemiology and risk factors from a Paediatric Intensive Care Unit

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.

Incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit

OBJECTIVES

To determine the incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit.

DESIGN

Prospective cohort study.

SETTING

Pediatric intensive care unit with 16 medical and surgical beds in a tertiary teaching hospital in Recife, northeast Brazil.

PATIENTS

Patients aged <18 yrs were consecutively enrolled between January 2005 and June 2006 into a cohort set to investigate health care-associated infections. Newborns and patients admitted for surveillance and those staying for <24 hrs were excluded. Patients were followed up daily throughout the stay and until 48 hrs after discharge from the unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

This report focuses on health care-associated pneumonia, defined as pneumonia that occurs >48 hrs after admission but that was not incubating at the time of admission, as the primary outcome. Intrinsic and extrinsic variables were prospectively recorded into a standardized form. Statistical analyses, including multivariable logistic regression, were performed in Stata version 9.1. There were 765 eligible admissions. Health care-associated pneumonia occurred in 51 (6.7%) patients with an incidence density of 13.1 episodes/1,000 patient-days. There were 366 (47.8%) patients on mechanical ventilation, of whom 39 (10.7%) presented with ventilator-associated pneumonia with an incidence density of 27.1/1,000 days on ventilation. Longer stay on ventilation (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01-1.08), use of gastric tube (OR, 2.88; 95% CI, 1.41-5.87), and of sedatives/analgesics (OR, 2.45; 95% CI, 1.27-4.72) were identified as independent risk factors for healthcare-associated pneumonia.

CONCLUSION

Identification of independent predictors of health care-associated pneumonia may inform preventive measures. Strategies to optimize use of sedatives/analgesics, reduce the use of gastric tubes, and reduce the time on ventilation should be considered for inclusion in future intervention studies.

Transfusion of leukocyte-depleted red blood cells is not a risk factor for nosocomial infections in critically ill children

OBJECTIVES

Transfusion of red blood cells is increasingly linked with adverse outcomes in critically ill children. We tested the hypothesis that leukocyte-depleted red blood cell transfusions were independently associated with increased development of bloodstream infections, ventilator-associated pneumonias, or urinary tract infections.

DESIGN

Historical, descriptive cohort study.

SETTING

Single-center, mixed medical-surgical, closed nine-bed pediatric intensive care unit of a tertiary university hospital.

PATIENTS

All children <18 yrs of age consecutively admitted to the pediatric intensive care unit during a 3-yr period (January 1, 2005, to December 31, 2007).

INTERVENTIONS

None.

RESULTS

One thousand one hundred twenty-three patients were admitted, of whom 503 (44.8%) were admitted for >48 hrs. Sixty-five (12.9%) had a nosocomial infection (incidence 19.3 per 1,000 pediatric intensive care unit admissions per year). Patients with a nosocomial infection were significantly more often male (72.3% vs. 27.7%, p = .033), had a higher Pediatric Risk of Mortality II score (median 19.1 [range, 6-44] vs. 18.0 [range, 2-39], p = .023), were more often ventilated (95.4% vs. 80.1%, p = .003), and received more often red blood cell transfusions (55.4% vs. 40.2%, p = .021). Multivariate logistic regression analysis showed that male gender (odds ratio, 2.07; 95% confidence interval, 1.14-3.76), presence of an indwelling central venous catheter (odds ratio, 2.41; 95% confidence interval, 1.29-4.48), and simultaneous use of more than one type of antimicrobial drug were independently associated with the development of nosocomial infections. Red blood cell transfusion was discarded as a predictor.

CONCLUSIONS

Transfusion of leukocyte-depleted red blood cells was not independently associated with the development of nosocomial infections in a heterogeneous group of critically ill children.