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Evaluation of healthcare associated infections at pediatric critical care units

Year 2019, , 94 - 103, 28.03.2019
https://doi.org/10.7197/223.vi.542646

Abstract

Objective: Health-care associated infection (HAI)
constitutes a major health care problem resulting in prolonged hospital stay
with increased medical costs. The burden is much greater by accompanying risk
factors among intensive care admissions. The incidence is reported 30% of all
ICU admissions in developed countries; however the estimated rates are clearly
higher in developing countries3.  

In order to prevent HAIs, the health-care
facilities should determine their own risk factors, analyse the microorganisms
isolated from the body fluids and provide the necessary precautions accordingly5.
Despite all the efforts and the advances at preventive protocols, the HAI
burden still exits. 

The pediatric intensive care unit (PICU)
of Sivas Cumhuriyet University Hospital is a tertiary critical care unit
serving to a broad range of population under 18 years with highly advanced
technology within a considerably populated territory. The demographic profiles
of the admissions account a wide range of childhood sicknesses from trauma to
neurological disorders. The aim of this retrospective study was to examine the
microorganism profiles isolated from the body fluids (blood, urine, tracheal
aspirates, wound cultures, spinal fluid) of all PICU admissions during the past
five years. Hence we decided to obtain our local surveillance data, deploy the
necessary precautions to decline HAIs and administer the appropriate
antimicrobial therapy accordingly.

Method: In this
retrospective descriptive study, we searched the medical records of all PICU
admissions between January 2014 and December 2018.  Children with i) PICU admission lasting over
48 hours, ii) culture positiviy at body fluids, iii) presenting clinical signs
of infection were enrolled in the study. Patient demographics, initial complaints,
admission diagnosis, the underlying chronical 
conditions, the source of PICU admission (admission from an indoor
clinic, emergency service or an outdoor clinic) and previous hospitalizations
were all recorded. We recalled HAI subgroups according to the definitions of
centers for disease control and prevention (CDC)6 such as:
ventilator-associated pneumonia (VAP), 
blood stream infection (BSI), central
line-associated bloodstream infections (CLABSIs),
catheter-associated
urinary tract infections (CAUTI) and surgical site infections (SSI).
SPSS-23
(Statistical Package for Social Sciences for Windows 23) was used for statics
of the study. Descriptive analyses were expressed as percentages, mean±standart
deviation (SD), median with minimum and maximum values. Chi square and Fischer
exact test were used for comparison of categorical variables. Normal and
non-normal distributions of continous variables were assessed by Student’s
t-test, Mann Whitney U test and Wilcoxon rank sum test. P-value < 0.05 was
considered significant.

Results: Investigation of
1566 PICU admissions between the periods January 2014 and December 2018,
presented 56 children with 71 culture positivity at body fluids (infection
rate:4.5%). The median age was 15 months (2 months-17 years) and male gender
occupied 58.9% of the study population. We observed respiratory distress and
acute pneumonia as the major complaint and the diagnosis at admission (48.5%
and 35.7% respectively). 76.7% of the children manifested previous
hospitalizations. Forty-three children presented an underlying chronical
condition; mainly involving the central nervous system. The sources of PICU
admission were identified as: first admission from the emergency service
(44.6%), an outdoor clinic (28.6%) and an indoor clinic (pediatric ward)  (26.8%).  

In terms of
culture positivity, we observed PICU-infections as (in decreasing order): VAP (26/71, 36.6%), BSI (18/71,
25.4%), CAUTI (18/71, 25.4%), SSI (7/71, 9.9%) and CLABSIs 
(2/71, 2.8%). Infections with gram-negative bacteria constituted the
major infection group (54/71, 77.1%); Acinetobacter
baumanii
and Klebsiella pneumonia
seemed as the most frequent isolated microorganisms (
25.3% and 14.1%).
Fungi infections incapsulated 12.6% of the infections overall. Amog the thirty
(42.2%) antibiotic resistant-culture positivity, carbapenem resistant and ESBL
positive bacteria occured as the common strains (21.1% and 12.7% respectively).
We observed Carbapenem resistant strains mostly at SSI (5/15, 33.3%), while
ESBL positive strains were developed at BSI and CAUTI.

In terms of
ventilator-associated events, the mean intubation length was 17.5±5.4 days. Pseudomonas aeruginosa ve Acinetobacter baumanii were the most
common bacterias reproduced at tracheal aspirates. For the resistance strains,
Colistin–resistant Acinetobacter baumanii
demonstrated the most prominent resistant strain at a rate of 50%, followed
by Carbapenem-resistant strains (15.4%). Colistin-resistant
strains seemed to have an escalating trend especially in 2018, on the contrary
the frequency of carbapenem-resistant strains have declined over ther years.
Length of PICU
stay and hospitalization were 38.1±27.6 days and 42.2±27.6 days respectively.
Twelve children died of infections (21.4%). Age less than five years and higher
PRISM-3 scores were associated with mortality (p=0.004 and p<0.001). Those
who died had longer intubation, PICU stay and hospitalization periods with
significant nasogastric tube insertion rates (in following order, p=0.007,
p=0.010, p=0.045, p=0.001).



















Conclusions:
Health-care
associated infections remain to be a major problem all around the world. What
we can do to overcome this challenge is, to initiate local
survaillance protocols, educate the health-care stuff on hand
hygiene, enforce appropriate isolation tactics and practice wise antibotic
administration. 

References

  • Sodhi J, Satpathy S, Sharma DK, Lodha R, Kapil A, Wadhwa N et al. Healthcare associated infections in Paediatric Intensive Care Unit ofa tertiary care hospital in India: Hospital stay & extra costs. Indian J Med Res. 2016 Apr;143(4):502-6. doi: 10.4103/0971-5916.184306.
  • Ay P, Teker AS, Hidiroglu S, Tepe P Surmen A , Sili U, Korten V, Karavus M. A qualitative study of hand hygiene compliance among health care workers in intensive care units. J Infect Dev Ctries 2019; 13(2):111-117. doi:10.3855/jidc.10926.
  • World Helth Organization (2017) Health care-associated infections_Fact Sheet. Available: http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_shee t_en.pdf Accessed:06.03.2017
  • Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SAA, Leblebicioglu H, Mehta Y, Rai V, Hung NV, Kanj SS, Salama MF, Salgado-Yepez E, Elahi N, Morfin Otero R, Apisarnthanarak A, De Carvalho BM, Ider BE, Fisher D, Buenaflor M, Petrov MM, Quesada-Mora AM, Zand F, Gurskis V, Anguseva T, Ikram A, Aguilar de Moros D, Duszynska W, Mejia N, Horhat FG, Belskiy V, Mioljevic V, Di Silvestre G, Furova K, Ramos-Ortiz GY, Gamar Elanbya MO, Satari HI, Gupta U, Dendane T, Raka L, Guanche-Garcell H, Hu B, Padgett D, Jayatilleke K, Ben Jaballah N, Apostolopoulou E, Prudencio Leon WE, Sepulveda-Chavez A, Telechea HM, Trotter A, Alvarez-Moreno C, Kushner-Davalos L, Remaining a (2016) International nosocomial infection control consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control 44: 1495-1504.
  • Anıl AB, Anıl M, Özdemir NÖ, Bayram N, Sahbudak Bal Z, Köse E et al. Çocuk Yoğun Bakım Ünitesinde Hastane Enfeksiyonu Risk Faktörleri. J Pediatr Emerg Intens Care Med 2014; 1: 9-16. Doi: 10.5505/cayd.2014.76486.
  • Centers for Disease Control and Prevention. Types of Healthcare-associated Infections. Available at: https://www.cdc.gov/hai/infectiontypes.html
  • Spencer RC. Epidemiology of infection in ICU’s. Intensive Care Med. 1994; 20 (Suppl. 4):2-6.
  • Widmer AF. Infection control and prevention strategies in the ICU. Intensive Care Med. 1994; 20 (Suppl. 4): S7-11.
  • de Oliveira AC, Kovner CT, da Silva RS. Nosocomial infection in an intensive care unit in a Brazilian university hospital. Rev Lat Am Enfermagem. 2010; 18(2): 233-9.
  • Haley RW, Culver DH, Morgan WM, Emori TG, Münn VP, Hooton TP. The efficacy infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121:182-205.
  • Celiloğlu C, Tolunay O, Çelik T et al. Çocuk Yoğun Bakım Ünitesindeki Hastane Enfeksiyonlarının Değerlendirilmesi. J Pediatr Inf 2017; 11(3): 129-134.
  • Kepenekli E, Soysal A, Yalindag-Ozturk N, Ozgur O, Ozcan I, Devrim I, & Turkish PICU-HCAI Study Group. (2015). Healthcare-associated infections in pediatric intensive care units in Turkey: a national point-prevalence survey. Japanese journal of infectious diseases, 68(5), 381-386.
  • Akyıldız B, Mese EA, Altun D, Kondolot M, Tunç A, Poyrazoğlu H, Akçakuş M. Çocuk yoğun bakım ünitesinde yatan olgularımızın üç yıllık gözetim (surveillance) verilerinin değerlendirilmesi. Türk Yoğun Bakım Derneği Dergisi - Journal of the Turkish Society of Intensive Care 2009;7:156-60.
  • Hacımustafaoğlu M, Çelebi S, Tuncer E, Özkaya G, Çakırı D, Bozdemir SE. Çocuk Kliniği ve Çocuk Yoğun Bakım Ünitesi Hastane Enfeksiyonları Sıklığı. Çocuk Enf Derg 2009;3:112-7.
  • Atici S, Soysal A, Kadayifci EK, Karaaslan A, Akkoç G, Yakut N & Öztürk N. (2016). Healthcare-associated infections in a newly opened pediatric intensive care unit in Turkey: Results of four-year surveillance. The Journal of Infection in Developing Countries, 10(03), 254-259.
  • Aktar, F., Tekin, R., Güneş, A., Ülgen, C., Tan, İ., Ertuğrul, S., ... & Yolbaş, I. (2016). Determining the independent risk factors and mortality rate of nosocomial infections in pediatric patients. BioMed research international, 2016.
  • Sevketoglu E. Prognozun belirlenmesi ve skorlama sistemleri. İçinde: Karaböcüoglu M, Köroglu TF (yazarlar). Çocuk Yoğun Bakım: Esaslar ve Uygulamalar. İstanbul: İstanbul Medikal Yayıncılık, 2008:163-70.
  • Gilio AE, Stape A, Pereira CR, Cardoso MF, Silva CV, Troster EJ. Risk factors for nosocomial infections in a critically ill paediatric population: a 25-month prospective cohort study. Infect Control Hosp Epidemiol 2000;21:340-2.
  • Elward AM, Fraser VJ. Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: a 2-year prospective cohort study. Infect Control Hosp Epidemiol 2006;27:553-60.

Çocuk yoğun bakım ünitesinde saptanan hastane enfeksiyonlarının retrospektif olarak değerlendirilmesi

Year 2019, , 94 - 103, 28.03.2019
https://doi.org/10.7197/223.vi.542646

Abstract





Amaç: Hastane enfeksiyonları (HE),
hastalarda hastaneye başvuru anında veya inkübasyon döneminde olmayan,
hastaneye başvurularından 48-72 saat sonra gelişen enfeksiyonlar olarak
tanımlanmaktadır. Bu çalışmada çocuk yoğun bakım ünitemizin HE açısından lokal
sürveyans verilerinin elde edilmesi, HE sıklığının azaltılması ve uygun
tedavinin gecikmeden uygulanabilmesi amaçlanmıştır.



Yöntem: Sivas Cumhuriyet
Üniversitesi Hastanesi Çocuk Yoğun Bakım(ÇYB) servisine Ocak2014-Aralık2018
tarihleri arasında yatan hastaların geriye dönük dosyaları incelendi. HE
tanımlamaları “Centers for Disease Control and Prevention” kriterlerine göre
değerlendirildi.



Bulgular: Çalışma süresince yatmış olan 1566 hastanın (7651 yoğun bakım
yatış günü) toplam 56’sında, 71 HE saptandı (enfeksiyon hızı:%4.5). Ortanca yaş
15 ay (2ay-17yaş), E/K:1.43 olarak gözlendi. Solunum sıkıntısı ve pönomoni en
sık başvuru şikâyetini ve yatış tanısını oluşturdu (%48.5,%35.7). HE yeri olarak,
azalan sıklıkla VİO (26/71, %36.6), KDE (18/71, %25.4), ÜSE (18/71, %25.4), CAE
(7/71, %9.9), SVK-KDE (2/71, %2.8) görüldü. Gram negatif bakteri
enfeksiyonlarının belirgin olduğu çalışmada (54/71, %77.1), Acinetobacter
baumanii ve Klebsiella pneumonia en sık bakteriyel etkenlerdi (%25.3, %14.1).
Çalışmamızda funguslar HE’nin %12.6’sından sorumlu bulundu. Antibiyotik
direncinin 30 kültür üremesinde var olduğu (%42.2), karbapenem direnci (%21.1)
ile ESBL (%12.7) pozitif bakteri oranının en sık iki antibiyotik direncini
oluşturduğu gözlendi. On iki hasta enfeksiyona ikincil sebeplerden eksitus oldu
(HE mortalite oranı: %21.4). Eksitus olan hastaların 5 yaşından küçük, yüksek
PRISM skoruna, uzun entübasyon süresine, sık nazogastrik sonda uygulamasına,
uzun yoğun bakım ve hastane yatış sürelerine sahip oldukları görüldü (sırasıyla
p=0.
004, p<0.001, p=0.007, p=0.001, p=0.010, p=0.045).



Sonuç:
Hastane enfeksiyonları, hastane yatış süresini uzatan, tedavi
maliyetleri ile morbidite ve mortalitesi yüksek olan enfeksiyonlardır. İnvazif
girişimlerin yoğun olduğu, kritik hasta takibinin yapıldığı çocuk yoğun bakım
servislerinde ise, diğer risk faktörlerinin de eklenmesi ile HE riski ve
sıklığı belirgin olarak artar. Bu nedenle yoğun bakım ünitelerinde sürveyans
çalışmaları yapılarak uygun tedavinin başlanması sağlanmalı ve gereksiz invaziv
girişimleri azaltarak hastane enfeksiyonu nedeniyle oluşan morbidite ve
mortalite azaltılmalıdır.

References

  • Sodhi J, Satpathy S, Sharma DK, Lodha R, Kapil A, Wadhwa N et al. Healthcare associated infections in Paediatric Intensive Care Unit ofa tertiary care hospital in India: Hospital stay & extra costs. Indian J Med Res. 2016 Apr;143(4):502-6. doi: 10.4103/0971-5916.184306.
  • Ay P, Teker AS, Hidiroglu S, Tepe P Surmen A , Sili U, Korten V, Karavus M. A qualitative study of hand hygiene compliance among health care workers in intensive care units. J Infect Dev Ctries 2019; 13(2):111-117. doi:10.3855/jidc.10926.
  • World Helth Organization (2017) Health care-associated infections_Fact Sheet. Available: http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_shee t_en.pdf Accessed:06.03.2017
  • Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SAA, Leblebicioglu H, Mehta Y, Rai V, Hung NV, Kanj SS, Salama MF, Salgado-Yepez E, Elahi N, Morfin Otero R, Apisarnthanarak A, De Carvalho BM, Ider BE, Fisher D, Buenaflor M, Petrov MM, Quesada-Mora AM, Zand F, Gurskis V, Anguseva T, Ikram A, Aguilar de Moros D, Duszynska W, Mejia N, Horhat FG, Belskiy V, Mioljevic V, Di Silvestre G, Furova K, Ramos-Ortiz GY, Gamar Elanbya MO, Satari HI, Gupta U, Dendane T, Raka L, Guanche-Garcell H, Hu B, Padgett D, Jayatilleke K, Ben Jaballah N, Apostolopoulou E, Prudencio Leon WE, Sepulveda-Chavez A, Telechea HM, Trotter A, Alvarez-Moreno C, Kushner-Davalos L, Remaining a (2016) International nosocomial infection control consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control 44: 1495-1504.
  • Anıl AB, Anıl M, Özdemir NÖ, Bayram N, Sahbudak Bal Z, Köse E et al. Çocuk Yoğun Bakım Ünitesinde Hastane Enfeksiyonu Risk Faktörleri. J Pediatr Emerg Intens Care Med 2014; 1: 9-16. Doi: 10.5505/cayd.2014.76486.
  • Centers for Disease Control and Prevention. Types of Healthcare-associated Infections. Available at: https://www.cdc.gov/hai/infectiontypes.html
  • Spencer RC. Epidemiology of infection in ICU’s. Intensive Care Med. 1994; 20 (Suppl. 4):2-6.
  • Widmer AF. Infection control and prevention strategies in the ICU. Intensive Care Med. 1994; 20 (Suppl. 4): S7-11.
  • de Oliveira AC, Kovner CT, da Silva RS. Nosocomial infection in an intensive care unit in a Brazilian university hospital. Rev Lat Am Enfermagem. 2010; 18(2): 233-9.
  • Haley RW, Culver DH, Morgan WM, Emori TG, Münn VP, Hooton TP. The efficacy infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985;121:182-205.
  • Celiloğlu C, Tolunay O, Çelik T et al. Çocuk Yoğun Bakım Ünitesindeki Hastane Enfeksiyonlarının Değerlendirilmesi. J Pediatr Inf 2017; 11(3): 129-134.
  • Kepenekli E, Soysal A, Yalindag-Ozturk N, Ozgur O, Ozcan I, Devrim I, & Turkish PICU-HCAI Study Group. (2015). Healthcare-associated infections in pediatric intensive care units in Turkey: a national point-prevalence survey. Japanese journal of infectious diseases, 68(5), 381-386.
  • Akyıldız B, Mese EA, Altun D, Kondolot M, Tunç A, Poyrazoğlu H, Akçakuş M. Çocuk yoğun bakım ünitesinde yatan olgularımızın üç yıllık gözetim (surveillance) verilerinin değerlendirilmesi. Türk Yoğun Bakım Derneği Dergisi - Journal of the Turkish Society of Intensive Care 2009;7:156-60.
  • Hacımustafaoğlu M, Çelebi S, Tuncer E, Özkaya G, Çakırı D, Bozdemir SE. Çocuk Kliniği ve Çocuk Yoğun Bakım Ünitesi Hastane Enfeksiyonları Sıklığı. Çocuk Enf Derg 2009;3:112-7.
  • Atici S, Soysal A, Kadayifci EK, Karaaslan A, Akkoç G, Yakut N & Öztürk N. (2016). Healthcare-associated infections in a newly opened pediatric intensive care unit in Turkey: Results of four-year surveillance. The Journal of Infection in Developing Countries, 10(03), 254-259.
  • Aktar, F., Tekin, R., Güneş, A., Ülgen, C., Tan, İ., Ertuğrul, S., ... & Yolbaş, I. (2016). Determining the independent risk factors and mortality rate of nosocomial infections in pediatric patients. BioMed research international, 2016.
  • Sevketoglu E. Prognozun belirlenmesi ve skorlama sistemleri. İçinde: Karaböcüoglu M, Köroglu TF (yazarlar). Çocuk Yoğun Bakım: Esaslar ve Uygulamalar. İstanbul: İstanbul Medikal Yayıncılık, 2008:163-70.
  • Gilio AE, Stape A, Pereira CR, Cardoso MF, Silva CV, Troster EJ. Risk factors for nosocomial infections in a critically ill paediatric population: a 25-month prospective cohort study. Infect Control Hosp Epidemiol 2000;21:340-2.
  • Elward AM, Fraser VJ. Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: a 2-year prospective cohort study. Infect Control Hosp Epidemiol 2006;27:553-60.
There are 19 citations in total.

Details

Primary Language English
Subjects Health Care Administration
Journal Section Medical Science Research Articles
Authors

Ebru Atike Ongun 0000-0002-1248-8635

Ahu Aksay 0000-0002-8671-3604

Publication Date March 28, 2019
Acceptance Date March 26, 2019
Published in Issue Year 2019

Cite

AMA Ongun EA, Aksay A. Evaluation of healthcare associated infections at pediatric critical care units. CMJ. March 2019;41(1):94-103. doi:10.7197/223.vi.542646