Cumhuriyet Medical Journal

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.