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.
Healthcare-associated infection, pediatric critical care unit, antibiotic resistant strain
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.
Birincil Dil | İngilizce |
---|---|
Konular | Sağlık Bilimleri ve Hizmetleri |
Yayınlanma Tarihi | March 2019 |
Bölüm | Dahili Tıp Bilimleri Araştırma Yazıları |
Yazarlar |
|
Yayımlanma Tarihi | 28 Mart 2019 |
Yayınlandığı Sayı | Yıl 2019, Cilt 41, Sayı 1 |