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Evaluation of healthcare associated infections at pediatric critical care units

Yıl 2019, Cilt 41, Sayı 1, 94 - 103, 28.03.2019
https://doi.org/10.7197/223.vi.542646

Öz

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. 

Kaynakça

  • 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

Yıl 2019, Cilt 41, Sayı 1, 94 - 103, 28.03.2019
https://doi.org/10.7197/223.vi.542646

Öz

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.

Kaynakça

  • 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.

Ayrıntılar

Birincil Dil İngilizce
Konular Sağlık Bilimleri ve Hizmetleri
Yayınlanma Tarihi March 2019
Bölüm Dahili Tıp Bilimleri Araştırma Yazıları
Yazarlar

Ebru Atike Ongun (Sorumlu Yazar)
Sivas Cumhuriyet University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Critical Care
0000-0002-1248-8635
Türkiye


Ahu Aksay
Sivas Cumhuriyet University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases
0000-0002-8671-3604
Türkiye

Yayımlanma Tarihi 28 Mart 2019
Yayınlandığı Sayı Yıl 2019, Cilt 41, Sayı 1

Kaynak Göster

APA Ongun, E. A. & Aksay, A. (2019). Evaluation of healthcare associated infections at pediatric critical care units . Cumhuriyet Medical Journal , 41 (1) , 94-103 . DOI: 10.7197/223.vi.542646