Trends in nosocomial infections and multidrug-resistant microorganisms in Spanish pediatric intensive care units

High rates of nosocomial infections and antimicrobial resistance in a Moroccan pediatric intensive care unit: A cause for alarm

Objectives

This study aimed to determine the epidemiology of nosocomial infections (NIs) in a pediatric intensive care unit and define the risk factors associated with NIs.

Methods

We performed a prospective descriptive and analytical monocentric study on the incidence of NIs in the pediatric intensive care unit between July 2021 and May 2022. Children with NIs (cases) were compared with matched controls without NIs.

Results

We analyzed 396 patients; 102 had NIs. The global incidence of NIs is 44.7% (incidence density of 10.6 per 1000 days of hospitalization). The incidence densities of blood stream infection, pneumonia associated with mechanical ventilation, and urinary tract infection were 10 per 1000 days of central venous catheter use, 7.2 per 1000 of mechanical ventilation use, and 11.1 per 1000 days urinary catheter use. The overall microbiological profile of NIs is dominated by gram-negative bacilli in 78%, followed by gram-positive cocci in 13%. The most common agents in sepsis were Klebsiella pneumoniae. In pneumonias, Acinetobacter Baumanii was the most common cause, and, in urinary tract infection, the most frequent agents were gram-negative bacteria, especially Escherichia coli (33.3%). The presence of NIs was associated with a long period of hospitalization, use of invasive devices (central venous catheter, mechanical ventilation, and bladder catheters), and use of antibiotics.

Conclusions

The incidence of NIs acquired in this unit was high and was associated with extrinsic and intrinsic factors.

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.

Antimicrobial Stewardship Improvement in Pediatric Intensive Care Units in Spain-What Have We Learned?

Antibiotic misuse in pediatric intensive care units (PICUs) can lead to increased antimicrobial resistance, antibiotic-triggered side effects, hospital costs, and mortality. We performed a multicenter, prospective study, analyzing critically ill pediatric patients (≥1 month to ≤18 years) admitted to 26 Spanish PICUs over a 3-month period each year (1 April−30 June) from 2014−2019. To make comparisons and evaluate the influence of AMS programs on antibiotic use in PICUs, the analysis was divided into two periods: 2014−2016 and 2017−2019 (once 84% of the units had incorporated an AMS program). A total of 11,260 pediatric patients were included. Total antibiotic prescriptions numbered 15,448 and, overall, 8354 patients (74.2%) received at least one antibiotic. Comparing the two periods, an increase was detected in the number of days without antibiotics in patients who received them divided by the number of days in PICUs, for community-acquired infections (p < 0.001) and healthcare-associated infections (HAIs) acquired in PICUs (p < 0.001). Antibiotics were empirical in 7720 infections (85.6%), with an increase in appropriate antibiotic indications during the second period (p < 0.001). The main indication for antibiotic adjustment was de-escalation, increasing in the second period (p = 0.045). Despite the high rate of antibiotic use in PICUs, our results showed a significant increase in appropriate antibiotic use and adjustment following the implementation of AMS programs.

Impact of duration of antibiotic therapy in central venous catheter-related bloodstream infection due to Gram-negative bacilli

BACKGROUND

A progressive increase in the incidence of catheter-related bloodstream infection (CRBSI) due to Gram-negative bacilli (GNB) has been reported. Current guidelines recommend antibiotic treatment for at least 7-14 days, although the supporting evidence is limited.

METHODS

We performed a retrospective single-centre study including all patients with a definite diagnosis of GNB CRBSI from January 2012 to October 2018 in which the central venous catheter (CVC) was removed. The occurrence of therapeutic failure [clinical failure (persistence of symptoms and laboratory signs of infection), microbiological failure (persistent bacteraemia or relapse) and/or all-cause 30 day mortality] was compared between episodes receiving short [≤7 days (SC)] or long courses [>7 days (LC)] of appropriate antibiotic therapy following CVC removal.

RESULTS

We included 54 GNB CRBSI episodes with an overall rate of therapeutic failure of 27.8% (15/54). Episodes receiving SC therapy were more frequently due to MDR GNB [60.9% (14/23) versus 34.5% (10/29); P = 0.058] and had higher Pitt scores [median (IQR) 1 (0-4) versus 0 (0-2); P = 0.086]. There were no significant differences in the rate of therapeutic failure between episodes treated with SC or LC therapy [30.4% (7/23) versus 27.6% (8/29); OR 1.15; 95% CI 0.34-3.83; P = 0.822]. The use of SCs was not associated with increased odds of therapeutic failure in any of the exploratory models performed.

CONCLUSIONS

The administration of appropriate antibiotic therapy for ≤7 days may be as safe and effective as longer courses in episodes of GNB CRBSI once the CVC has been removed.

Device-associated multidrug-resistant bacteria surveillance in critically ill children: 10 years of experience

AIM

Multidrug-resistant bacterial infections are a public health problem worldwide. However, most of the information available refers to adults. The main objectives were to determine the incidence, risk factors, and outcomes for device-associated infections, especially those involving multidrug-resistant bacteria.

METHODS

This is a prospective, observational study. Children aged ≥1 month and <18 years admitted to the paediatric intensive care unit from 2008 to 2017, with a device-associated infection microbiologically confirmed were included. Patients infected with resistant bacteria were compared with those who had a drug-susceptible infection.

RESULTS

The study included 213 patients. Out of all the device-associated infections, 22% (48 patients) were caused by multidrug-resistant bacteria. The most frequent were extended-spectrum beta-lactamase (ESBL)-producing enterobacteria. Cardiovascular diseases, age under 1year, comorbidity, prolonged use of invasive device, and length of stay until infection were risk factors for resistant bacteria, but not specifically for ESBL-producing bacteria. Length of stay and mortality was increased in patients with multidrug-resistant bacteria.

CONCLUSION

Being under 1-year-old and having a cardiovascular disease were the two major risk factors for resistant bacterial infection. ESBL-producing bacteria were the most frequent multidrug-resistant agents. However, patients with ESBL-producing bacteria did not have any additional risk factors, so they may have been colonised in the community.

Prevalence and Anti-Microbial Susceptibility of Hospital Acquired Infections in Two Pediatric Intensive Care Units in Egypt

BACKGROUND

Hospital-acquired (nosocomial) infection is a common serious health problem worldwide, especially in pediatric intensive care units and is associated with high mortality and morbidity, prolonged hospital stays and high cost.

AIM

To determine the types of organisms involved in hospital-acquired an infection in two pediatric intensive care units during the one-year study and its anti-microbial susceptibility.

MATERIAL AND METHODS

This study was carried out in the pediatric intensive care units (PICU) of Ain Shams & Cairo Universities, where 86 pediatric patients were recruited. Their age ranged from 1 month to 156 months with mean 20.7 ± 25.8 months. Male to female ratio was 37:29. Four samples were collected from each child for culture and sensitivity: blood, endotracheal aspirate, urine and skin swab.

RESULTS

The most common microorganism was staphylococcus while Gram-negative bacteria were the commonest group. Amikacin and imipenem are the most sensitive antibiotics. Risk estimate for different risk factors among studied patients revealed no significance.

CONCLUSION

Staphylococcus was the commonest micro-organism while Gram-negative infections were the commonest group among PICU with a predominance of Acinetobacter and Klebsiella. Respiratory infections were the most common, followed by blood-borne infection. Risk factors for mortality were not significant.

Incidence of Multidrug-Resistant Organism Among Children Admitted to Pediatric Intensive Care Unit in a Developing Country

AIM

Multidrug-resistant infections are an increasingly common condition particularly in critical care units. This study aimed to determine the incidence and types of resistant bacteria acquired in a pediatric intensive care unit (PICU) of a university hospital.

SUBJECT AND METHODS

A prospective study was conducted during the year 2016. All children aged below 16 years were studied for infection development and pattern of susceptibility to various groups of antibiotics.

RESULTS

A total of 264 patients were admitted to the PICU: 16 patients had community-acquired infection (CAI), 23 had hospital-acquired infection, and 24 patients had PICU-acquired infection (with 36 episodes) which is equivalent to 14.75 case/1,000 patient days. The study revealed high incidence of resistant organisms in the PICU but more important is the appearance of multi- and extreme drug-resistant bacteria in CAI. The study revealed that gram-negative bacteria were more prevalent in PICU, especially Klebsiella (30.5%), Acinetobacter baumanii (22.22%), and Pseudomonas (16.67%). Infection with resistant organisms in the PICU caused initial treatment failure and increased fourfold risk of mortality.

CONCLUSION

The incidence of resistant bacteria especially gram-negative pathogens was very high in the PICU. The top three resistant organisms of concern were Klebsiella, Acinetobacter, and Pseudomonas. This is a global concern that necessitates new strategies.

[Yeasts from the CTG clade (Candida clade): Biology, impact in human health, and biotechnological applications]

Among the subdivision of Saccharomycotina (ascomycetes budding yeasts), the CTG clade (formerly the Candida clade) includes species that display a particular genetic code. In these yeasts, the CTG codon is predominantly translated as a serine instead of a leucine residue. It is now well-known that some CTG clade species have a major impact on human and its activities. Some of them are recognized as opportunistic agents of fungal infections termed candidiasis. In addition, another series of species belonging to the CTG clade draws the attention of some research groups because they exhibit a strong potential in various areas of biotechnology such as biological control, bioremediation, but also in the production of valuable biocompounds (biofuel, vitamins, sweeteners, industrial enzymes). Here we provide an overview of recent advances concerning the biology, clinical relevance, and currently tested biotechnological applications of species of the CTG clade. Future directions for scientific research on these particular yeasts are also discussed.