Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation

The Relationship Between the Type of Microorganisms Isolated in Cultures and Outcomes in Children on Extracorporeal Membrane Oxygenation Support Following Corrective Surgery for Congenital Heart Disease

ObjetivesExtracorporeal membrane oxygenation (ECMO) after surgery for congenital heart disease (CHD) provides hemodynamic support to patients when their myocardial function is temporarily affected. Postoperative infections in children with CHD on ECMO are a significant challenge, as they complicate recovery and affect outcomes during this critical period of hemodynamic support. The objective of this study was to analyze the mortality related to the micro-organism isolated in children with ECMO after surgery for CHD.MethodsRetrospective cohort study from January 2014 to December 2021 at a university hospital in Colombia. The primary outcome was the infection-related inpatient mortality of children undergoing surgery for CHD who received ECMO support, according to the type of microorganisms isolated in cultures.ResultsA total of 3307 surgeries for CHD were performed during the study period. Of these, 108 (3.3%) required veno-arterial ECMO after surgery. We found positive cultures in 35% of these patients. The incidence of infection was 14.5 cases per 1000 days of ECMO. The overall mortality of infected patients was 54.1%. Isolation of Gram-negative bacteria in cultures was associated with higher odds of dying compared with other isolations, regardless of age and type of CHD (aOR 6.92 95% CI 1.91-25.02; p < .01). We found no differences in hospital length of stay or PICU stay based on the type of bacteria isolated. The most commonly isolated Gram-negative bacteria was Klebsiella pneumoniae, which was associated with longer mechanical ventilation [26 (IQR 18.2-31.0) versus 11 (IQR 8.0-15.0) days; p < .01].ConclusionsThe presence of a Gram-negative bacterium as the cause of infection in any sample was associated with increased odds of mortality in children receiving ECMO support in the postoperative period following corrective surgery for congenital heart disease. Infections occurred in 1 out of 3 children on ECMO following surgery for CHD.

Nosocomial infection in paediatric patients undergoing extracorporeal membrane oxygenation: a systematic review and meta-analysis

Nosocomial infection has emerged as a significant complication of extracorporeal membrane oxygenation (ECMO) treatment and is closely associated with poor prognosis. Studies have shown that paediatric patients are more likely to benefit from ECMO. However, nosocomial infection in paediatric patients has not been comprehensively analysed. The aim of this review was to systematically analyse the incidence, timing, locations, primary pathogens, antibiotic use and risk factors associated with nosocomial infection and their effects on mortality among paediatric patients undergoing ECMO. Seven databases were searched for eligible articles; Stata 15.0 was used to calculate the combined effect and 95% confidence interval, and descriptive analysis was employed for other data. A total of 31 articles were included. The incidence of nosocomial infections was 0.19, 95% confidence interval (CI, 0.17-0.22). Respiratory infection was identified as the most common infection type. Staphylococcus species were the predominant pathogens. Antibiotic use was widespread across centres. Prolonged ECMO support was associated with an increased occurrence of nosocomial infections in patients (odds ratio (OR) = 1.09, 95% CI (1.06-1.13)). Nosocomial infection was not associated with an increase in mortality (OR = 1.44, 95% CI (0.98-2.11)). In conclusion, nosocomial infection was common among paediatric ECMO patients and was affected by various factors. However, nosocomial infection did not increase the risk of mortality.

Mortality prediction in pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation: A comparison of scoring systems

Background

Pediatric postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO) patients have high mortality and morbidity. There are currently three scoring systems available to predict mortality: the Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model, Precannulation Pediatric Survival After VA-ECMO (Pedi-SAVE) score, and Postcannulation Pedi-SAVE score. These methods provide risk stratification scores for pediatric patients requiring ECMO for cardiac support. However, comparative validation of these scoring systems remains scarce. We aim to assess the ability of these models to predict outcomes in a cohort of pediatric patients undergoing VA-ECMO after cardiac surgery, and identify predictors of in-hospital mortality.

Methods

A retrospective analysis of 101 children admitted to Fuwai Hospital who received VA-ECMO from January 1, 2010 to December 31, 2020 was performed. Patients were divided into two groups, survivors (n = 49) and non-survivors (n = 52) according to in-hospital mortality. PEP model and Pedi-SAVE scores were calculated. The primary outcomes were the risk factors of in-hospital mortality, and the ability of the PEP model, Precannulation Pedi-SAVE and Postcannulation Pedi-SAVE scores to predict in-hospital mortality.

Results

Postcannulation Pedi-SAVE score accessing the entire ECMO process had the greatest area under receiver operator curve (AUROC), 0.816 [95% confidence interval (CI): 0.733–0.899]. Pre-ECMO PEP model could predict in-hospital mortality [AUROC = 0.691 (95% CI: 0.565–0.817)], and Precannulation Pedi-SAVE score had the poorest prediction [AUROC = 0.582(95% CI: 0.471–0.694)]. Lactate value at ECMO implantation [OR = 1.199 (1.064–1.351), P = 0.003] and infectious complications [OR = 5.169 (1.652–16.172), P = 0.005] were independent risk factors for in-hospital mortality.

Conclusion

Pediatric cardiac ECMO scoring systems, including multiple risk factors before and during ECMO, were found to be useful in this cohort. Both the pre-ECMO PEP model and the Postcannulation Pedi-SAVE score were found to have high predictive value for in-hospital mortality in pediatric postcardiotomy VA-ECMO.

Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship

Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.

Diagnostic Stewardship in the Pediatric Intensive Care Unit

In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?

Neurological Outcome According to the Site of Cannulation in Septic Children Supported by Venoarterial Extracorporeal Membrane Oxygenation

The impact of cervical cannulation on neurologic outcome has not been yet studied among children receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the context of severe sepsis or septic shock. A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. A total of 559 children weighing less than 20 kg with a primary or secondary diagnosis of severe sepsis, septic shock or toxic shock syndrome were included between January 1, 2010, and December 31, 2019. Cervical cannulation was performed in 485 children (87%) and central cannulation in 74 children (13%). The prevalence of acute neurologic event (ANE) was 32%, including clinical and/or electroencephalographic seizures, cerebral infarction, cerebral hemorrhage, and/or brain death. In multivariable analysis, we did not find an association between cervical cannulation and greater/lesser odds of ANE during ECMO (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] 0.72-2.65; P = 0.326). Only pre-ECMO acidosis was independently associated with the development of ANE (pH < 6.99; aOR = 2.71, 95% CI 1.34-5.49; P = 0.006; pH 6.99 to <7.12; aOR = 2.57, 95% CI 1.37-4.82; P = 0.003). Thus, the site of cannulation appears not as a modifiable neurologic risk factor in this young septic population.

Cell Saver Blood Reinfusion Up to 24 Hours Post Collection in Pediatric Cardiac Surgical Patients Does Not Increase Incidence of Hospital-Acquired Infections or Mortality

Cell saver blood reinfusion, a blood conservation technique recently available for pediatric use, is typically limited to 6 hours post processing to guard against bacterial contamination. We hypothesize that reinfusion of cell saver blood up to 24 hours post collection in children after cardiac surgery will not increase the incidence of hospital-acquired infections (HAI). The primary aim is to compare incidence of HAI between children receiving cell saver blood ≤6 hours vs. >6 to ≤24 hours from its collection. The secondary aim is to compare mortality and clinical outcomes. Retrospective chart review of children ≤18 years undergoing cardiac surgery with cardiopulmonary bypass (CPB) from 2013 to 2018 when cell saver collection and bedside temperature controlled storage became standard of care. Patients on extracorporeal membrane oxygenation (ECMO) within 48 hours postoperatively and those who did not receive cell saver were excluded. The primary outcome was HAI incidence postoperative days 0-6. Demographic data included diagnosis, surgical severity score, and clinical outcomes. 466 patients, 45% female. No significant between-group differences identified. There was no significant difference in HAI (control 8.5% vs. treatment 8.0%, p = .80) and death (control 7.9% vs. treatment 4.9%, p = .20). Noninferiority testing indicated the treatment group was not statistically inferior to the control group (p = .0028). Kaplan-Meier curve depicted similar status between-group rates of no infection or death; 92% treatment vs. 91% control. Total volume allogeneic red blood cell transfusion (allogeneic blood transfusion [ABT]) up to 24 hours postoperatively was significantly less in the treatment group, p < .0001. Incidence of HAI or mortality was not increased in patients receiving cell saver blood reinfusion >6 to ≤24 hours post collection. Treatment subjects received significantly less volume of ABT. Considering the risks of ABT, these findings support cell saver blood reinfusion up to 24 hours post collection.