Healthcare-associated infections in pediatric cancer patients: results of a prospective surveillance study from university hospitals in Germany and Switzerland

Central-line–associated bloodstream infections in a pediatric oncology and hematology hospital at home program

Objective:

Central-line–associated bloodstream infections (CLABSIs) are associated with significant morbidity among pediatric oncology-hematology patients, and risk factors remain largely unknown in the setting of hospital at home (HAH). Children in HAH receive intensive treatment (eg, chemotherapy and parenteral nutrition), with frequent central-line handling; thus, they may be at higher risk for CLABSI.

Methods:

We conducted a monocentric retrospective study of patients with a central line included in our HAH program from January 1 to December 31, 2016. HAH patient characteristics for children developing CLABSIs were compared to those who did not, based on blood cultures positive for infection and clinical data of all patients included.

Results:

Overall, 492 HAH stays were analyzed, with 144 patients. The overall CLABSI rate in these patients was 2.6 per 1,000 central-line days. Children who developed CLABSIs were younger (median age, 2.5 vs 8.8 years; P < .001), suffered more from hematological pathologies (malignant or nonmalignant, 75% vs 52%; P = .02), and had more frequently undergone hematopoietic stem-cell transplantation (30.8% vs 6.5%; P = .01). In addition, these patients often had a tunneled externalized catheter as the central line and were more frequently given parenteral nutrition at home (46% vs 8%; P < .001).

Conclusions:

CLABSI rates for children in HAH were more similar to those of inpatients than to rates previously reported for ambulatory patients. The factors associated with infection identified herein should be further validated in multicentric studies and considered to improve HAH practices, parallel to prevention measures used in the inpatient setting.

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?

OUP accepted manuscript

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.

Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach

OBJECTIVES

Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients.

DESIGN

A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time.

SETTING

Experts' institutions; in-person discussion in Baltimore, MD.

SUBJECTS

Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations.

CONCLUSIONS

Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.

Prevalence surveillance of healthcare-associated infections at a Tunisianonco-hematology ward

Background : Healthcare-associated infections (HAIs) are with high rates of mortality and an additional cost, in onco-hematology patients.

Aim : The study aims to assess the prevalence trends of HAIs in the onco-hematology ward of the Tunisian National Bone Marrow Transplant Center (NBMTC), and to determine the principal associated risk factors.

Methods: Six repeated point prevalence surveys were conducted, from May 2018 to March 2019, using a two months interval. All patients hospitalized in the day of the survey were included. Risk factors of HAIs were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). They were assessed using a logistic regression model.

Results: Nineteen patients out of a total of 74 patients have been diagnosed with 19 HAIs, representing a prevalence of 25.7%. No significant downward or upward trend of prevalence was revealed over time (p=0.3). The most common HAI was respiratory tract infection (57.9%) with a prevalence of 14.9%. Multiple logistic regression analysis revealed that HAI was significantly associated with neutropenia (Adjusted OR: 14; 95% CI: 1.5-127; p=0.01) and duration of central venous catheter (Adjusted OR: 1.1; 95% CI: 1-1.2; p=0.005).

Conclusion: High prevalence of HAIs in our center with a high rate of mortality, requiring identifying potential problems in infection control practices.

The burden of healthcare-associated infections among pediatrics: a repeated point prevalence survey from Pakistan

BACKGROUND

Healthcare-associated infections (HAIs) are considered a major threat to public health resulting in significant morbidity, mortality, and additional costs. The present study aimed to assess the current patterns and risk factors of HAIs among hospitalized children.

MATERIALS AND METHODS

Three repeated point prevalence surveys were conducted in the pediatric inpatients of four hospitals by using the methodology developed by the European Center for Disease Prevention and Control. All patients present in the ward at 8:00 AM on the survey day and not discharged from the hospital on the same day were included. A standardized data collection form containing information on the presence of HAIs and the associated risk factors was completed for the patients.

FINDINGS

Out of 888 hospitalized patients, 116 (13.1%) had the symptoms of HAIs. Most common infections were bloodstream infections (BSIs) (32.8%), pneumonia (21.0%), ear, eyes, nose and throat infections (11.8%), and skin and soft tissue infections (SSTs) (19.0%). Factors significantly associated with infections were the length of hospital stay (p = 0.000), admission to the medicine ward (p = 0.034), and male gender (p = 0.010). BSIs were most common in children belonging to the age group of less than one month (78.9%), who were admitted to intensive care units (73.7%). SSTs including surgical site infections were more prevalent in surgery wards (78.3%).

CONCLUSIONS

A high rate of HAIs among pediatrics was found in Pakistan. Infection control and prevention strategies are needed with a major focus on interventions to prevent the spread of most prevalent HAIs.

Impact of a Best Practice Prevention Bundle on Central Line-associated Bloodstream Infection (CLABSI) Rates and Outcomes in Pediatric Hematology, Oncology, and Hematopoietic Cell Transplantation Patients in Inpatient and Ambulatory Settings

BACKGROUND

Pediatric hematology, oncology, and hematopoietic cell transplantation (HCT) patients are at increased risk for bloodstream infections. The authors sought to evaluate the influence of a standardized best practice central venous catheter (CVC) maintenance bundle on the burden of and risk factors for mucosal barrier injury (MBI) and non-MBI central line-associated bloodstream infections (CLABSIs) across a common inpatient and ambulatory continuum in this high-risk population.

METHODS

A retrospective cohort study of patients with underlying malignancy, hematologic disorders, and HCT recipients with a CVC in place at the time of CLABSI diagnosis in both inpatient and ambulatory settings from January 1, 2012 to December 31, 2016. Descriptive, nonparametric statistics were used to describe patient characteristics and outcomes. Logistic regression analyses were applied to identify potential risk factors for inpatient versus ambulatory and MBI versus non-MBI CLABSI.

RESULTS

During the 5-year period, 118 of 808 (14.6%) patients had 159 laboratory-confirmed CLABSIs for ambulatory and inpatient CLABSI rates of 0.27 CLABSI/1000 and 2.2 CLABSI/1000 CVC days, respectively. CLABSI occurred more frequently in hospitalized patients after HCT and with underlying leukemia, most frequently caused by Gram-negative bacteria. MBI CLABSI accounted for 42% of all CLABSI with a 3-fold higher risk in hospitalized patients. Having multiple CVC or a CVC that was not a port independently associated with higher CLABSI risk.

CONCLUSIONS

In our cohort, non-MBI CLABSI continued to account for the majority of CLABSI. CVC type is independently associated with higher overall CLABSI risk. Further studies are needed to reliably define additional prevention strategies when CLABSI maintenance bundles elements are optimized in this high-risk population.

Oncology during the COVID-19 pandemic: challenges, dilemmas and the psychosocial impact on cancer patients

COVID-19 has caused unprecedented societal turmoil, triggering a rapid, still ongoing, transformation of healthcare provision on a global level. In this new landscape, it is highly important to acknowledge the challenges this pandemic poses on the care of the particularly vulnerable cancer patients and the subsequent psychosocial impact on them. We have outlined our clinical experience in managing patients with gastrointestinal, hematological, gynaecological, dermatological, neurological, thyroid, lung and paediatric cancers in the COVID-19 era and have reviewed the emerging literature around barriers to care of oncology patients and how this crisis affects them. Moreover, evolving treatment strategies and novel ways of addressing the needs of oncology patients in the new context of the pandemic are discussed.

Antimicrobial-resistant pathogens associated with pediatric healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017

OBJECTIVE

To describe common pathogens and antimicrobial resistance patterns for healthcare-associated infections (HAIs) among pediatric patients that occurred in 2015-2017 and were reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).

METHODS

Antimicrobial resistance data were analyzed for pathogens implicated in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonias (VAPs), and surgical site infections (SSIs). This analysis was restricted to device-associated HAIs reported from pediatric patient care locations and SSIs among patients <18 years old. Percentages of pathogens with nonsusceptibility (%NS) to selected antimicrobials were calculated by HAI type, location type, and surgical category.

RESULTS

Overall, 2,545 facilities performed surveillance of pediatric HAIs in the NHSN during this period. Staphylococcus aureus (15%), Escherichia coli (12%), and coagulase-negative staphylococci (12%) were the 3 most commonly reported pathogens associated with pediatric HAIs. Pathogens and the %NS varied by HAI type, location type, and/or surgical category. Among CLABSIs, the %NS was generally lowest in neonatal intensive care units and highest in pediatric oncology units. Staphylococcus spp were particularly common among orthopedic, neurosurgical, and cardiac SSIs; however, E. coli was more common in abdominal SSIs. Overall, antimicrobial nonsusceptibility was less prevalent in pediatric HAIs than in adult HAIs.

CONCLUSION

This report provides an updated national summary of pathogen distributions and antimicrobial resistance patterns among pediatric HAIs. These data highlight the need for continued antimicrobial resistance tracking among pediatric patients and should encourage the pediatric healthcare community to use such data when establishing policies for infection prevention and antimicrobial stewardship.

Novel risk factors for central-line associated bloodstream infections in critically ill children

OBJECTIVE

Central-line-associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies.

METHODS

This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay.

RESULTS

Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration >7 days (8-14 days: OR, 4.2; P = .01; 15-29 days: OR, 9.8; P < .01; 30-59 days: OR, 17.3; P < .01; 60-89 days: OR, 39.8; P < .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05).

CONCLUSIONS

Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and >80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.

Multiple sequence types responsible for healthcare-associated Acinetobacter baumannii dissemination in a single centre in Egypt

Background

Acinetobacter baumannii is an increasingly worrying organism in the healthcare setting, due to its multidrug resistance and persistence. Prolonged hospitalisation, immunocompromised patients and excessive antibiotic exposure all contribute to increasing the risk of A. baumannii infections, which makes cancer patients a significant risk group. This study aims to investigate the dissemination of A. baumannii at the National Cancer Institute (NCI) in Cairo – Egypt.

Methods

All bacterial isolates were typed using Multi-locus Sequence Typing (MLST) to characterise the epidemiology of isolates. The intrinsic OXA-51-like, and the acquired carbapanemases OXA-23, − 24/40, − 58, NDM, IMP, and VIM were also amplified and sequenced to genetically identify mechanisms of carbapenem resistance.

Results

MLST results show a high degree of multi-clonal dissemination, with 18 different Sequence Types (STs) identified, including 5 novel. The majority of isolates belonged to International Clone (IC) 2, and carbapenem resistance was detected in 93% of isolates and mediated by bla_OXA-23, bla_OXA-58, bla_NDM-1 and bla_VIM-1. We also report the presence of a resistant ST732 (OXA-378) which has been previously identified in migratory birds_.

Conclusions

Multiple highly resistant clones were identified in a Cancer hospital in Cairo. It is vital that clinicians and healthcare workers are aware of the population of A. baumannii present in order to have appropriate treatment and infection control practices.

Incidence, severity and outcome of central line related complications in pediatric oncology patients; A single center study

BACKGROUND

Central venous access device (CVAD)-related complications are associated with high morbidity rates. This study was performed to underline the importance of CVAD-complication prevention and treatment.

METHODS

An audit of practice of CVAD-related complications in pediatric oncology patients receiving a CVAD between January 2015 and June 2017 was performed. CVADs included were totally implantable venous access ports (TIVAPs), Hickman-Broviac® (HB), nontunneled, and peripherally inserted CVADs.

RESULTS

A total of 201 children, with 307 CVADs, were analyzed. The incidence rates per 1000 CVAD-days for the most common complications were 1.66 for malfunctions, and 1.51 for central line-associated bloodstream infections (CLABSIs). Of all CVADs inserted, 37.1% were removed owing to complications, of which 45.6% were owing to CLABSIs. In 42% of the CLABSIs, the CLABSI could be successfully cured with systemic antibiotic treatment only. Of all included patients, 5.0% were admitted to the intensive care unit owing to CLABSI. The HB-CVAD compared to the TIVAP was a risk factor for CVAD-related complications, CLABSIs and dislocations in particular.

CONCLUSIONS

The incidence of CVAD-related complications is high. Research on the prevention and treatment of CVAD-related complications in pediatric oncology patients should be a high priority for all health care professionals.

TYPE OF STUDY

Prognosis study (retrospective).

LEVEL OF EVIDENCE

Level II.

Antibiotic-Resistant Septicemia in Pediatric Oncology Patients Associated with Post-Therapeutic Neutropenic Fever

Death in cancer patients can be caused by the progression of tumors, their malignity, or other associated conditions such as sepsis, which is a multiphasic host response to a pathogen that can be significantly amplified by endogenous factors. Its incidence is continuously rising, which reflects the increasing number of sick patients at a higher risk of infection, especially those that are elderly, pediatric, or immunosuppressed. Sepsis appears to be directly associated with oncological treatment and fatal septic shock. Patients with a cancer diagnosis face a much higher risk of infections after being immunosuppressed by chemotherapy, radiotherapy, or anti-inflammatory therapy, especially caused by non-pathogenic, Gram-negative, and multidrug-resistant pathogens. There is a notorious difference between the incidence and mortality rates related to sepsis in pediatric oncologic patients between developed and developing countries: they are much higher in developing countries, where investment for diagnosis and treatment resources, infrastructure, medical specialists, cancer-related control programs, and post-therapeutic care is insufficient. This situation not only limits but also reduces the life expectancy of treated pediatric oncologic patients, and demands higher costs from the healthcare systems. Therefore, efforts must aim to limit the progression of sepsis conditions, applying the most recommended therapeutic regimens as soon as the initial risk factors are clinically evident-or even before they are, as when taking advantage of machine learning prediction systems to analyze data.

Incidence of acute kidney injury among pediatric hematology/oncology patients receiving vancomycin in combination with piperacillin/tazobactam or cefepime

There is mounting evidence that combination of antibiotic therapy with vancomycin and piperacillin/tazobactam (pip/tazo) is associated with acute kidney injury (AKI). To determine whether vancomycin plus pip/tazo is associated with higher rates of AKI compared to vancomycin plus cefepime among pediatric hematology/oncology (heme/onc) patients, we examined 121 heme/onc patients receiving at least two consecutive days of therapy with vancomycin and either pip/tazo or cefepime. Rate of AKI was higher in the pip/tazo than the cefepime group (4/27 [14.8%] vs 2/94 [2.1%], P = 0.022).

The efficacy of a non-leaching antibacterial central venous catheter - a prospective, randomized, double-blind study

BACKGROUND

Antimicrobial coatings of central venous catheters (CVC) have the potential to reduce the risk of infectious complications. The aim of this study was to examine the efficacy of a catheter with a non-leaching antimicrobial coating against catheter colonization and bloodstream infections (BSI).

METHODS

The study was conducted in two centers using a prospective, randomized, double-blind and controlled design (680 intensive care patients; a protective CVC (Certofix® protect) or a standard CVC (Certofix®). Primary objectives were the rates of catheter colonization and BSI in the two groups. Other baseline demographics, APACHE II score, insertion site, location of CVC placement (ICU or theatre), indwelling time and length of ICU stay were comparable for both groups.

RESULTS

While the rate of catheter colonization between the coated and uncoated CVC (17.4% vs. 18.7%, P=0.7477) and the rate of microbiologically confirmed catheter associated infections were similar (1.4% vs. 1.9%, P=0.7521), the coated CVC showed a significantly lower incidence of BSI (2.0% vs. 6.5%, P=0.0081) and a significantly lower mean incidence of BSI per 1000 catheter days (3.2 vs. 8.3, P=0.0356).

CONCLUSION

The non-leaching antibacterial coating of the protective catheter was effective in reducing the incidence of BSI but not the rate of catheter colonization. However, the incidence of BSI is a better surrogate marker for the risk of developing clinical signs of infection suggesting that use of the non-leaching protective catheter is effective in this regard. Trial number: ClinicalTrials.gov (ID: NCT00555282), https://clinicaltrials.gov/show/NCT00555282.

Central Line-Associated Bloodstream Infections in Children With Hematologic and Oncologic Diseases: First Prevalence Results From a University Hospital

Central line-associated bloodstream infections (CLABSIs) are still a major cause of morbidity and mortality in pediatric hematology-oncology patients in many countries. This cross-sectional study was a retrospective review of CLABSI in inpatient pediatric hematology-oncology cases with long-term central venous catheter at the Pediatric Hematology Department from January 2013 to June 2014. Characteristics of CLABSI events in pediatric patients with hematologic malignancies and related nonmalignant hematologic conditions are documented. CLABSI developed in 61.8% (n = 21) of the 34 hospitalized patients included in the study. The CLABSI rate was 7.8 per 1,000 inpatient central venous catheter days. Coagulase-negative staphylococci was the predominant pathogen in 47.6% of the patients with CLABSI. The high rate of CLABSI requires prevention strategies to reduce CLABSI immediately. This study provides guidance in prioritizing strategies for reducing rates of infection.

Antifungal activity in the methanolic, aqueous and hexane extracts of Calligonum polygonoides

Calligonum polygonoides is locally called as Phog which belongs to the Polygonaceae family. It is traditionally used as an antifungal. The methanolic extract, hexane extract, ethyl acetate extract and aqueous extract were screened against Candida albicans and Aspergillus niger in seven concentrations, that is, 1.8, 2.9, 6.5, 12.6, 25, 50 and 75 µg/mL/disc. Calligonum polygonoides showed significant activity against Candida albicans as the observed minimum inhibitory concentration (MIC) is 6.5 µg/mL for methanolic extract, 9.8 µg/mL for ethyl acetate extract, whereas aqueous and hexane extracts showed no activity. Calligonum polygonoides did not show any significant activity against Aspergillus niger.

High Rates of Community and Hospital Acquired Infections in Patients with Cellular Immunodeficiencies

PURPOSE

Patients with primary immunodeficiency diseases (PID) are perceived to be at high risk for acquiring as well as developing complications from infections. There is little data describing the infection type and frequency these patients may acquire in the community or during hospital admissions. Data is critically needed in order to inform best practices on how to protect these vulnerable patients.

METHODS

This is a retrospective study which included PID patients who were discharged from Children's National Health System (CNHS) from January 1, 2011, through August 31, 2017, and were assigned a discharge diagnosis code indicating PID. Hospitalizations that occurred in the study period were reviewed to extract information on the type of infections upon admission and during hospitalization. The rate of hospital acquired infections (HAIs) was calculated by the number of HAIs divided by the total number of days between date of admission and date of discharge or receiving the first bone marrow transplant, whichever the one came first. The rates were then compared to the HAI rate among oncology patients receiving treatment at CNHS during the same study period.

RESULTS

During this study period, 33 PID patients were admitted 80 times for a total of 1855 patient days. Of these 80 admissions, 31 were due to an infection. Ten of the 31 admissions with severe combined immunodeficiency disease (SCID) were infection related, 4/4 in ectodermal dysplasia with immunodeficiency due to gain of function mutation (IkappaBalpha) patients, 8/10 in Wiskott-Aldrich patients, 1/2 in STAT3 mutation patients, 1/1 in Hyper IGM patient, 1/5 in severe chronic active EBV (SCAEBV) patients, 1/1 NK defect, 2/21 in primary hemophagocytic lymphohistiocytosis patients, 3/4 chronic granulomatous disease, and 0/1 congenital neutropenia. HAI occurred in 11 out of 80 admissions (13.75%). Patients with SCID had the highest HAI rate of 13.09 per 1000 patient days, followed by SCAEBV (11.10), IkappaBalpha (6.58), and Wiskott-Aldrich (4.91). Comparing to oncology patients in which the HAI rate was 0.92 per 1000 patient days. SCID patients had 11.7 (95% confidence interval 3.7-29; p < 0.001) and T cell defects excluding SCID had 4.8 (95% CI 1.0-14.8; p = 0.03) times greater risk of acquiring an infection during a hospitalization.

CONCLUSIONS

Patients with severe T cell defects such as SCID are at greater risk for infections in the community and in hospital settings. Additional infection prevention measures are likely needed when caring for these patients in a clinic or as an inpatient. Further studies are urgently needed to determine the most appropriate measures for these patients.

Investigation of Clostridium difficile ribotypes in symptomatic patients of a German pediatric oncology center

In a German pediatric oncology unit, the attending physicians diagnosed 27 cases of Clostridium difficile-associated disease (CDI) from January 01, 2010 to October 31, 2013. This refers to a CDI incidence density of 2.0/1000 inpatient days. According to the hospital hygiene standard, symptomatic patients with CDI were kept in contact isolation. Most patients (median age 8.2 years) suffered from acute lymphoblastic leukemia; 88.9% were treated with broad-spectrum antibiotics during the preceding 4 weeks. 29.6% received intravenous morphine/metamizole and parenteral nutrition due to severe chemotherapy-induced mucositis. None of the patients experienced severe complications such as lower gastrointestinal tract bleeding, sepsis, or toxic megacolon. Genotyping of the isolates derived from symptomatic patients revealed many different ribotypes without detection of the hypervirulent 027 strain and did not point at hospital transmission as an important promoter of CDI in our unit.

CONCLUSION

Under strict standard hygiene and contact isolation for symptomatic patients, genotyping of clinical isolates revealed that in pediatric cancer patients, CDI is not necessarily based on nosocomial transmission. The rate of CDI-related severe complications was low. What is Known: • Pediatric cancer patients face an increased risk of Clostridium difficile-associated disease due to immunosuppression, cancer chemotherapy, mucositis, and dysbiosis following intravenous broad-spectrum antimicrobial treatment. • C. difficile may be transmitted from patient to patient. What is New: • Under strict standard hygiene and contact isolation for symptomatic patients, genotyping of clinical isolates revealed that in pediatric cancer patients, CDI is not necessarily based on nosocomial transmission. • The rate of CDI-related severe complications was low.

Evaluation of bloodstream infections, Clostridium difficile infections, and gut microbiota in pediatric oncology patients

Bloodstream infections (BSI) and Clostridium difficile infections (CDI) in pediatric oncology/hematology/bone marrow transplant (BMT) populations are associated with significant morbidity and mortality. The objective of this study was to explore possible associations between altered microbiome composition and the occurrence of BSI and CDI in a cohort of pediatric oncology patients. Stool samples were collected from all patients admitted to the pediatric oncology floor from Oct.-Dec. 2012. Bacterial profiles from patient stools were determined by bacterial 16S rRNA gene profiling. Differences in overall microbiome composition were assessed by a permutation-based multivariate analysis of variance test, while differences in the relative abundances of specific taxa were assessed by Kruskal-Wallis tests. At admission, 9 of 42 patients (21%) were colonized with C. difficile, while 6 of 42 (14%) subsequently developed a CDI. Furthermore, 3 patients (7%) previously had a BSI and 6 patients (14%) subsequently developed a BSI. Differences in overall microbiome composition were significantly associated with disease type (p = 0.0086), chemotherapy treatment (p = 0.018), BSI following admission from any cause (p < 0.0001) or suspected gastrointestinal organisms (p = 0.00043). No differences in baseline microbiota were observed between individuals who did or did not subsequently develop C. difficile infection. Additionally, multiple bacterial groups varied significantly between subjects with post-admission BSI compared with no BSI. Our results suggest that differences in gut microbiota not only are associated with type of cancer and chemotherapy, but may also be predictive of subsequent bloodstream infection.

Risk for Health Care-Associated Bloodstream Infections in Pediatric Oncology Patients With Various Malignancies

This was a retrospective cohort study to identify the rates, predictors, and outcomes of health care-associated bloodstream infections (HA-BSI) among children with solid tumors, lymphoma, lymphoid leukemia, and myeloid leukemia. The study population included 4500 children ≤18 years old at a pediatric hospital in New York City from 2006 to 2014. A total of 147 HA-BSI cases were identified; using multivariable logistic regression modeling, children with a hematologic diagnosis (lymphoma, lymphoid leukemia, myeloid leukemia) were at greater risk for HA-BSI than those with a solid tumor diagnosis (all P values <.0001). The odds of mortality for patients with HA-BSI were 6.98 (95% confidence interval 3.02-16.10) times that of those without HA-BSI. Although malignancy type was identified as risk factor for HA-BSI, there was no significant difference in overall mortality from HA-BSI by tumor type ( P = .51).

Central Line Associated Blood Stream Infections in Pediatric Hematology/Oncology Patients With Different Types of Central Lines

BACKGROUND

Central line associated bloodstream infections (CLABSIs) are a significant cause of morbidity and mortality in pediatric hematology/oncology (PHO) patients. Understanding the differences in CLABSI rates by central line (CL) type is important to inform clinical decisions.

PROCEDURE

CLABSI, using similar definitions, noted with three commonly used CL types (totally implanted catheter [port], tunneled externalized catheter [TEC], peripherally inserted central catheter [PICC]) and CL-specific line days were prospectively tracked across 15 US PHO centers from May 2012 until April 2015 and CLABSI rates (CLABSI per 1,000 CL-specific line days) were calculated. Host and organism characterstics associated with the CLABSI events were analyzed.

RESULTS

Over the course of 2.8 million line days, 1,113 CLABSI events (397 in inpatients and 716 in ambulatory patients) were noted. The inpatient CLABSI rate was higher than the ambulatory CLABSI rate for each of the CL types: 1.48 versus 0.16 for ports, 3.51 versus 1.38 for TECs, and 3.07 versus 1.16 for PICCs, respectively. TECs and PICCs were associated with higher CLABSI rates than ports, inpatient and ambulatory.

CONCLUSIONS

We found that CLABSI rates were significantly higher for inpatients compared to ambulatory PHO patients for all CL types. Among ambulatory patients, TECs had the highest CLABSI rate and ports the lowest. Among inpatients, TECs and PICCs had higher CLABSI rates than ports but were not statistically different from one another. Cognizant that host and underlying disease attributes may contribute to these differences, these results can still inform CL choice in clinical practice.

Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on?

Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.

The role of Clostridium difficile in the paediatric and neonatal gut - a narrative review

Clostridium difficile is an important nosocomial pathogen in adults. Its significance in children is less well defined, but cases of C. difficile infection (CDI) appear to be increasingly prevalent in paediatric patients. This review aims to summarize reported Clostridium difficile carriage rates across children of different age groups, appraise the relationship between CDI and factors such as method of delivery, type of infant feed, antibiotic use, and co-morbidities, and review factors affecting the gut microbiome in children and the host immune response to C. difficile. Searches of PubMed and Google Scholar using the terms 'Clostridium difficile neonates' and 'Clostridium difficile children' were completed, and reference lists of retrieved publications screened for further papers. In total, 88 papers containing relevant data were included. There was large inter-study variation in reported C. difficile carriage rates. There was an association between CDI and recent antibiotic use, and co-morbidities such as immunosuppression and inflammatory bowel disease. C. difficile was also found in stools of children with diarrhoea attributed to other pathogens (e.g. rotavirus). The role of C. difficile in the paediatric gut remains unclear; is it an innocent bystander in diarrhoeal disease caused by other organisms, or a pathogen causing subclinical to severe symptoms? Further investigation of the development of serological and local host response to C. difficile carriage may shed new light on disease mechanisms. Work is underway on defining a framework for diagnosis and management of paediatric CDI.

The Centers for Disease Control and Prevention definition of mucosal barrier injury-associated bloodstream infection improves accurate detection of preventable bacteremia rates at a pediatric cancer center in a low- to middle-income country

BACKGROUND

The US National Healthcare Safety Network has provided a definition of mucosal barrier injury-associated, laboratory-confirmed bloodstream infection (MBI-LCBI) to improve infection surveillance. To date there is little information about its influence in pediatric oncology centers in low- to middle-income countries.

OBJECTIVES

To determine the influence of the definition on the rate of central line-associated bloodstream infection (CLABSI) and compare the clinical characteristics of MBI versus non-MBI LCBI cases.

METHODS

We retrospectively applied the National Healthcare Safety Network definition to all CLABSIs recorded at a pediatric oncology center in Tijuana, Mexico, from January 2011 through December 2014. CLABSI events were reclassified according to the MBI-LCBI definition. Clinical characteristics and outcomes of MBI and non-MBI CLABSIs were compared.

RESULTS

Of 55 CLABSI events, 44% (24 out of 55) qualified as MBI-LCBIs; all were MBI-LCBI subcategory 1 (intestinal flora pathogens). After the number of MBI-LCBI cases was removed from the numerator, the CLABSI rate during the study period decreased from 5.72-3.22 infections per 1,000 central line days. Patients with MBI-LCBI were significantly younger than non-MBI-LCBI patients (P = .029) and had a significantly greater frequency of neutropenia (100% vs 39%; P = .001) and chemotherapy exposure (87% vs 58%; P = .020) and significantly longer median hospitalization (34 vs 23 days; P = .008).

CONCLUSION

A substantial proportion of CLABSI events at our pediatric cancer center met the MBI-LCBI criteria. Our results support separate monitoring and reporting of MBI and non-MBI-LCBIs in low- to middle-income countries to allow accurate detection and tracking of preventable (non-MBI) bloodstream infections.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.

Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks.

Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).

Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors

In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI.

CONCLUSION

This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles.

WHAT IS KNOWN

• Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.

Preventing CLABSIs among pediatric hematology/oncology inpatients: national collaborative results

OBJECTIVES

Central lines (CLs) are essential for the delivery of modern cancer care to children. Nonetheless, CLs are subject to potentially life-threatening complications, including central line-associated bloodstream infections (CLABSIs). The objective of this study was to assess the feasibility of a multicenter effort to standardize CL care and CLABSI tracking, and to quantify the impact of standardizing these processes on CLABSI rates among pediatric hematology/oncology inpatients.

METHODS

We conducted a multicenter quality improvement collaborative starting in November 2009. Multidisciplinary teams at participating sites implemented a standardized bundle of CL care practices and adopted a common approach to CLABSI surveillance.

RESULTS

Thirty-two units participated in the collaborative and reported a mean, precollaborative CLABSI rate of 2.85 CLABSIs per 1000 CL-days. Self-reported adoption of the CL care bundle was brisk, with average compliance approaching 80% by the end of the first year of the collaborative and exceeding 80% thereafter. As of August 2012, the mean CLABSI rate during the collaborative was 2.04 CLABSIs per 1000 CL-days, a reduction of 28% (relative risk: 0.71 [95% confidence interval: 0.55-0.92]). Changes in self-reported CL care bundle compliance were not statistically associated with changes in CLABSI rates, although there was little variability in bundle compliance rates after the first year of the collaborative.

CONCLUSIONS

A multicenter quality improvement collaborative found significant reductions in observed CLABSI rates in pediatric hematology/oncology inpatients. Additional interventions will likely be required to bring and sustain CLABSI rates closer to zero for this high-risk population.

Bacterial bloodstream infections and antimicrobial susceptibility pattern in pediatric hematology/oncology patients after anticancer chemotherapy

Purpose

Bloodstream infections in pediatric hematology and oncology represent a major problem worldwide, but this has not been studied in Qatar. In this study, we investigated the burden of infection and the resistance pattern in the bacterial etiology, in the only tertiary pediatric hematology and oncology center in Qatar.

Methods

All pediatric cancer patients (n=185) were evaluated retrospectively during the period 2004–2011; a total of 70 (38%) patients were diagnosed with bloodstream infections. Bacterial etiology was determined, along with their susceptibility patterns. Neutropenia, duration of neutropenia, fever, duration of fever, and C-reactive protein (CRP) were evaluated throughout the study.

Results

A total of 70 patients (38%) were diagnosed with acute leukemias, lymphomas, solid tumors, or brain tumors; those patients experienced 111 episodes of bacteremia. The most common Gram-positive (n=64 [55%]) isolates were Staphylococcus epidermidis (n=26), Staphylococcus hominis (n=9), and Staphylococcus haemolyticus (n=7), and the common Gram-negative (n=52 [45%]) isolates were Klebsiella pneumoniae (n=14), Pseudomonas aeruginosa (n=10), and Escherichia coli (n=7). There was a significant association observed between fever with positive blood culture and different types of cancer (P=0.035). The majority of bacteremia (n=68 [61.3%]) occurred in nonneutropenic episodes. Elevated values of CRP (≥5 mg/L) were detected in 82 (95.3%) episodes and were negatively correlated with absolute neutrophil count (ANC) (r=−0.18; P=0.248) among all cases. However, the infection-related fatality rate was 2.2% (n=4), with three caused by Gram-negative pathogens. Multidrug resistant organisms were implicated in 33 (28.4%) cases and caused three of the mortality cases.

Conclusion

Multidrug resistant organisms cause mortality in pediatric cancer patients. Investigation of antimicrobial susceptibility of these organisms may guide successful antimicrobial therapy and improve the surveillance and quality of pediatric malignancy care.

Which decision rules meet methodological standards in children with febrile neutropenia? Results of a systematic review and analysis

BACKGROUND

Clinical decision rules (CDRs) have sought to identify the few children with chemotherapy-induced febrile neutropenia (FN) really at risk of severe infection to reduce the invasive procedures and costs for those at low risk. Several reports have shown that most rules do not perform well enough to be clinically useful. Our objective was to analyze the derivation methods and validation procedures of these CDRs.

PROCEDURE

A systematic review using Medline, Ovid, Refdoc, and the Cochrane Library through December 2012 searched for all CDRs predicting the risk of severe infection and/or complications in children with chemotherapy-induced FN. Their methodological quality was analyzed by 17 criteria for deriving and validating a CDR identified in the literature. The criteria published by the Evidence Based Medicine Working Group were applied to the published validations of each CDR to assess their level of evidence.

RESULTS

The systematic research identified 612 articles and retained 12 that derived CDRs. Overall, the CDRs met a median of 65% of the methodological criteria. The criteria met least often were that the rule made clinical sense, or described the course of action, or that the variables and the CDR were reproducible. Only one CDR, developed in South America, met all methodological criteria and provided the highest level of evidence; unfortunately it was not reproducible in Europe.

CONCLUSION

Only one CDR developed for children with FN met all methodological standards and reached the highest level of evidence.

A prospective multicenter study of microbiologically defined infections in pediatric cancer patients with fever and neutropenia: Swiss Pediatric Oncology Group 2003 fever and neutropenia study

BACKGROUND

Fever and neutropenia (FN) often complicate anticancer treatment and can be caused by potentially fatal infections. Knowledge of pathogen distribution is paramount for optimal patient management.

METHODS

Microbiologically defined infections (MDI) in pediatric cancer patients presenting with FN by nonmyeloablative chemotherapy enrolled in a prospective multicenter study were analyzed. Effectiveness of empiric antibiotic therapy in FN episodes with bacteremia was assessed taking into consideration recently published treatment guidelines for pediatric patients with FN.

RESULTS

MDI were identified in a minority (22%) of pediatric cancer patients with FN. In patients with, compared with patients without MDI, fever [median, 5 (interquartile range: 3-8) vs. 2 (interquartile range: 1-3) days, P < 0.001] and hospitalization [10 (6-14) vs. 5 (3-8) days, P < 0.001] lasted longer, transfer to the intensive care unit was more likely [13 of 95 (14%) vs. 7 of 346 (2.0%), P < 0.001], and antibiotics were given longer [10 (7-14) vs. 5 (4-7) days, P < 0.001]. Empiric antibiotic therapy in FN episodes with bacteremia was highly effective if not only intrinsic and reported antimicrobial susceptibilities were considered but also the purposeful omission of coverage for coagulase-negative staphylococci and enterococci was taken into account [81% (95% confidence interval: 68-90) vs. 96.6% (95% confidence interval: 87-99.4), P = 0.004].

CONCLUSIONS

MDI were identified in a minority of FN episodes but they significantly affected management and the clinical course of pediatric cancer patients. Compliance with published guidelines was associated with effectiveness of empiric antibiotic therapy in FN episodes with bacteremia.

Aetiology and resistance in bacteraemias among adult and paediatric haematology and cancer patients

OBJECTIVES

A knowledge of current epidemiology and resistance patterns is crucial to the choice of empirical treatment for bacteraemias in haematology and cancer patients.

METHODS

A literature review on bacteraemias in cancer patients considered papers published between January 1st 2005 and July 6th 2011. Additionally, in 2011, a questionnaire on the aetiology and resistance in bacteraemias, and empirical treatment, was sent to participants of the European Conference on Infections in Leukemia (ECIL) meetings; recipients were from 80 haematology centres.

RESULTS

For the literature review, data from 49 manuscripts were analysed. The questionnaire obtained responses from 39 centres in 18 countries. Compared with the published data, the questionnaire reported more recent data, and showed a reduction of the Gram-positive to Gram-negative ratio (55%:45% vs. 60%:40%), increased rates of enterococci (8% vs. 5%) and Enterobacteriaceae (30% vs. 24%), a decreased rate of Pseudomonas aeruginosa (5% vs. 10%), and lower resistance rates for all bacteria. Nevertheless the median rates of ESBL-producers (15-24%), aminoglycoside-resistant Gram-negatives (5-14%) and carbapenem-resistant P. aeruginosa (5-14%) were substantial, and significantly higher in South-East vs. North-West Europe.

CONCLUSIONS

The published epidemiological data on bacteraemias in haematology are scanty and mostly dated. Important differences in aetiology and resistance exist among centres. Updated analyses of the local epidemiology are mandatory to support appropriate empirical therapy.

Prospective study estimating healthcare associated infections in a paediatric hemato-oncology unit of a tertiary care hospital in North India

BACKGROUND & OBJECTIVES

Healthcare associated infections (HAIs) are responsible for morbidity and mortality among immunocompromised and critically ill patients. We undertook this study to estimate the burden of HAIs in the paediatric cancer patients in a tertiary care hospital in north India.

METHODS

This prospective, observational study, based on active surveillance for a period of 11 months was undertaken in a 4-bedded isolated, cubicle for paediatric cancer patients. Patients who stayed in the cubicle for ≥48 h, were followed prospectively for the development of HAIs.

RESULTS

Of the 138 patients, 13 developed 14 episodes of HAIs during the study period. Patient-days calculated were 1273 days. Crude infection rate (CIR) and incidence density (ID) of all HAIs were 9.4/100 patients and 11/1000 patient-days, respectively. Of the 14 episodes of HAIs, seven (50%) were of blood stream infections (HA-BSI), five (36%) of pneumonia (HAP) and two (14%) urinary tract infections (HA-UTI). The CIRs of HA-BSI, HAP and HA-UTI were 5.1, 3.6 and 1.4/100 patients, respectively. The corresponding IDs were 5.5, 3.9 and 1.6/1000 patient-days, respectively. Mean length of stay was significantly higher in patients who developed an HAI [13.8 (range 7-30), median (Interquartile range) 12 (11-14)] vs 7.5 days [range 2-28, median (interquartile range) 7 (5-9); P<0.0001]. Also mortality was significantly higher in patients who developed an HAI [23% (3/13) vs 3% (4/125), P<0.05].

INTERPRETATION & CONCLUSIONS

The incidence of HAIs in the paediatric cancer patients in the study was 11/1000 patient days, of which HA-BSIs were the commonest. HAIs were associated with an increase in morbidity and mortality amongst this high risk patient population.

A comparison of central lines in pediatric oncology patients: Early removal and patient centered outcomes

BACKGROUND

While there is increasing evidence supporting the choice of subcutaneous ports (SPs) over external venous catheters (EVCs) in pediatric oncology patients, prior conflicting studies exist and little data have been gathered as to which type of central line is preferred from the patient/family perspective.

PROCEDURE

We performed a single institution, 10 years, retrospective analysis of central lines in pediatric oncology patients (n = 878) to evaluate unplanned early removal and cause of removal while simultaneously obtaining a cross sectional survey of 143 of the primary caretakers/parents of these patients to evaluate their overall satisfaction with the line.

RESULTS

EVCs have significantly higher odds of unplanned early removal in comparison to SPs (6.7% of SPs vs. 27.3% of EVCs, odds ratio (OR) = 6.3, P < 0.0001 when controlling for age and diagnosis) secondary to increased infection, malfunction and patient preference. Patients with SPs felt like their central line was easier to care for, had less daily impact in their life, and were overall more satisfied with their central line compared to patients with EVCs, even when controlling for early removal (P < 0.0001 for all). SP patients were much more likely to state that they would choose the same type of line again (OR = 15, P < 0.0001) than EVC patients.

CONCLUSION

SPs demonstrated lower removal rates and greater patient satisfaction than EVCs. These data should be considered when choosing a central line for pediatric cancer patients.

Trends in paediatric nosocomial bacteraemia in a London tertiary hospital

AIM

To describe the incidence and microbiological characteristics of nosocomial bloodstream infections in childhood over a 9-year period at a South London tertiary hospital.

METHODS

Analysis of prospective data collected for clinically significant nosocomial bloodstream infections in children aged <16 years during 2001-2009.

RESULTS

During the study period, although the absolute number of nosocomial bloodstream infections were similar for the neonatal unit (n = 254) and paediatric wards (n = 224), rates were 11.6-fold (95% CI, 9.8-13.9) higher for the former (5.8 vs. 0.50/100 discharges, respectively). Analysis of trends revealed a significant reduction in rates for both the neonatal unit (7.8-2.5 episodes/100 discharges; p < 0.001) and paediatric wards (1.2-0.4 episodes/100 discharges; p < 0.001), mainly due a decline in catheter-associated staphylococcal bacteraemia, which accounted for 115 (45%) and 164 (73%) episodes in the paediatric wards and neonatal units, respectively. Gram-positive cocci were the most frequent pathogens recovered, accounting for 200 (79%) and 185 (83%) cases in the neonatal unit and paediatric wards, respectively. Overall, antimicrobial resistance rates were low compared with other industrialized countries.

CONCLUSION

Nosocomial bloodstream infections rates declined significantly in our hospital over the past decade, likely driven by local introduction of national infection-control bundles particularly focussing on insertion and maintenance of intravascular catheters.

Central venous catheters and catheter locks in children with cancer: a prospective randomized trial of taurolidine versus heparin

BACKGROUND

To determine if the catheter lock taurolidine can reduce the number of catheter-related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC).

PROCEDURE

During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution (ClinicalTrials.gov Identifier NCT00735813).

RESULTS

Sixty-five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC-days. A lower rate of CRBSI (0.4 per 1,000 CVC-days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC-days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09-0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC-days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC-days, IRR = 0.49; 95% CI 0.29-0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12-602) compared with the experimental group (300 days, range 12-1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups.

CONCLUSION

Locking of long-term tunneled CVC with taurolidine significantly reduces catheter-related bloodstream infections in children with cancer.

Clostridium difficile infection in children: a comprehensive review

OBJECTIVE

To provide a comprehensive review of the literature relating to Clostridium difficile (C. difficile) infection (CDI) in the pediatric population.

METHODS

Two investigators conducted independent searches of PubMed, Web of Science, and Scopus until March 31st, 2013. All databases were searched using the terms 'Clostridium difficile infection', 'Clostridium difficile associated diarrhea' 'antibiotic associated diarrhea', 'C. difficile', in combination with 'pediatric' and 'paediatric'. Articles which discussed pediatric CDI were reviewed and relevant cross references also read and evaluated for inclusion. Selection bias could be a possible limitation of this approach.

FINDINGS

There is strong evidence for an increased incidence of pediatric CDI. Increasingly, the infection is being acquired from the community, often without a preceding history of antibiotic use. The severity of the disease has remained unchanged. Several medical conditions may be associated with the development of pediatric CDI. Infection prevention and control with antimicrobial stewardship are of paramount importance. It is important to consider the age of the child while testing for CDI. Traditional therapy with metronidazole or vancomycin remains the mainstay of treatment. Newer antibiotics such as fidaxomicin appear promising especially for the treatment of recurrent infection. Conservative surgical options may be a life-saving measure in severe or fulminant cases.

CONCLUSIONS

Pediatric providers should be cognizant of the increased incidence of CDI in children. Early and judicious testing coupled with the timely institution of therapy will help to secure better outcomes for this disease.

Microbiology and risk factors for central line-associated bloodstream infections among pediatric oncology outpatients: a single institution experience of 41 cases

BACKGROUND

Risk factors for central line-associated bloodstream infections (CLABSI) among children with cancer in the outpatient setting remain poorly defined, and the microbiology may differ from hospital-onset CLABSI.

MATERIALS AND METHODS

We conducted a matched case-control study of oncology patients followed at the Dana Farber/Children's Hospital Cancer Center. Cases (N=41) were patients with CLABSI as per National Healthcare Safety Network criteria who had not been hospitalized in the preceding 48 hours. For each case we randomly selected 2 oncology outpatients with a central venous catheter and a clinic visit within 30 days of the case subject's CLABSI. Multivariate conditional logistic regression models were used to identify independent risk factors for CLABSI. We compared the microbiology to that of 54 hospital-onset CLABSI occurring at our institution during the study period.

RESULTS

Independent predictors of community-onset CLABSI included neutropenia in the prior week (odds ratio 17.46; 95% confidence interval, 4.71-64.67) and tunneled externalized catheter (vs. implantable port; odds ratio 10.30; 95% confidence interval, 2.42-43.95). Nonenteric gram-negative bacteria were more frequently isolated from CLABSI occurring among outpatients.

DISCUSSION

Pediatric oncology outpatients with recent neutropenia or tunneled externalized catheters are at increased risk of CLABSI. The microbiology of community-onset CLABSI differs from hospital-onset CLABSI.

Surveillance of hospital-acquired central line-associated bloodstream infections in pediatric hematology-oncology patients: lessons learned, challenges ahead

Across 36 US pediatric oncology centers, 576 central line-associated bloodstream infections (CLABSIs) were reported over a 21-month period. Most infections occurred in those with leukemia and/or profound neutropenia. The contribution of viridans streptococci infections was striking. Study findings depict the contemporary epidemiology of CLABSIs in hospitalized pediatric cancer patients.

Five years experience of Clostridium difficile infection in children at a UK tertiary hospital: proposed criteria for diagnosis and management

Background

Clostridium difficile infection (CDI) is associated with significant morbidity and mortality in adults. There is increasing evidence of the pathogenic role of C. difficile in the paediatric population. We sought to ascertain the clinical presentation and severity of CDI in children at our institution and develop criteria to aid management.

Methods

Clinical data was retrospectively collected from all children (0–16 yrs) with a positive C. difficile toxin result over a 5-year period. National adult guidelines were used to assess the severity and management of CDI.

Results

Seventy-five patients were included with a mean age of 2.97 years. Forty-nine were hospital onset, 22 community onset and 4 healthcare-associated. The most common co-morbidity among the hospital onset infections was malignancy. Gastrointestinal conditions were most common among community onset infections. Fifty-five cases (73.3%) had received antibiotics in the preceding month, 7 (9.3%) had cow’s milk intolerance and 9 (12%) had co-infection with another gut pathogen. According to national adult guidelines 57 cases (76%) were categorised as severe. Thirty cases received oral metronidazole, two patients required intensive care and one patient had a sub-total colectomy for pseudomembranous colitis. No mortality was observed.

Discussion

We confirm the association of paediatric CDI with co-morbidities such as haematological and solid organ malignancies, recent antibiotic use and hospitalisation. We observed an association between cows milk protein intolerance and C. difficile. The use of adult criteria overestimated severity of disease in this cohort, as most cases experienced a mild course of illness with low morbidity and no mortality. This indicates that adult scoring criteria are not useful in guiding management and we propose specific criteria for children.

Clostridium difficile Infection in Children: Current State and Unanswered Questions

The incidence of Clostridium difficile infection (CDI) in children has increased over the past decade. In recent years, new and intriguing data on pediatric CDI have emerged. Community-onset infections are increasingly recognized, even in children who have not previously received antibiotics. A hypervirulent strain is responsible for up to 20% of pediatric CDI cases. Unique risk factors for CDI in children have been identified. Advances in diagnostic testing strategies, including the use of nucleic acid amplification tests, have raised new questions about the optimal approach to diagnosing CDI in children. Novel therapeutic options are available for adult patients with CDI, raising questions about the use of these agents in children. Updated recommendations about infection prevention and control measures are now available. We summarize these recent developments in pediatric CDI in this review and also highlight remaining knowledge gaps that should be addressed in future research efforts.

A point prevalence survey of health care-associated infections in Canadian pediatric inpatients

BACKGROUND

Health care-associated infections (HAIs) cause considerable morbidity and mortality to hospitalized patients. The objective of this point prevalence study was to assess the burden of HAIs in the Canadian pediatric population, updating results reported from a similar study conducted in 2002.

METHODS

A point prevalence survey of pediatric inpatients was conducted in February 2009 in 30 pediatric or combined adult/pediatric hospitals. Data pertaining to one 24-hour period were collected, including information on HAIs, microorganisms isolated, antimicrobials prescribed, and use of additional (transmission based) precautions. The following prevalent infections were included: pneumonia, urinary tract infection, bloodstream infection, surgical site infection, viral respiratory infection, Clostridium difficile infection, viral gastroenteritis, and necrotizing enterocolitis.

RESULTS

One hundred eighteen patients had 1 or more HAI, corresponding to a prevalence of 8.7% (n = 118 of 1353, 95% confidence interval: 7.2-10.2). Six patients had 2 infections. Bloodstream infections were the most frequent infection in neonates (3.0%), infants (3.1%), and children (3.5%). Among all patients surveyed, 16.3% were on additional precautions, and 40.1% were on antimicrobial agents, whereas 40.7% of patients with a HAI were on additional precautions, and 89.0% were on antimicrobial agents.

CONCLUSION

Overall prevalence of HAI in 2009 has remained similar to the prevalence reported from 2002. The unchanged prevalence of these infections nonetheless warrants continued vigilance on their prevention and control.

Incidence and risk factors for infection in oral cancer patients undergoing different treatments protocols

BACKGROUND

Over the past decade, advances in cancer treatments have been counterbalanced by a rising number of immunosuppressed patients with a multitude of new risk factors for infection. Hence, the aim of this study was to determine risk factors, infectious pathogens in blood and oral cavity of oral cancer patients undergoing different treatment procedures.

METHODS

The present prospective cohort analysis was conducted on the patients undergoing treatment in the radiotherapy unit of Regional Cancer Institute, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, during the period of January 2007 to October 2009. Total 186 patients with squamous cell carcinoma of oral cavity were analyzed in the study. Based on treatment procedures patients were divided into three groups, group I were under radiotherapy, group II under chemotherapy and group III were of radio chemotherapy together. Clinical isolates from blood and oral cavity were identified by following general microbiological, staining and biochemical methods. The absolute neutrophile counts were done by following the standard methods.

RESULTS

Prevalent bacterial pathogens isolated were Staphylococcus aureus, Escherichia coli, Staphylococcus epidermidis, Pseudomonas aeruginosa, Klebsiella pneumonia, Proteus mirabilis, Proteus vulgaris and the fungal pathogens were Candida albicans, Aspergillus fumigatus. The predominant gram negative bacteria, Pseudomonas aeruginosa and Klebsiella pneumonia were isolated from blood of radiotherapy and oral cavity of chemotherapy treated cases respectively. The predominance of gram positive bacteria (Staphylococcus aureus and Staphylococcus epidermidis) were observed in blood of chemotherapy, radio chemotherapy cases and oral cavity of radiotherapy, radio chemotherapy treated cases. Our study also revealed the presence of C. albicans fungi as most significant oral cavity pathogens in radiotherapy and radio chemotherapy cases.

CONCLUSION

Gram positive bacteria and Gram negative were reported from the blood of all the three groups of patients. Oral mucositis played a significant role in oral cavity infection and make patients more prone to C. albicans infection.