Nosocomial respiratory syncytial virus infections: the cost-effectiveness and cost-benefit of infection control

Respiratory syncytial virus nosocomial outbreak in neonatal intensive care: A review of the incidence, management, and outcomes

BACKGROUND

The main objective was to determine the incidence, management, and outcomes of respiratory syncytial virus nosocomial infection (RSVNI) outbreaks in neonatal intensive care units.

METHODS

A comprehensive search of RSVNI in 9 databases was conducted from January 1, 2000 to May 1, 2021, of which the Cochrane Library comprised the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. Two hundred and twenty-eight articles were retrieved and 17 were retained. A descriptive analysis was performed, and frequencies are reported as mean, median, and range where pertinent.

RESULTS

One hundred and seventeen infants were analyzed and comprised preterms (88.1%) and those with pre-existing co-morbidities. The estimated proportional incidence of RSVNI was 23.8% (177/744) infants. Outbreaks were principally managed by conventional protective measures, neonatal intensive care unit closure, and visitor restriction. Palivizumab was used to control RSVNI in 10 studies. RSVNI-related mortality was 8.5% (15/177) and 8.0% (7/87) among infants where infection control was solely employed.

CONCLUSION

RSVNI is associated with significant morbidity and mortality. The use of palivizumab should be a multidisciplinary decision, based on rapidly spreading infection. Prospective studies are essential to determine the cost-benefit of palivizumab versus standard prevention control for an RSVNI outbreak.

Viral Respiratory Infections in Hospitalized Children With Symptomatic Caregivers

OBJECTIVES

The burden of healthcare-associated viral respiratory infections (HAVRIs) among children is significant. While healthcare workers are often the focus for infection prevention strategies, little is known about the impact of sick caregivers and hospital visitors on the incidence of pediatric HAVRIs. The objective of this descriptive study was to determine the proportion of pediatric HAVRIs following contact with a sick caregiver or visitor.

METHODS

A retrospective chart review was performed of all HAVRIs that occurred between December 2017 and July 2019 in a pediatric tertiary care center. A HAVRI was defined as a laboratory-confirmed respiratory viral illness occurring more than 72 hours after admission.

RESULTS

Forty-four HAVRIs occurred in 37 patients during the study, predominantly among patients aged <24 months (n = 32, 72.7%) and with comorbidities (n = 42, 95.5%). For 9 HAVRIs (20.5%), contact with a sick caregiver (n = 8, 18.2%) or visitor (n = 2, 4.5%) in the 7 days before diagnosis was documented. In the 72 hours before HAVRI onset, 18 of the 44 patients (40.9%) were in a single-bed room and 6 of them (33.3%) were under additional precautions. Twelve patients (27.3%) had new or increased oxygen requirements and 4 (9.1%) were transferred to the ICU. There were no associated deaths.

CONCLUSIONS

Contact with a sick caregiver or visitor is a potential risk factor for acquiring a HAVRI. Our study reinforces the importance of engaging family caregivers in infection prevention and control strategies in pediatric care settings.

Multiple Respiratory Syncytial Virus Introductions Into a Neonatal Intensive Care Unit

BACKGROUND

Outbreaks of respiratory syncytial virus (RSV) in neonatal intensive care units (NICUs) are of concern because of the risk of severe disease in young infants. We describe an outbreak of RSV in a NICU and use whole genome sequencing (WGS) to better understand the relatedness of viruses among patients.

METHODS

An investigation was conducted to identify patients and describe their clinical course. Infection control measures were implemented to prevent further spread. Respiratory specimens from outbreak-related patients and the community were tested using WGS. Phylogenetic trees were constructed to understand relatedness of the viruses.

RESULTS

Seven patients developed respiratory symptoms within an 11-day span in December 2017 and were diagnosed with RSV; 6 patients (86%) were preterm and 1 had chronic lung disease. Three patients required additional respiratory support after symptom onset, and none died. Six of 7 patients were part of the same cluster based on > 99.99% nucleotide agreement with each other and 3 unique single-nucleotide polymorphisms were identified in viruses sequenced from those patients. The seventh patient was admitted from the community with respiratory symptoms and had a genetically distinct virus that was not related to the other 6. Implementation of enhanced infection control measures likely limited the spread.

CONCLUSIONS

Using WGS, we found 2 distinct introductions of RSV into a NICU, highlighting the risk of healthcare-associated infections during RSV season. Early recognition and infection control measures likely limited spread, emphasizing the importance of considering RSV in the differential diagnosis of respiratory infections in healthcare settings.

Safe Healthcare Facilities: A Systematic Review on the Costs of Establishing and Maintaining Environmental Health in Facilities in Low- and Middle-Income Countries

A hygienic environment is essential to provide quality patient care and prevent healthcare-acquired infections. Understanding costs is important to budget for service delivery, but costs evidence for environmental health services (EHS) in healthcare facilities (HCFs) is lacking. We present the first systematic review to evaluate the costs of establishing, operating, and maintaining EHS in HCFs in low- and middle-income countries (LMICs). We systematically searched for studies costing water, sanitation, hygiene, cleaning, waste management, personal protective equipment, vector control, laundry, and lighting in LMICs. Our search yielded 36 studies that reported costs for 51 EHS. There were 3 studies that reported costs for water, 3 for sanitation, 4 for hygiene, 13 for waste management, 16 for cleaning, 2 for personal protective equipment, 10 for laundry, and none for lighting or vector control. Quality of evidence was low. Reported costs were rarely representative of the total costs of EHS provision. Unit costs were infrequently reported. This review identifies opportunities to improve costing research through efforts to categorize and disaggregate EHS costs, greater dissemination of existing unpublished data, improvements to indicators to monitor EHS demand and quality necessary to contextualize costs, and development of frameworks to define EHS needs and essential inputs to guide future costing.

Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions

Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.

Clinical impact and direct costs of nosocomial respiratory syncytial virus infections in the neonatal intensive care unit

BACKGROUND

Nosocomial infections are a leading cause of morbidity, costs, and mortality in preterm newborns. Most reports regarding nosocomial infections in neonatal intensive care units (NICU) are focused on bacterial infections and there is limited information regarding the impact of nosocomial viruses. The objective of this study was to assess the impact of nosocomial respiratory syncytial virus (RSV) infections in a NICU.

METHODS

This was a retrospective cohort design from a NICU in a general hospital in Mexico. We included 24 newborn infants with nosocomial RSV infection and 24 infants without RSV matched by gestational age, birth weight, and the period of time of hospitalization.

RESULTS

Infants with nosocomial RSV infection had longer hospitalization duration (median 24 days vs. 13 days; P = .05), increased antibiotic use (45.8% vs. 8.3%; P = .003), more mechanical ventilation requirement (54.2% vs. 0.4%; P <.001), more frequent nosocomial infections (45.8% vs. 0%; P <.001), and higher hospitalization direct costs (median 3,587.20 USD vs. 1,123.60 USD; P = .001) after nosocomial RSV detection.

CONCLUSIONS

Nosocomial RSV infections are associated to a significant increase of costs in infants hospitalized in the NICU. Evaluation of interventions that may reduce the incidence of nosocomial RSV infections in this setting is warranted.

Nosocomial Infections in Patients Hospitalized with Respiratory Syncytial Virus: A Practice Review

Viral testing is not always recommended in children with bronchiolitis due to doubts concerning its prognostic use. In this retrospective study, we investigated how the RSV testing would influence the frequency of nosocomial infections (NI). The files of 305 children, hospitalized due to the respiratory syncytial virus (RSV) infection in the period 2010-2014, were reviewed in the study. We found ten cases of NI. The RSV preventive measures did not vary in the consecutive years investigated, but the number of viral tests substantially varied. In 2010, 2012, and 2014, when ca. 2 tests per RSV(+) patient were performed, the risk of NI per patient was 1.3%, while in 2011 and 2013, when the RSV testing was less frequent, the accumulated risk per patient was 5.2%. There was a strong adverse relationship between the number of tests performed and the number of NI (rho = -0.975). The children with NI, when compared to those without NI, required a longer hospital stay, generating higher hospital costs regarding treatment, productivity loss, and indirect costs. The expenditure for RSV testing in the years of a low NI risk was higher than that in the high-risk years. Conversely, the expenditure related to NI management was lower in the years of a low NI risk. Each euro spent on RSV testing saved over 26 € from the NI management expenditure. We conclude that RSV testing is needed in the hospital setting to isolate the infected children and to prevent nosocomial RSV spread. This strategy is health advantageous and requires less resources than NI treatment.

Prevention of respiratory outbreaks in the rehabilitation setting

Background

Respiratory viral (RV) outbreaks in rehabilitation facilities can jeopardise patient safety, interfere with patient rehabilitation goals and cause unit closures that impede patient flow in referring facilities.

Problem

Despite education about infection prevention practices, frequent RV outbreaks were declared each year at our rehabilitation facility.

Methods

Before and after study design. The primary outcome was the number of bed closure days due to outbreak per overall bed days. Process measures included delays in initiation of transmission-based precautions, RV testing and reporting of staff to occupational health and safety (OHS). Balancing measures included the number of isolation days and staff missed work hours.

Interventions

Based on comprehensive analysis of prior outbreaks, the following changes were implemented: (1) clear criteria for initiation of transmission-based precautions, (2) communication to visitors to avoid visitation if infectious symptoms were present, (3) exemption of staff absences if documented due to infectious illness, (4) development of an electronic programme providing guidance to staff about whether they should be excluded from work due to infectious illness.

Results

The number of bed closure days due to outbreak per overall bed days dropped from 2.8% to 0.5% during the intervention season and sustained at 0.6% during the postintervention season (p<0.001). There were fewer delays in initiation of droplet and contact precautions (28.8% to 15.5%, p=0.005) and collection of RV testing (42.9% to 20.3%, p<0.001), better reporting to OHS (9 vs 28.8 reports per 100 employees; p<0.001) and fewer isolation days (7.8% vs 7.3%; p=0.02) without a significant increase in missed work hours per 100 hours worked (4.0 vs 3.9; p=0.12).

Conclusion

This Quality Improvement study highlights the process changes that can prevent respiratory outbreaks in the rehabilitation setting.

Respiratory syncytial virus: diagnosis, prevention and management

Respiratory syncytial virus (RSV) is responsible for a large burden of disease globally and can present as a variety of clinical syndromes in children of all ages. Bronchiolitis in infants under 1 year of age is the most common clinical presentation hospitalizing 24.2 per 1000 infants each year in the United Kingdom. RSV has been shown to account for 22% of all episodes of acute lower respiratory tract infection in children globally. RSV hospitalization, that is, RSV severe disease, has also been associated with subsequent chronic respiratory morbidity. Routine viral testing in all children is not currently recommended by the United Kingdom National Institute for Health and Care Excellence (NICE) or the American Academy of Pediatrics (AAP) guidance and management is largely supportive. There is some evidence for the use of ribavirin in severely immunocompromised children. Emphasis is placed on prevention of RSV infection through infection control measures both in hospital and in the community, and the use of the RSV-specific monoclonal antibody, palivizumab, for certain high-risk groups of infants. New RSV antivirals and vaccines are currently in development. Ongoing work is needed to improve the prevention of RSV infection, not only because of the acute morbidity and mortality, but also to reduce the associated chronic respiratory morbidity after severe infection.

Development of a Rapid Fluorescent Immunochromatographic Test to Detect Respiratory Syncytial Virus

Human respiratory syncytial virus (RSV) is one of the most common viruses infecting the respiratory tracts of infants. The rapid and sensitive detection of RSV is important to minimize the incidence of infection. In this study, novel monoclonal antibodies (mAbs; B11A5 and E8A11) against RSV nucleoprotein (NP) were developed and applied to develop a rapid fluorescent immunochromatographic strip test (FICT), employing europium nanoparticles as the fluorescent material. For the FICT, the limits of detection of the antigen and virus were 1.25 µg/mL and 4.23 × 10⁶ TCID₅₀/mL, respectively, corresponding to 4.75 × 10⁶ ± 5.8 ×10⁵ (mean ± SD) RNA copy numbers per reaction mixture for RSV NP. A clinical study revealed a sensitivity of 90% (18/20) and specificity of 98.18% (108/110) for RSV detection when comparing the performance to that of reverse transcription polymerase chain reaction (RT-PCR), representing a 15% improvement in sensitivity over the SD Bioline rapid kit. This newly developed FICT could be a useful tool for the rapid diagnosis of RSV infection.

Visitor restriction policies and practices in children's hospitals in North America: results of an Emerging Infections Network Survey

OBJECTIVE

To delineate the timing of, indications for, and assessment of visitor restriction policies and practices (VRPP) in pediatric facilities.

DESIGN

An electronic survey to characterize VRPP in pediatric healthcare facilities.

METHODS

The Infectious Diseases Society of America Emerging Infections Network surveyed 334 pediatric infectious disease consultants via an electronic link. Descriptive analyses were performed.

RESULTS

A total of 170 eligible respondents completed a survey between 12 July and August 15, 2016, for a 51% response rate. Of the 104 respondents (61%) familiar with their VRPP, 92 (88%) had VRPP in all inpatient units. The respondents reported age-based VRPP (74%) symptom-based VRPP (97%), and outbreak-specific VRPP (75%). Symptom-based VRPP were reported to be seasonal by 24% of respondents and to be implemented year-round according to 70% of respondents. According to the respondents, communication of VRPP to families occurred at admission (87%) and through signage in care areas (64%), while communication of VRPP to staff occurred by email (77%), by meetings (55%), and by signage in staff-only areas (49%). Respondents reported that enforcement of VRPP was the responsibility of nursing (80%), registration clerks (58%), unit clerks (53%), the infection prevention team (31%), or clinicians 16 (16%). They also reported that the effectiveness of VRPP was assessed through active surveillance of hospital acquired respiratory infections (62%), through active surveillance of healthcare worker exposures (28%) and through patient/family satisfaction assessments (29%).

CONCLUSION

Visitor restriction policies and practices vary in scope, implementation, enforcement, and physician awareness in pediatric facilities. A prospective multisite evaluation of outcomes would facilitate the adoption of uniform guidance.

Evaluation of the national laboratory-based surveillance system for respiratory syncytial virus in Sweden, 2015-2016

BACKGROUND

Most laboratories use RSV PCR but near-patient tests (NPT) performed at paediatric clinics are believed to be increasingly used. Anonymised data on RSV infections has been collected since 1990 in Sweden. No evaluation of Swedish RSV surveillance or use of laboratory testing had previously been performed.

OBJECTIVES

Swedish RSV data and methods used for RSV laboratory testing and reporting were evaluated in order to improve RSV surveillance in a forthcoming vaccine era.

STUDY DESIGN

RSV data obtained in Sweden 2015-2016 were reviewed. Data on methods used for the RSV laboratory detection and reporting were collected via on-line questionnaires submitted to laboratories (n = 26) and clinics (n = 4) known to perform virological testing. Swedish Quality Control Program reports from 2013 to 2015 on the performance of RSV testing were also evaluated.

RESULTS

Over 60% of RSV infections were diagnosed in children under 5 years (1917/2925), but infections were also common in those 65 years and older (n = 607). Two laboratories limited RSV testing to children only. RSV NPT was utilised in eight clinics; four participated in RSV surveillance. RSV NPTs evaluated could only detect 50% of RSV positive samples. Reporting was complete and timely, but took too much time (18 min/week/laboratory).

CONCLUSIONS

Although most common in children, RSV infections are also common in the elderly, and testing should not be limited to children only. The poor performance of RSV NPT and importance of confirming results should be communicated to all relevant laboratories and clinics. All clinics should be encouraged to participate in surveillance. Automated case-based reporting should be considered.

Parallel Validation of Three Molecular Devices for Simultaneous Detection and Identification of Influenza A and B and Respiratory Syncytial Viruses

Rapid identification of respiratory pathogens, such as influenza virus A (FluA), influenza virus B (FluB), and respiratory syncytial virus (RSV), reduces unnecessary antimicrobial use and enhances infection control practice. We performed a comparative evaluation of three molecular methods: (i) the Aries Flu A/B & RSV, (ii) the Xpert Xpress Flu/RSV, and (iii) the Cobas Flu A/B & RSV assays. The clinical performances of the three methods were evaluated using 200 remnant nasopharyngeal swab (NPS) specimens against a combined reference standard. The limits of detection (LODs) were determined using FluA, FluB, and RSV control strains with known titers. The 95% LODs were between 1.702 and 0.0003 50% tissue culture infective dose (TCID₅₀), with no significant differences revealed among the three assays. Perfect qualitative detection agreement was obtained in the reproducibility study. The Cobas assay failed at the first run on 13 clinical specimens, resulting in an invalid rate of 6.5%. The sensitivities and specificities for all assays were 96.0 to 100.0% and 99.3 to 100% for all three viruses. For on-demand single-specimen and batched 12-specimen workflows, the test turnaround times were 115.5 and 128.8 min for the Aries assay (12 sample capacity), 34.2 and 44.2 min for the Xpress assay (16 sample capacity), and 21.0 and 254.4 min for the Cobas assay (one instrument), respectively. In summary, the Aries, Xpress, and Cobas Liat assays demonstrated excellent sensitivities and specificities for simultaneous detection and identification of FluA, FluB, and RSV from NPS specimens in cancer patients. Test turnaround time was significantly shorter on the Xpress when instrument scalability is unlimited.

Respiratory RNA Viruses

Acute upper and lower respiratory infections are a major public health problem and a leading cause of morbidity and mortality worldwide. At greatest risk are young children, the elderly, the chronically ill, and those with suppressed or compromised immune systems. Viruses are the predominant cause of respiratory tract illnesses and include RNA viruses such as respiratory syncytial virus, influenza virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus. Laboratory testing is required for a reliable diagnosis of viral respiratory infections, as a clinical diagnosis can be difficult since signs and symptoms are often overlapping and not specific for any one virus. Recent advances in technology have resulted in the development of newer diagnostic assays that offer great promise for rapid and accurate detection of respiratory viral infections. This chapter emphasizes the fundamental characteristics and clinical importance of the various RNA viruses that cause upper and lower respiratory tract diseases in the immunocompromised host. It highlights the laboratory methods that can be used to make a rapid and definitive diagnosis for the greatest impact on the care and management of ill patients, and the prevention and control of hospital-acquired infections and community outbreaks.

Development of TaqMan RT-qPCR for the detection of type A human respiratory syncytial virus

The human respiratory syncytial virus is a common respiratory pathogen in children. Improved diagnosis of the virus is dependent on the development of tools for the rapid detection and estimation of the viral loads. In the current study, RT-qPCR using TaqMan hydrolysis probe based on the F gene detection was developed to identify and quantify hRSV in clinical samples. The assay was validated by comparing the results with a commercially available RT-qPCR kit. The newly developed assay was sensitive in detecting hRSV positive samples (59/126) which were equivalent to those detected by the commercial kit (57/126) with a detection limit of 1 × 10² copies/mL. A high correlation was found between the results of the newly developed assay and the commercial one. It was concluded that the newly developed RT-qPCR assay can be used as a sensitive detection tool for hRSV-A.

Direct costs of acute respiratory infections in a pediatric long-term care facility

Acute respiratory tract infections (ARI) are a major burden in pediatric long‐term care. We analyzed the financial impact of ARI in 2012–2013. Costs associated with ARI during the respiratory viral season were ten times greater than during the non‐respiratory viral season, $31 224 and $3242 per 1000 patient‐days, respectively (P < 0·001). ARI are burdensome for pediatric long‐term care facilities not only because of the associated morbidity and mortality, but also due to the great financial costs of prevention.

Strategies to Prevent MRSA Transmission in Community-Based Nursing Homes: A Cost Analysis

OBJECTIVE To estimate the costs of 3 MRSA transmission prevention scenarios compared with standard precautions in community-based nursing homes. DESIGN Cost analysis of data collected from a prospective, observational study. SETTING AND PARTICIPANTS Care activity data from 401 residents from 13 nursing homes in 2 states. METHODS Cost components included the quantities of gowns and gloves, time to don and doff gown and gloves, and unit costs. Unit costs were combined with information regarding the type and frequency of care provided over a 28-day observation period. For each scenario, the estimated costs associated with each type of care were summed across all residents to calculate an average cost and standard deviation for the full sample and for subgroups. RESULTS The average cost for standard precautions was $100 (standard deviation [SD], $77) per resident over a 28-day period. If gown and glove use for high-risk care was restricted to those with MRSA colonization or chronic skin breakdown, average costs increased to $137 (SD, $120) and $125 (SD, $109), respectively. If gowns and gloves were used for high-risk care for all residents in addition to standard precautions, the average cost per resident increased substantially to $223 (SD, $127). CONCLUSIONS The use of gowns and gloves for high-risk activities with all residents increased the estimated cost by 123% compared with standard precautions. This increase was ameliorated if specific subsets (eg, those with MRSA colonization or chronic skin breakdown) were targeted for gown and glove use for high-risk activities. Infect Control Hosp Epidemiol 2016;37:962-966.

Best practice in the prevention and management of paediatric respiratory syncytial virus infection

Respiratory syncytial virus (RSV) infection is ubiquitous with almost all infants having been infected by 2 years of age and lifelong repeated infections common. It is the second largest cause of mortality, after malaria, in infants outside the neonatal period and causes up to 200,000 deaths per year worldwide. RSV results in clinical syndromes that include upper respiratory tract infections, otitis media, bronchiolitis (up to 80% of cases) and lower respiratory tract disease including pneumonia and exacerbations of asthma or viral-induced wheeze. For the purposes of this review we will focus on RSV bronchiolitis in infants in whom the greatest disease burden lies. For infants requiring hospital admission, the identification of the causative respiratory virus is used to direct cohorting or isolation and infection control procedures to minimize nosocomial transmission. Nosocomial RSV infections are associated with poorer clinical outcomes, including increased mortality, the need for mechanical ventilation and longer length of hospital stay. Numerous clinical guidelines for the management of infants with bronchiolitis have been published, although none are specific for RSV bronchiolitis. Ribavirin is the only licensed drug for the specific treatment of RSV infection but due to drug toxicity and minimal clinical benefit it has not been recommended for routine clinical use. There is currently no licensed vaccine to prevent RSV infection but passive immunoprophylaxis using a monoclonal antibody, palivizumab, reduces the risk of hospitalization due to RSV infection by 39-78% in various high-risk infants predisposed to developing severe RSV disease. The current management of RSV bronchiolitis is purely supportive, with feeding support and oxygen supplementation until the infant immune system mounts a response capable of controlling the disease. The development of a successful treatment or prophylactic agent has the potential to revolutionize the care and outcome for severe RSV infections in the world's most vulnerable infants.

Risk of nosocomial respiratory syncytial virus infection and effectiveness of control measures to prevent transmission events: a systematic review

Respiratory syncytial virus (RSV) causes a significant public health burden, and outbreaks among vulnerable patients in hospital settings are of particular concern. We reviewed published and unpublished literature from hospital settings to assess: (i) nosocomial RSV transmission risk (attack rate) during outbreaks, (ii) effectiveness of infection control measures. We searched the following databases: MEDLINE, EMBASE, CINAHL, Cochrane Library, together with key websites, journals and grey literature, to end of 2012. Risk of bias was assessed using the Cochrane risk of bias tool or Newcastle–Ottawa scale. A narrative synthesis was conducted. Forty studies were included (19 addressing research question one, 21 addressing question two). RSV transmission risk varied by hospital setting; 6–56% (median: 28·5%) in neonatal/paediatric settings (n = 14), 6–12% (median: 7%) in adult haematology and transplant units (n = 3), and 30–32% in other adult settings (n = 2). For question two, most studies (n = 13) employed multi‐component interventions (e.g. cohort nursing, personal protective equipment (PPE), isolation), and these were largely reported to be effective in reducing nosocomial transmission. Four studies examined staff PPE; eye protection appeared more effective than gowns and masks. One study reported on RSV prophylaxis for patients (RSV‐Ig/palivizumab); there was no statistical evidence of effectiveness although the sample size was small. Overall, risk of bias for included studies tended to be high. We conclude that RSV transmission risk varies widely during hospital outbreaks. Although multi‐component control strategies appear broadly successful, further research is required to disaggregate the effectiveness of individual components including the potential role of palivizumab prophylaxis.

Design of the PROUD study: PCR faeces testing in outpatients with diarrhoea

Background

Infectious intestinal disease (IID) is an important cause of morbidity in developed countries and a frequent reason for general practitioner (GP) consultation. In recent years polymerase chain reaction (PCR) based techniques have gradually replaced conventional enteropathogen detection techniques like microscopy and culture in primary care patients suspected of IID. PCR features testing of multiple enteropathogens in a single faecal sample with shorter turnaround times and greater sensitivity compared to conventional techniques. However, the associated costs and benefits have not been quantified. Furthermore, primary care incidence and prevalence estimates of enteropathogens associated with IID are sparsely available and predominantly based on conventional techniques. The PROUD-study (PCR diagnostics in Outpatients with Diarrhoea) determines: 1) health (care) effects and 2) cost-effectiveness of PCR introduction in primary care patients suspected of IID; 3) occurrence of major enteropathogens in primary care patients suspected of IID.

Methods

A before-after cohort study will be performed of patients with suspected IID consulting a GP in the Utrecht General Practitioner Network (UGPN), covering the before period (2010–2011) with conventional testing and the after period (2013–2014) with PCR testing. Prospective study data on patient characteristics and primary outcome measures (i.e. healthcare use and disease outcome) will be collected from electronic patient and laboratory records in 2015 and 2016. The effect of PCR introduction is investigated by comparing the primary outcome measures and their associated healthcare costs between the conventional period and the PCR period, and is followed by a cost-effectiveness analysis. To determine the occurrence of enteropathogens associated with IID in primary care, routine care faeces samples from the year 2014 will be screened using PCR.

Discussion

The PROUD-study will quantify the costs and effects of the introduction of PCR techniques for enteropathogens in primary care patients suspected of IID and generate up-to-date and sensitive estimates of enteropathogen occurrence among primary care patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1371-z) contains supplementary material, which is available to authorized users.

Revised recommendations concerning palivizumab prophylaxis for respiratory syncytial virus (RSV)

Respiratory Syncytial Virus infections are one of the leading causes of severe respiratory diseases that require hospitalization and, in some cases, intensive care. Once resolved, there may be respiratory sequelae of varying severity. The lack of effective treatments for bronchiolitis and the lack of vaccines for RSV accentuate the role of prevention in decreasing the impact of this disease. Prevention of bronchiolitis strongly relies on the adoption of environment and the hygienic behavior measures; an additional prophylactic effect may be offered, in selected cases, by Palivizumab, a humanized monoclonal antibody produced by recombinant DNA technology, able to prevent RSV infection by blocking viral replication.After many years the Italian Society of Neonatology, on the basis of the most recent scientific knowledge, has decided to revise recommendations for the use of palivizumab in the prevention of RSV infection.

Effect of an Infection Control Program on the Frequency of Nosocomial Viral Respiratory Infections

We determined the rate of nosocomial viral respiratory infection in infants and the effect of an infection control program during 4 winter seasons. The rate of nosocomial viral respiratory infection decreased from 6.09 episodes per 100 patients admitted during the first study year to 1.46 episodes per 100 patients admitted during the last study year.

Surveillance for Healthcare-Acquired Febrile Respiratory Infection in Pediatric Hospitals Participating in the Canadian Nosocomial Infection Surveillance Program

Objective.

To determine the rates of healthcare-acquired febrile respiratory infection (HA-FRI) in Canadian pediatric hospitals and to determine the vaccination status of patients with healthcare-acquired respiratory syncytial virus (RSV) infection, influenza, or pneumococcal infection who were also eligible for immunoprophylaxis.

Methods.

Prospective surveillance was conducted in 8 hospitals from January 1 to April 30, 2005. All hospitalized patients less than 18 years of age were eligible, except for patients housed in standard newborn nurseries or psychiatric units. Infection control professionals reviewed laboratory reports, conducted ward rounds, and reviewed medical records to identify case patients. Descriptive analyses were completed, as well.

Results.

A total of 96 case patients were identified; 52 (54%) were male, and 48 (50%) were aged 1 year or less. Seventy-two patients (75%) had chronic medical conditions. Respiratory viruses accounted for 72 (71%) of 101 pathogens identified, and RSV was the virus most frequently identified. Of these 96 patients, 9 (9%) died, and 3 (3%) of the deaths were related to the patient's HA-FRI. The mean incidence rate was 0.97 infections/1,000 patient-days (range, 0.29–1.50 infections/1,000 patient-days). Only 2 (15%) of 13 influenza vaccine-eligible children who acquired influenza while hospitalized were reported to have been vaccinated, but influenza vaccination status was unknown for most children. However, 4 (80%) of 5 RSV prophylaxis-eligible children who had healthcare-acquired RSV infection had received immunoprophylaxis with anti-RSV monoclonal antibody.

Conclusions.

HA-FRI is mainly caused by viruses such as RSV, and it primarily affects children under 1 year of age and those with chronic medical conditions.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants

Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.

Nosocomial respiratory syncytial virus infections in the palivizumab-prophylaxis era with implications regarding high-risk infants

BACKGROUND

Although respiratory syncytial virus (RSV) infection continues to be a leading cause of infant hospitalization with a high transmission rate, recent data on nosocomial RSV infection are scarce. This study investigated the clinical and epidemiologic characteristics of nosocomial RSV infection in the palivizumab-prophylaxis era.

METHODS

The database of a tertiary pediatric medical center was searched for all hospitalized patients with RSV-positive respiratory disease in 2008-2010. Data were compared between patients with community-associated and nosocomial disease, and the qualification of the latter group for palivizumab was evaluated.

RESULTS

Of the 873 children identified, 30 (3.4%) had a nosocomial infection. This group accounted for 0.06% of all admissions during the study period. The nosocomial infection group had higher rates of preterm birth and severe underlying disease than the community-associated RSV group and a longer mean hospital stay. The nosocomial infection group also had higher rates of intensive care unit admission and mechanical ventilation. Although 73% had underlying conditions, most (80%) did not qualify for RSV immunoprophylaxis, including 7 children (23%) with immune deficiency.

CONCLUSION

Nosocomial RSV infection is a significant cause of morbidity among hospitalized infants, especially those with comorbidities and lengthy hospital stay, and is associated with a complicated clinical course. In addition to strict infection-control measures, extending palivizumab prophylaxis to additional selected high-risk populations should be considered.

Preventing severe respiratory syncytial virus disease: passive, active immunisation and new antivirals

In most high-income countries palivizumab prophylaxis is considered safe, efficacious and cost-effective for preventing respiratory syncytial virus (RSV) hospital admissions among specific subgroups of infants born preterm, with chronic lung disease or with congenital heart disease. Virtually all babies acquire RSV during infancy and previously healthy babies are not eligible to receive palivizumab. Emerging evidence suggests some benefit of palivizumab use in reducing recurrent wheeze among infants born preterm. Better longitudinal studies are needed to examine its clinical and cost-effectiveness on recurrent and chronic respiratory illness and associated healthcare burden on resources in the community and hospitals. Since 99% of child deaths attributed to RSV occur in resource poor countries where expensive prophylaxis is not available or affordable, palivizumab has limited potential to impact on the current global burden of RSV lower respiratory tract infection (LRTI). A range of candidate vaccines for active immunisation against RSV are now in clinical trials. Two promising new antivirals are also currently in phase I/II trials to test their effectiveness in preventing severe RSV LRTI. These agents may be effective in preventing severe disease and phase III studies are in development. In the absence of effective active immunisation against RSV infection, population level approaches to prevent severe RSV LRTI should continue to focus on reducing prenatal and environmental risk factors including prematurity, smoking and improving hygiene practices.

A model of the costs of community and nosocomial pediatric respiratory syncytial virus infections in Canadian hospitals

BACKGROUND

Approximately one in 10 hospitalized patients will acquire a nosocomial infection (NI) after admission to hospital, of which 71% are due to respiratory viruses, including the respiratory syncytial virus (RSV). NIs are concerning and lead to prolonged hospitalizations. The economics of NIs are typically described in generalized terms and specific cost data are lacking.

OBJECTIVE

To develop an evidence-based model for predicting the risk and cost of nosocomial RSV infection in pediatric settings.

METHODS

A model was developed, from a Canadian perspective, to capture all costs related to an RSV infection hospitalization, including the risk and cost of an NI, diagnostic testing and infection control. All data inputs were derived from published literature. Deterministic sensitivity analyses were performed to evaluate the uncertainty associated with the estimates and to explore the impact of changes to key variables. A probabilistic sensitivity analysis was performed to estimate a confidence interval for the overall cost estimate.

RESULTS

The estimated cost of nosocomial RSV infection adds approximately 30.5% to the hospitalization costs for the treatment of community-acquired severe RSV infection. The net benefits of the prevention activities were estimated to be equivalent to 9% of the total RSV-related costs. Changes in the estimated hospital infection transmission rates did not have a significant impact on the base-case estimate.

CONCLUSIONS

The risk and cost of nosocomial RSV infection contributes to the overall burden of RSV. The present model, which was developed to estimate this burden, can be adapted to other countries with different disease epidemiology, costs and hospital infection transmission rates.

Detection of respiratory coinfections in pediatric patients using a small volume polymerase chain reaction array respiratory panel: more evidence for combined droplet and contact isolation

BACKGROUND

In fall 2009, Children's Hospital of Michigan (CHM) instituted combined isolation precautions (contact and droplet isolation) for pediatric inpatients with upper respiratory infection (URI) symptoms to prevent health care-associated infection.

METHODS

Pediatric patients with symptoms of URI had nasopharyngeal (NP) swab samples obtained prospectively between January and April and September and December 2010 for small volume polymerase chain reaction (SVPCR) array respiratory panel (RP) multiplex nucleic acid testing. NP swabs or nasal washes were obtained for viral culture and rapid antigen testing (RAT).

RESULTS

Of 499 evaluable SVPCR array RP samples, 344 (69%) tested positive for at least 1 of the 21 tested organisms. The most commonly identified pathogen was rhinovirus/enterovirus (181/344 [53%]) for which no RAT exists at CHM. Of 344 positive specimens, 57 (17%) had at least 2 identified pathogens; 8 (2%) of these had 3. In 11% of patients, molecular testing detected pathogens or pathogen combinations requiring both contact and droplet precautions.

CONCLUSION

SVPCR array RP testing detected respiratory pathogens in pediatric patients with URI at rates higher than that of RAT and viral culture. Because of the pathogens and pathogen combinations detected, the study findings suggest that combined contact and droplet isolation precautions may be warranted to prevent health care-associated infection in pediatric inpatients with URI. Further studies will be needed to confirm these results.

Benefits of universal gloving on hospital-acquired infections in acute care pediatric units

BACKGROUND

To prevent transmission, some pediatric units require clinicians to wear gloves for all patient contacts during RSV season. We sought to assess whether a mandatory gloving policy reduced the risk of other health care-acquired infections (HAIs).

METHODS

This retrospective cohort study included all patients admitted to pediatric units of a tertiary care center between 2002 and 2010. Poisson regression models were used to measure the association between mandatory gloving and HAI incidence. Autoregressive models were used to adjust for time correlation.

RESULTS

During the study period, 686 HAIs occurred during 363 782 patient-days. The risk of any HAI was 25% lower during mandatory gloving periods compared with during nongloving periods (relative risk [RR]: 0.75; 95% confidence interval [CI]: 0.69-0.93; P = .01), after adjusting for long-term trends and seasonal effect. Mandatory gloving was associated with lower risks of bloodstream infections (RR: 0.63; 95% CI: 0.49-0.81; P < .001), central line-associated bloodstream infections (RR: 0.61; 95% CI: 0.44-0.84; P = 0.003), and hospital-acquired pneumonia (RR: 0.20; 95% CI: 0.03-1.25; P= 0.09). The reduction was significant in the PICU (RR: 0.63; 95% CI: 0.42-0.93; P = .02), the NICU (RR: 0.62; 95% CI: 0.39-0.98; P = .04), and the Pediatric Bone Marrow Transplant Unit (RR: 0.52; 95% CI: 0.29-0.91, P = .02).

CONCLUSIONS

Universal gloving during RSV season was associated with significantly lower rates of bacteremia and central line-associated bloodstream infections, particularly in the ICUs and the Pediatric Bone Marrow Transplant Unit.

Rotavirus, respiratory syncytial virus and non-rotaviral gastroenteritis analysis of hospital readmissions in England and Wales

AIM

To quantify readmissions with infectious diseases and differences in readmission patterns.

METHODS

Using the CHKS database, children <5 years admitted to hospital in England and Wales, between 2000 and 2008, with rotavirus (RV), respiratory syncytial virus (RSV) or non-rotaviral gastroenteritis (NRV) were identified. All admissions within a 30-day prior period were similarly identified, and the proportion of readmissions was calculated.

RESULTS

There were 365,693 admissions for RV, RSV and NRV; 17.2% were readmissions. In 36% of cases, the cause of the prior admission was also RV, RSV or NRV, with 64% having a different prior diagnosis. The majority of readmissions were within 5 days of their prior admission, the majority of those with RV (n = 2,566/58.7%) within 3 days, NRV (n = 11 326/53.5%) within 4 days and RSV (n = 18 811/50.2%) within 9 days of prior discharge. Readmission for RV was associated with greater LOS than RSV (p < 0.001) and NRV (p < 0.001), while cost per admission was greater for RV compared to RSV (p < 0.001) and NRV (p < 0.001).

CONCLUSIONS

Thirty-six percent of readmissions indicated discharge without resolution from the first admission; nosocomial infection needs to be considered as a cause in the other. Although RSV represented the largest readmission group, higher costs and longer LOS were associated with RV.

Respiratory syncytial virus disease: prevention and treatment

Respiratory syncytial virus (RSV) is one of the most clinically important viruses infecting young children, the elderly, and the immunocompromised. Over the past decade, the most significant advance in the prevention of RSV disease has been the development of high-titered antibody products. Infection control is the only other strategy to prevent RSV disease. A humanized monoclonal antibody directed against the fusion (F) protein palivizumab, (Synagis®, MedImmune, Inc., Gaithersburg, MD), is given routinely on a monthly basis to premature infants and young children less than 24 months of age with underlying medical problems including prematurity, chronic lung disease, or cardiac disease to prevent RSV disease and hospitalization. Other products utilizing polyclonal or monoclonal antibodies or antibody fragments against the F protein have been developed and some already tested in patient populations. The only licensed antiviral treatment available today is ribavirin, a guanosine analogue generally administered as a small particle aerosol to immunocompromised patients with lower respiratory tract disease due to RSV. This drug has also been utilized in oral and intravenous forms, again mainly in immunocompromised patients. Promising new antiviral agents under development by multiple pharmaceutical and biotechnology companies include small molecule fusion inhibitors, attachment inhibitors, inhibitors of RNA synthesis, and small interfering RNA particles (siRNA).

The impact of infection control upon hospital-acquired influenza and respiratory syncytial virus

BACKGROUND

Respiratory syncytial virus (RSV) and influenza are important pediatric community-acquired (CA) and hospital-acquired (HA) pathogens. The occurrence of pandemic (H1N1) 2009 influenza resulted in additional efforts to intensify infection control (IC) strategies. We detail the impact of IC strategies between 2003 and 2010 on influenza and RSV.

METHODS

We assessed the rates of CA infections per 100 admissions and HA infections per 1000 patient-days for both RSV and influenza at Children's Memorial Hospital during the winter seasons (September through May) 2003-2010. The season of 2009, however, was extended through June due to ongoing admissions as a result of pandemic (H1N1) 2009 influenza. IC strategies implemented in response to pandemic (H1N1) 2009 influenza are described. The transmission ratio (HA cases/CA cases) was determined and correlated with IC efforts.

RESULTS

Substantial season- to-season variability exists for CA RSV and CA influenza rates. The rates of HA RSV and HA influenza and the transmission ratios for these viruses remained unchanged in 2009-10 in comparison to the prior year (at 0.02 and 0.01, respectively) despite implementation of multiple IC strategies. In contrast, since 2005 an inverse association was noted between hand hygiene compliance and the transmission ratio of both RSV and influenza, with Spearman correlation coefficients of -0.84 (p = 0.051) and -0.89 (p = 0.008), respectively.

CONCLUSIONS

We observed that improvements in hand hygiene compliance correlated with less transmission of RSV and influenza in the hospital. The important role of hand hygiene in preventing transmission of RSV and influenza to hospitalized children should be emphasized.

The economic burden of patient safety targets in acute care: a systematic review

BACKGROUND

Our objective was to determine the quality of literature in costing of the economic burden of patient safety.

METHODS

We selected 15 types of patient safety targets for our systematic review. We searched the literature published between 2000 and 2010 using the following terms: "costs and cost analysis," "cost-effectiveness," "cost," and "financial management, hospital." We appraised the methodologic quality of potentially relevant studies using standard economic methods. We recorded results in the original currency, adjusted for inflation, and then converted to 2010 US dollars for comparative purposes (2010 US$1.00 = 2010 €0.76). The quality of each costing study per patient safety target was also evaluated.

RESULTS

We screened 1948 abstracts, and identified 158 potentially eligible studies, of which only 61 (39%) reported any costing methodology. In these 61 studies, we found wide estimates of the attributable costs of patient safety events ranging from $2830 to $10,074. In general hospital populations, the cost per case of hospital-acquired infection ranged from $2132 to $15,018. Nosocomial bloodstream infection was associated with costs ranging from $2604 to $22,414.

CONCLUSION

There are wide variations in the estimates of economic burden due to differences in study methods and methodologic quality. Greater attention to methodologic standards for economic evaluations in patient safety is needed.

The epidemiology and clinical characteristics of respiratory syncytial virus infection in children at a public pediatric referral hospital in Mexico

OBJECTIVES

The aim of this study was to determine the epidemiological and clinical characteristics of children with respiratory syncytial virus (RSV) treated at a public referral children's hospital in Mexico.

METHODS

We reviewed RSV infection in patients aged 0-18 years who were treated at Hospital Infantil from January 2004 to December 2008.

RESULTS

During the 5 years, 2797 samples were tested for respiratory viruses; 356 samples were positive for any virus, including 266 (74.7%) positive for RSV. Complete clinical information was available for 205 RSV patients. The mean age was 22 months, and 33.7% of the infections were nosocomially acquired. Hospitalization occurred in 187 children. Of 14 deaths, nine were directly attributed to RSV infection. During the study, RSV infections were seen throughout the year, predominating in the colder months. Of the 205 patients, 79.0% (162/205) had an underlying disease. Congenital heart disease was found in 30.2% (49/162), including three children (33.3%) who died of RSV. Thirty-three patients (16.1%) with RSV required mechanical ventilation. None of the children with RSV received palivizumab or ribavirin.

CONCLUSIONS

RSV caused high hospitalization rates and admission to intensive care units, especially among those with underlying illnesses and young infants. The data presented here will be useful for strategies to improve outcomes in children at risk of complications.

A sensitive real-time PCR for detection and subgrouping of human respiratory syncytial virus

Improved diagnostic tools for rapid detection, quantitation, and subgrouping of human respiratory syncytial virus (RSV) are needed to aid the development and evaluation of novel intervention strategies. A quantitative real-time RT-PCR using specific locked nucleic acid (LNA) probes was developed to identify RSV and to distinguish RSV subgroups A and B (RSV LNA assay). RSV subgroup diversity and the relationship between viral load and disease severity in confirmed RSV infections were also explored. 264 archived respiratory specimens from pediatric patients were tested in parallel using the commercial multiplex Seeplex™ RV detection kit (Seegene) and the novel RSV LNA assay. The LNA assay demonstrated a significantly higher sensitivity than Seeplex, improving overall detection rates from 24% (64/264) to 32% (84/264). Detection limits of 9.0 × 10¹ and 6.0 × 10² copies/mL were observed for RSV A and B, respectively. RSV A was detected in 53/84 (63%) cases, and 31/84 (37%) were positive for RSV B. This novel method offers a rapid, quantitative, highly specific and sensitive approach to laboratory diagnosis of RSV.

Low frequency of endemic patient-to-patient transmission of antibiotic-resistant gram-negative bacilli in a pediatric intensive care unit

We sought to determine the frequency of horizontal transmission of antibiotic-resistant gram-negative bacilli (ARGNB) in a pediatric intensive care unit during a nonoutbreak period. Among 5,300 admissions over 39 consecutive months, 13 ARGNB clusters involving 35 children were identified by pulsed-filed gel electrophoresis analysis, which suggests that person-to-person transmission was uncommon.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections like influenza or severe acute respiratory syndrome pose a global threat. Antiviral drugs and vaccinations may be insufficient to prevent their spread.

OBJECTIVES

To review the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

SEARCH STRATEGY

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3), which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to October 2010), OLDMEDLINE (1950 to 1965), EMBASE (1990 to October 2010), CINAHL (1982 to October 2010), LILACS (2008 to October 2010), Indian MEDLARS (2008 to October 2010) and IMSEAR (2008 to October 2010).

SELECTION CRITERIA

In this update, two review authors independently applied the inclusion criteria to all identified and retrieved articles and extracted data. We scanned 3775 titles, excluded 3560 and retrieved full papers of 215 studies, to include 66 papers of 67 studies. We included physical interventions (screening at entry ports, isolation, quarantine, social distancing, barriers, personal protection, hand hygiene) to prevent respiratory virus transmission. We included randomised controlled trials (RCTs), cohorts, case-controls, before-after and time series studies.

DATA COLLECTION AND ANALYSIS

We used a standardised form to assess trial eligibility. We assessed RCTs by randomisation method, allocation generation, concealment, blinding and follow up. We assessed non-RCTs for potential confounders and classified them as low, medium and high risk of bias.

MAIN RESULTS

We included 67 studies including randomised controlled trials and observational studies with a mixed risk of bias. A total number of participants is not included as the total would be made up of a heterogenous set of observations (participant people, observations on participants and countries (object of some studies)). The risk of bias for five RCTs and most cluster-RCTs was high. Observational studies were of mixed quality. Only case-control data were sufficiently homogeneous to allow meta-analysis. The highest quality cluster-RCTs suggest respiratory virus spread can be prevented by hygienic measures, such as handwashing, especially around younger children. Benefit from reduced transmission from children to household members is broadly supported also in other study designs where the potential for confounding is greater. Nine case-control studies suggested implementing transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. Surgical masks or N95 respirators were the most consistent and comprehensive supportive measures. N95 respirators were non-inferior to simple surgical masks but more expensive, uncomfortable and irritating to skin. Adding virucidals or antiseptics to normal handwashing to decrease respiratory disease transmission remains uncertain. Global measures, such as screening at entry ports, led to a non-significant marginal delay in spread. There was limited evidence that social distancing was effective, especially if related to the risk of exposure.

AUTHORS' CONCLUSIONS

Simple and low-cost interventions would be useful for reducing transmission of epidemic respiratory viruses. Routine long-term implementation of some measures assessed might be difficult without the threat of an epidemic.

National athletic trainers' association position statement: skin diseases

OBJECTIVE

To present recommendations for the prevention, education, and management of skin infections in athletes.

BACKGROUND

Trauma, environmental factors, and infectious agents act together to continually attack the integrity of the skin. Close quarters combined with general poor hygiene practices make athletes particularly vulnerable to contracting skin diseases. An understanding of basic prophylactic measures, clinical features, and swift management of common skin diseases is essential for certified athletic trainers to aid in preventing the spread of infectious agents.

RECOMMENDATIONS

These guidelines are intended to provide relevant information on skin infections and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Costs of hospital-acquired infection and transferability of the estimates: a systematic review

Hospital-acquired infections (HAIs) present a substantial problem for healthcare providers, with a relatively high frequency of occurrence and considerable damage caused. There has been an increase in the number of cost-effectiveness and cost-savings analyses of HAI control measures, and the quantification of the cost of HAI (COHAI) is necessary for such calculations. While recent guidelines allow researchers to utilize COHAI estimates from existing published literature when evaluating the economic impact of HAI control measures, it has been observed that the results of economic evaluations may not be directly applied to other jurisdictions due to differences in the context and circumstances in which the original results were produced. The aims of this study were to conduct a systematic review of published studies that have produced COHAI estimates from 1980 to 2006 and to evaluate the quality of these estimates from the perspective of transferability. From a total of 89 publications, only eight papers (9.0%) had a high level of transferability in which all components of costs were described, data for costs in each component were reported, and unit costs were estimated with actual costing. We also did not observe a higher citation level for studies with high levels of transferability. We feel that, in order to ensure an appropriate contribution to the infection control program decision-making process, it is essential for researchers who estimate COHAI, analysts who use COHAI estimates for decision-making, as well as relevant journal reviewers and editors to recognize the importance of a transferability paradigm.

Health care-acquired viral respiratory diseases

Health care-associated viral respiratory infections, common among hospitalized children, also occur among adults and institutionalized persons and result in increased patient morbidity, mortality, and health care costs. Approximately 20% of patients with healthcare-associated pneumonia have viral respiratory infections, with 70% of these infections caused by adenovirus, influenza virus, parainfluenza virus, and respiratory syncytial virus (RSV). These infections typically reflect the level of viral activity within the community. This article focuses on the epidemiology, transmission, and control of health care-associated RSV and influenza virus.

Children, parents and Respiratory Syncytial Virus in Palermo, Italy: prevention is primary

A study was conducted to describe the characteristics of the Respiratory Syncytial Virus (RSV) infection cases occurring in the season 2006-7 in Palermo, Italy, and to evaluate the parents' knowledge and behaviours concerning prevention and control of acute respiratory infections (ARIs). All children aged between 0 and 2 years, admitted for a lower respiratory tract infection (LRTI) between October 2006 and May 2007, were enrolled in the study. Data were collected about demographic and household characteristics. Furthermore, their parents were asked to compile a structured questionnaire on transmission, prevention and management of ARIs in children. A total of 198 children with a diagnosis of LRTI were enrolled. Ninety-eight (62.0%) of 157 were positive for RSV. Parents were generally aware of transmission of ARIs through sneezing and/or coughing, but less through contaminated objects or hands. Nationality, age and education level of parents and also the age of the patients proved to be associated with some self-reported knowledge and behaviours. Only 24 (12.3%) of the 195 respondents had received advice from GPs or paediatricians about good hygiene practices. It seems essential to implement public health interventions promoting behavioural changes aimed at the primary prevention of ARIs at the community level.

Prospective surveillance of nosocomial viral infections during and after hospitalization at a university children's hospital

BACKGROUND

In Switzerland 5% to 10% of hospitalized adults acquire nosocomial infections (NI) but few data are available in children. Most former studies on NI in hospitalized children analyzed specific units or pathogens and neglected the postdischarge period. We aimed to prospectively assess viral NI occurring during and shortly after hospitalization in children.

METHODS

Prospective surveillance was performed during a 24-month period. Electronic standardized questionnaires were completed for each patient by physicians during hospital stay. On a ward-based rotational schedule, follow-up information was obtained from a subset of patients 1 week after hospital discharge. NI were defined using CDC recommendations.

RESULTS

Overall, 6250 patients (34,608 patient hospitalization days, PHD) were enrolled and 1272 patients were recruited for postdischarge surveillance. Mean hospitalization duration was 5 days. Fifty-two (0.8%) patients acquired 54 viral NI during hospitalization and 12 patients (1.1%) acquired 12 viral NI after hospital discharge (NI incidence: 1.9 per 1000 PHD including follow-up period). NI rate in infants was higher compared with children >12 months old (2.0% vs. 0.8%; P 0.05) and the infant ward also had the highest incidence (4.0 NI per 1000 PHD). Most NI were gastrointestinal tract infections with 55% caused by rotavirus infection. NI rates were highest between November and March.

CONCLUSIONS

A significant part of NI will only be detected if surveillance includes the immediate postdischarge period. Given the strong seasonality of pediatric NI, intensifying hygiene measurements particularly on infant wards and prior to the cold season would be beneficial in reducing NI incidence.

An intervention to improve compliance with transmission precautions for influenza in the emergency department: successes and challenges

Background: Concern with the potential for hospital-based transmission of influenza has come to the forefront due to emergency department (ED) crowding and the novel H1N1 pandemic. Compliance with infection control guidelines for influenza in the ED is generally unknown, and effective yet low-resource training is needed to educate staff on the importance of decreasing the potential for ED transmission of the virus. Objectives: This study evaluates compliance with patient assignment and transport precautions for influenza in an urban ED before and after implementation of electronic reminders. Methods: We included patients with a diagnosis of influenza for two consecutive influenza seasons, and retrospectively collected limited patient encounter data on patient location, transport, and compliance with assignment and transport precautions for both years. For the second influenza season we sent monthly reminders to all ED providers via the electronic medical record (EMR), explaining the importance and proper use of infection control precautions in patients with suspected influenza. Compliance between the two seasons was compared using descriptive statistics and chi-squared analysis. Results: Overall compliance with infection control precautions was poor, but increased with the use of electronic reminders from 29% to 45% (p = 0.015). Compliance with precautions for patients moved to the hallway or Radiology increased from 7% to 24% (p = 0.001). Conclusions: The EMR may be a useful tool for improving compliance with transmission-based precautions by implementing reminders on order sets and informational mailings, and by tracking compliance. Future study should be undertaken to determine the most effective interventions to prevent ED transmission of influenza.

[Consensus conference on acute bronchiolitis (v): prevention of acute bronchiolitis. Review of scientific evidence]

A review of the evidence on prevention of acute bronchiolitis is presented. Acute bronchiolitis prevention arises from three basic approaches: preventive treatment to reduce recurrent wheezing following an episode of acute bronchiolitis, preventive treatment to reduce the frequency and severity of RSV bronchiolitis in the population at risk (prematurity, bronchopulmonary dysplasia, congenital heart disease, etc.), and general preventive measures to reduce nosocomial infection with RSV. There is sufficient evidence on the lack of efficacy of inhaled corticosteroids, oral corticosteroids and montelukast. Intravenous RSV immunoglobulin has an unfavorable risk-benefit balance, particularly with the availability of monoclonal antibodies. Palivizumab is effective as preventive treatment of RSV infection in risk populations (high risk preterm infants and hemodynamically significant congenital heart disease), but not in the frequency and severity (ICU admission, need for mechanical ventilation and mortality) of the acute bronchiolitis. The benefits of palivizumab (less admissions) seem to be worth the adverse effects, but we do not know the cost-benefit ratio. The control and prevention measures of nosocomial transmission of RSV infection (isolation, hand washing, use of mask, gloves, cap and shoes) are based on indirect evidence.