Healthcare-Associated Infections in Pediatric and Neonatal Intensive Care Units: Impact of Underlying Risk Factors and Antimicrobial Resistance on 30-Day Case-Fatality in Italy and Brazil

Abstract

objectives. To describe trends in the epidemiology of healthcare-associated Infections (HAIs) in pediatric/neonatal intensive care units (ICUs) and to evaluate risk factors and impact of multidrug resistance in children admitted to ICUs.design. Multicenter, retrospective, cohort study with a nested case-control study conducted from January 1, 2010, through December 31, 2014.setting. Three tertiary care pediatric hospitals in Italy and Brazil with a total of 103 ICU beds.patients. Inclusion criteria were admission to ICU during the study period, age at onset less than 18 years, and microbiologically confirmed HAI.results. A total of 538 HAIs in 454 children were included; 93.3% of patients had comorbidities. Bloodstream infections were the leading pattern (45.4%). The cumulative incidence of HAI was 3.6/100 ICU admissions and the crude 30-day fatality rate was 5.7/1,000 admissions. The most frequently isolated pathogens were Enterobacteriaceae, followed by Pseudomonas aeruginosa and Staphylococcus aureus. Forty-four percent of isolates were multidrug-resistant (MDR). Two multivariate logistic regressions were performed. Factors independently associated with an MDR-HAI were country, previous antibiotics, transplantation, major surgery, and colonization by an MDR strain. Factors independently associated with 30-day case fatality were country, previous transplantation, fungal infection, bloodstream infection, lower respiratory tract infection, and infection caused by MDR strains.conclusions. Infection control and prevention can limit the spread of MDR strains and improve outcomes. Targeted surveillance programs collecting neonatal and pediatric HAI/bloodstream infection data and outcomes would allow global benchmarking. The next step is to identify methods to monitor key HAIs and integrate these into affordable intervention programs. 2016;37:1302-1309 Healthcare-associated infections (HAIs) are one of the most frequent adverse events affecting children admitted to intensive care units (ICUs). Infect Control Hosp Epidemiol1,2 Exposure to invasive devices and procedures, immune suppression, and underlying conditions are considered as main determinants of patients' increased susceptibility.3,4 The impact of multidrug-resistant (MDR) organisms in pediatrics is increasing globally. [5][6][7] It is assumed that infections caused by MDR bacteria will have a worse prognosis because of the delay in the administration of appropriate therapy. However, it is difficult to estimate the clinical impact of MDR-HAI in children.Previous literature has shown conflicting results about the impact of different underlying risk factors on the clinical outcome of patients with HAI admitted to ICUs. There is no clear independent correlation between antimicrobial resistance and patients' mortality. [8][9][10][11] Clarifying the relationship between patient risk factors and pediatric HAI mortality could allow improved targeting of interventions on the patients most at risk of adverse outcome. The aims of this study were to describe trends i...

Trends, risk factors and outcomes of healthcare-associated infections in a neonatal intensive care unit in Italy during 2013–2017

“…P-values are obtained using Poisson Regression for testing whether incidence densities significantly differ between the two periods for each etiology CLABSI incidence densities per 1000 catheter days, although not significant, was observed during 2013-2017 period respect to 2006-2010 period (7.16 versus 5.58 p = 0.206), which can be dependent by the increase in the number of patient days and central line utilization in the ≤750 g BW class in the second study period (Table 4). This finding is in agreement with previous studies showing that bloodstream infections prevailed among HAIs in Italian NICUs [16,17] and that bloodstream infections were the main infections (45,4%), followed by lower respiratory tract infections (27.8%) and urinary tract infections (15.8%) in Italian and Brazilian PICUs and NICUs [19]. High percentage of bloodstream infections in NICUs has been also reported by NHSN in USA [4], neonINnetwork in UK [12] and worldwide [28][29][30][31].…”

“…The elevated number of device-associated infections in the NICU strengthen the importance to calculate device utilization rates and use as risk factors for the development of CLABSIs and VAPs according to NHSN surveillance protocol [3][4][5]. Also, in agreement with previous surveillance studies of HAIs in other NICUs [16,19,29] and in the same NICU during 2006-2010 [18], UTIs were the third most frequent cause of HAIs after CLABSIs and VAPs in our NICU, but decreased from 28.8% [18] to 8.8% during 2013-2017.…”

“…In partial accordance with our data, a single center cohort study in an Italian NICU reported an infection rate of 13.2% and an incidence density of 7.8 HAIs per 1000 patient days [16] and a multicenter prospective cohort study in six Italian NICUs reported an infection rate of 12.8% and an incidence density of 6.93 HAIs per 1000 patient-days [17]. Also, a multicenter retrospective cohort study in pediatric intensive care units (PICUs) and NICUs in Italy and Brazil during 2010-2014 described a cumulative incidence of HAI of 3.6/100 ICU admissions and an infection rate of 3.6/1000 ICU days [19].…”

“…A national framework for the surveillance of HAIs in Italy-SPIN-UTI project is active in Italy since 2008, which involves adult Intensive care units (ICUs) with none of NICUs [13,14]. Although no surveillance network for HAIs in NICUs is present in Italy, few studies reported the prevalence [15], incidence of HAIs [16][17][18][19][20] and epidemics of specific nosocomial pathogens [20][21][22][23][24] in selected Italian NICUs.…”

Role of antimicrobial stewardship programmes in children: a systematic review

“…ASP may have an important contribution to rationalizing antibiotic use in critically-ill children in PICUs, where the combination of AMR and high rates of invasive device use put patients at risk for HAI due to MDR pathogens. 20 In addition to tackle inappropriate antibiotic use, there is an urgency to conduct research on new antibiotics/antibiotic classes for critical MDR pathogens such as carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, and extended spectrum beta-lactamase (ESBL)-producing enterobacteriaceae. 21,22 It is plausible to assume that reducing antibiotic use would also reduce AMR in paediatric hospitals.…”