Suspicion of respiratory tract infection with multidrug-resistant Enterobacteriaceae: epidemiology and risk factors from a Paediatric Intensive Care Unit

Abstract

BackgroundMultidrug-resistant (MDR) infections are a serious concern for children admitted to the Paediatric Intensive Care Unit (PICU). Tracheal colonization with MDR Enterobacteriaceae predisposes to respiratory infection, but underlying risk factors are poorly understood. This study aims to determine the incidence of children with suspected infection during mechanical ventilation and analyses risk factors for the finding of MDR Enterobacteriaceae in tracheal aspirates.MethodsA retrospective single-centre analysis of Enterobacteriaceae isolates from the lower respiratory tract of ventilated PICU patients from 2005 to 2014 was performed. Resistance status was determined and clinical records were reviewed for potential risk factors. A classification and regression tree (CRT) to predict risk factors for infection with MDR Enterobacteriaceae was employed. The model was validated by simple and multivariable logistic regression.ResultsOne hundred sixty-seven Enterobacteriaceae isolates in 123 children were identified. The most frequent isolates were Enterobacter spp., Klebsiella spp. and E.coli. Among these, 116 (69%) isolates were susceptible and 51 (31%) were MDR. In the CRT analysis, antibiotic exposure for ≥ 7 days and presence of gastrointestinal comorbidity were the most relevant predictors for an MDR isolate. Antibiotic exposure for ≥ 7 days was confirmed as a significant risk factor for infection with MDR Enterobacteriaceae by a multivariable logistic regression model.ConclusionsThis study shows that critically-ill children with tracheal Enterobacteriaceae infection are at risk of carrying MDR isolates. Prior use of antibiotics for ≥ 7 days significantly increased the risk of finding MDR organisms in ventilated PICU patients with suspected infection. Our results imply that early identification of patients at risk, rapid microbiological diagnostics and tailored antibiotic therapy are essential to improve management of critically ill children infected with Enterobacteriaceae.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-017-2251-x) contains supplementary material, which is available to authorized users.

Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review

“…As colonization of an endotracheal tube occurs quickly, the mere presence of bacteria in surveillance cultures from endotracheal aspirates does not warrant antibiotic treatment [75]. Of note, > 30% of Enterobacterales in endotracheal aspirates may be MDR, with a clear link to previous antibiotic exposure of > 7 days [76]. Studies in adults revealed that only very recent cultures (from endotracheal aspirates taken ≤ 2 days before onset of VAP) are reliable in predicting the responsible pathogen [77].…”

Prior antibiotic use and acquisition of multidrug-resistant organisms in hospitalized children: A systematic review

“…The articles included in this review were all observational studies: 12 were cohort studies (7 retrospective studies [19][20][21][22][23][24] and 5 prospective studies [25][26][27][28][29] ) and 17 were case-control studies. [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] The study sample for all articles were hospitalized children, although their ages differed among the studies.…”

“…Seven studies included specific age ranges, 20,23,25,27,30,41,42 10 studies included only neonates, 19,21,24,26,28,29,32,37,38,47 and 12 studies did not provide an age range for the children included. 22,31,[33][34][35][36]39,40,[43][44][45][46] Organisms included in the articles were Enterobacteriaceae (n = 10), 19,22,26,35,36,[41][42][43][44][45] Klebsiella pneumoniae (n = 8), 21,23,27,28,34,38,46,47 Escherichia coli (n = 5), 23,33,37,46...…”

“…25 For HAIs, 8 studies included all types of infections, 19,21,24,25,29,30,41,47 5 studies focused on bloodstream infections (BSI), 20,23,27,31,46 1 study focused on urinary tract infections (UTIs), 42 1 study focused on ventilatorassociated pneumonia (VAP), 32 and 1 study was respiratory tract infections (RTIs). 22 All HAIs were specified as occurring during the hospitalization, however only 6 studies provided HAI case definitions. [19][20][21][30][31][32] Furthermore, 5 studies examined HACs only, 26,34,39,43,45 and 8 studies did not distinguish between HAIs and HACs.…”

Development and Validation of a Model to Predict Growth of Potentially Antibiotic-Resistant Gram-Negative Bacilli in Critically Ill Children With Suspected Infection

“…There is a paucity of literature regarding factors associated with high-risk GNRs in children and no statistical models that predict increased risk for these pathogens [ 17 , 18 ]. Such a model could aid in the development and testing of empirical antimicrobial prescribing strategies in critically ill children.…”