Health Care–Associated Infections in Children

Abstract

HEALTH CARE–ASSOCIATED INFECTIONS (HAI) REsult in significant morbidity, prolong hospitalization, increase health care costs, and contribute to patient deaths. Among the aggressive national and local endeavors to address HAI, the subtle (and not so subtle) differences between pediatric and adult patients are often overlooked. Rates of central line–associated bloodstream infections (CLABSI), surgical site infections (SSI), and respiratory viral infections differ between children and adults, reflecting the unique susceptibilities of each population. Efforts to reduce the rates of HAI in children are often hampered by the lack of pediatric-specific research, lack of national pediatricspecific quality measures to guide prevention of SSI, and the implementation of infection prevention practices validated only in adult populations. The US Centers for Disease Control and Prevention/ National Healthcare Safety Network surveillance definitions for HAI in children and adults are in general the same, differing slightly for patients 1 year or younger. The commonality of definitions, however, belies the fact that children and adults differ in both susceptibility to infection and in the steps necessary to prevent these infections. Furthermore, identification of pediatric-specific risk factors for infection and the solutions needed to reduce pediatric HAI have not been well investigated. Central line–associated bloodstream infections, SSI, and viral infections in pediatric patients illustrate the important but overlooked differences between adult and pediatric HAI. Pediatric patients younger than 2 years and those requiring care in neonatal intensive care units (ICUs) and pediatric ICUs have especially high rates of HAI, and bloodstream infections are the most common HAI in all pediatric age groups. Pediatric patients have higher rates of bloodstream infections and viral lower respiratory tract infections than adult patients, whereas rates of catheter-related urinary tract infections, ventilator-associated pneumonia, and SSI are higher in adult patients, although rates for particular pediatric surgical procedures may be high. Data on CLABSI illustrate the difference between children and adults. Reported rates for CLABSI are frequently higher in pediatric ICUs than in adult ICUs. In adults, implementation of a multifaceted insertion bundle has been demonstrated to reduce the rates of CLABSI substantially. In contrast with adult data, maximizing insertion-bundle adherence is not sufficient to eliminate CLABSI in children. Data from the National Association of Children’s Hospitals and Related Institutions collaborative demonstrate that the main driver for reducing CLABSI in pediatric patients in the ICU involves optimizing the daily maintenance and care of central line catheters. Unique considerations are involved in the prevention of CLABSI in pediatric patients. Difficult intravenous access often requires placement of catheters in locations that have higher infection rates. In addition, catheters need to be maintained for longer periods of time because of difficult vascular access and the need to obtain blood. Maintenance practices must be tailored to the maturity of an infant’s skin. In very lowbirthweight infants, chlorhexadine may cause a chemical dermatitis or burn, and chlorhexadine-impregnated biopatches may cause pressure ulcers. However, individual neonatal ICUs and pediatric ICUs have been able to decrease their rates of CLABSI substantially, in some cases by incorporating novel technological approaches such as the use of closed intravenous systems to prevent maintenance-related intravascular catheter infections. The Surgical Care Improvement Project (SCIP) is a national quality improvement project to reduce surgical complications. Six of the 9 publicly reported SCIP measures focus on reducing SSI. Adherence rates to individual SCIP measures provide a benchmark to track infection prevention measures, and emerging data suggest that adherence with core SCIP measures may reduce SSI. Although several of the SCIP measures to reduce infection are appropriate for children, some measures such as postoperative glucose control for cardiac surgery and postoperative temperature control after colorectal surgery are intended for adults. It is perhaps not surprising that SCIP measures, and the requirement for hospitals to track and report SCIP adherence, do not apply to patients younger than 18 years. What is surprising is that similar measures are not in place for prevention of SSI in children. It is important that a national quality improvement program to reduce HAI does not apply to pediatric patients. The Surgical Care Improvement Project measures are tracked by the Joint Commission, the agency that accredits and certifies