Bloodstream Infections In Children Research Articles

400: Reducing central venous catheter related bloodstream infections in children with cancer

400: Reducing central venous catheter related bloodstream infections in children with cancer

ETIOLOGY AND OUTCOMES OF BLOODSTREAM INFECTIONS AT A CHILDRENʼS HOSPITAL IN TBILISI, REPUBLIC OF GEORGIA.

Background H. influenzae and S. pneumoniae are leading cause of childhood bloodstream infections (BSIs) in areas where vaccination is not available for these organisms. The prevalence of H. influenzae and S. pneumoniae BSI has not been established in Tbilisi, Republic of Georgia. This study attempts to determine the prevalence and outcomes of BSI in children at Children9s Central Hospital (CCH), a referral pediatric hospital. Methods We carried out a retrospective study of laboratory and medical records from January of 2004 to June of 2006. Patients with positive blood cultures were initially chosen for the study. Community-acquired (CA) BSIs were within the first 48 hours of admission and hospital acquired (HA) were 48 hours or greater. Results Of 1,693 cultures performed in the study period, 339 (20%) were positive. Twenty-nine of these were omitted from the analysis due to incomplete medical records. Among the 310 children with positive cultures, the following organisms were identified: gram-negative rods (GNRs) (135, 43.6%); coagulase-negative S. aureus (CNS) (111, 35.8%); Klebsiella (17, 5.5%); S. aureus (12, 4.9%); Pseudomonas (10, 3.2%); yeast (9, 2.9%); Streptococcus spp. (5, 1.6%); Enterococcus (4, 1.3%); gram-positive rods (GPRs) (2, 0.7%); Listeria (2, 0.7%); Salmonella spp. (2, 0.7%); and Mixed (S. aureus and Klebsiella; 1, 0.3%). One hundred eighty-four (59%) patients with BSI were male; mean age was 0.4 (0-14) years. Ninety-three (30%) children with a BSI died, 90 of whom were under 1 year of age. CA BSI was present in 87 of 93 patients who died (p = .005). Death was primarily attributed to GNRs (59, 63%), followed by CNS (18, 19%), Pseudomonas (5, 5%), Klebsiella (4, 4%), and Enterococcus and yeast with 2 each (2%), and Listeria, S. aureus, and GPRs were responsible for one death each (1%). Any GNR BSI was significantly associated with mortality versus all none GNR BSI (OR = 3.4, 95% CI = 2.0, 5.7). No positive identifications were made for either H. influenzae or S. pneumoniae. Conclusions Microbiologic identification of common organisms known to cause BSI in children is difficult in the Republic of Georgia due to limited resources available in the microbiology laboratory in the leading children9s hospital. It is likely that causes of BSI due to vaccine-preventable etiologies are underdiagnosed due to laboratory capacity. Improving the infrastructure of diagnostic microbiology laboratories in resource-limited areas is critical to conduct appropriate surveillance and improve patient care.

Bloodstream infections in hospitalized adults with sickle cell disease: A retrospective analysis

Bloodstream infections (BSI) are a common cause of morbidity and mortality in people with sickle cell disease (SCD). In children with SCD, BSI are most often caused by encapsulated organisms. There is a surprising paucity of medical literature that is focused on evaluating SCD adults with BSI. We reviewed the charts of adults with SCD and BSI who were admitted to our hospital between April 1999 and August 2003. During this period a total of 1,692 hospital admissions for 193 adults with SCD were identified and 28% of these patients had at least 1 episode of positive blood cultures, with 69 episodes (17%) considered true BSI. Nosocomial BSI occurred in 34 episodes (49%). Among community BSI, in contrast to BSI in children with SCD, Streptococcus pneumoniae was rarely encountered. A high incidence of staphylococcal BSI in adults with SCD was noted. Twenty-eight percent of all BSI were caused by Staphylococcus aureus, and 15 of 22 isolates (68%) of these were methicillin-resistant. Gram-negative organisms, anaerobes, and yeast were found in 21 (27%), 3 (4%), and 4 isolates (5%) of BSI, respectively. Since over 80% of BSI were considered catheter-related, the higher incidence of gram-positive bacterial infections was likely due to the presence of indwelling central venous catheters. Empiric therapy for adults with SCD suspected of having BSI, especially in the presence of indwelling central venous catheters, should include antimicrobial therapy targeted at gram-positive bacteria (especially MRSA) and gram-negative bacteria. Also, if patients are critically ill, consideration should be made to include antifungal agents. Additional research into the adult SCD population appears necessary to further define this problem.

Evaluation of the gram stain-acridine orange leukocyte cytospin test for diagnosis of catheter-related bloodstream infection in children on long-term parenteral nutrition

Evaluation of the gram stain-acridine orange leukocyte cytospin test for diagnosis of catheter-related bloodstream infection in children on long-term parenteral nutrition

Community-acquired bloodstream infections in children > one month old in southern Israel (1992–2001): Epidemiological, clinical and microbiological aspects

We studied the epidemiology, microbiology, clinical picture and outcome of community-acquired bloodstream infections (CABI) in children in southern Israel during 1992-2001. Information was collected prospectively by daily surveillance. CABI was diagnosed when a positive blood culture was reported in a patient discharged from the emergency room or during <48 h since admission if hospitalized. There were 1439 CABI episodes in 1396 children aged 1 month to 14 y. CABI incidence was 100/100,000 children with no increase during the study period. Risk of CABI was 3.8 times higher in a Bedouin than in a Jewish child. 1561 bacteria (793, 50%, gram-positive and 768, 49% gram-negative organisms, respectively) and 13 fungi were recovered. Most frequent gram-positive organisms were Streptococcus pneumoniae (509 isolates, 32% of all isolates, 64% of all gram-positive), Staphylococcus aureus (137, 9%, 17%) and Streptococcus pyogenes (46, 3%, 6%). Enterobacteriaceae spp. were the most frequent gram-negative pathogens (279, 18%, 36%), followed by Brucella (205, 13%, 27%). S. pneumoniae was the most common pathogen in children <12 months and 1-5 y age; Brucella was the most frequent pathogen in children >5 y of age. Coverage of 7-valent pneumococcal conjugated vaccine for CABI was 38.5%. 38 (2.7%) patients died; 16 cases were caused by S. pneumoniae.

Qualitative versus quantitative blood cultures in the diagnosis of catheter‐related bloodstream infections in children with malignancy

Paired quantitative and qualitative blood cultures have been introduced for the diagnosis of catheter-related bloodstream infections (CRBI) with the catheter in situ. The aim of the study was to compare the diagnostic performance and the prognostic value of the two methods in the evaluation of febrile episodes without an apparent source in children with cancer. During a 4-year period, in every febrile episode without an apparent focus, blood was drawn simultaneously from the catheter lumen and a peripheral vein in order to perform paired quantitative (Isolator) as well as qualitative (BacT/Alert) blood cultures. The diagnosis of a CRBI was defined as either a case of greater (at least 10 fold) or earlier (differential time to positivity >2 h) bacterial growth from the catheter compared to the peripheral blood sample, respectively. Nineteen febrile episodes manifested in 16 children (total period of observation 11,150 catheter-days) were evaluated with both methods. A concordant diagnosis of CRBI was stated with both methods in six episodes; one episode was diagnosed as CRBI only with qualitative culture criteria. Treatment failure resulted in catheter removal in five out of the seven episodes defined as CRBI with either method. Episodes where a CRBI was ruled out with both methods had a favorable outcome. In this study the two methods showed comparable results in the diagnosis of CRBI and both were of prognostic significance, regarding the outcome of the treatment. However, large scale studies are required in order to evaluate the clinical relevance and the cost effectiveness of performing routinely paired blood cultures with either method.

Bloodstream infection in children

To establish the definitions of bloodstream infection (BSI) in children for the purposes of identifying BSI for early therapy, enrollment in sepsis trials, and epidemiology and surveillance studies. Generalized medical literature search using various combinations of the terms "bloodstream infection," "children," and "sepsis." The medical literature is sparse on these topics; therefore, these recommendations are adapted from guidelines designed for adults. BSI overlaps with other areas of sepsis, such as catheter-related BSI, which will be covered separately. This discussion focuses on BSI of unknown origin, also known as primary BSI. A BSI is the presence of a pathogen in the blood. Its clinical significance should be determined by the presence of the host response as defined by the modified criteria for systemic inflammatory response syndrome SIRS in children or a clinically recognizable syndrome. Definitions of BSI for the purposes of sepsis trials may differ from those for epidemiologic or surveillance studies.

Risk Factors for and Outcomes of Bloodstream Infection Caused by Extended-Spectrum β-Lactamase–Producing Escherichia coli and Klebsiella Species in Children

The increasing prevalence of infections caused by extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) has become a growing concern in the hospitalized patient population. Previous studies on risk factors for infection with ESBL-EK have mainly focused on adult populations, and these findings may not be relevant among the pediatric population that experiences a unique set of health care exposures and underlying conditions. The objective of this study was to define the risk factors and outcomes associated with ESBL-EK bloodstream infections in children. We conducted a nested case-control study using data from the Children's Hospital of Philadelphia from May 1, 1999, to September 30, 2003. Eligible patients were identified from the hospital database of microbiology laboratory records. All patients with ESBL-EK bloodstream infections were compared to a random sample of patients with non-ESBL-EK bloodstream infections. Risk factors analyzed included prior antimicrobial use, comorbid conditions, and demographic characteristics. Pulsed-field gel electrophoresis was performed to determine genetic relatedness of the ESBL-EK isolates. Thirty-five cases and 105 control subjects were included in the study. The median age among the cases was 2 years (interquartile range: 0-11), compared with 1 year (interquartile range: 0-8) among control subjects. Patients with ESBL-EK infections were 5.8 times (95% confidence interval: 1.9-17.7) more likely to have had exposure to an extended-spectrum cephalosporin in the 30 days before infection than those with non-ESBL-EK infections. Other independent predictors of ESBL-EK infection were being female, infection with a Klebsiella species, and steroid use in the 30 days before infection. All ESBL-EK isolates were susceptible to carbapenem antibiotics. Pulsed-field gel electrophoresis analysis revealed that the ESBL-EK isolates were polyclonal. Although a substantially higher proportion of children with ESBL-EK died (in-hospital mortality: 36% vs 13%), this difference was not statistically significant. Receipt of extended-spectrum cephalosporins in the 30 days before infection by an Escherichia coli or Klebsiella species is significantly associated with having an ESBL-EK infection in hospitalized children. Curtailed use of cephalosporins among high-risk groups may reduce the occurrence of ESBL-EK infections. Future studies on identifying high-risk children and investigating the impact of curtailed third-generation cephalosporin use to limit additional emergence of ESBL-EK infections should be undertaken.

Nosocomial bloodstream infections in children and adolescents in southern Israel: A 10-year prospective study (1992–2001)

We studied the epidemiology, microbiology, clinical presentation and outcome of nosocomial bloodstream infections (NBI) in children and adolescents in southern Israel during 1992-2001. Information on NBI was collected prospectively by active surveillance. NBI was diagnosed when a clinically significant positive blood culture was drawn in a patient during >48 h after admission. 469 episodes occurred in 370 children and adolescents aged 1 m-18 y. The overall incidence of NBI was 5.3/1000 patients, with no increase during the study period. A significant decrease in NBI incidence was recorded at the neonatal intensive care unit (NICU) during 1997-2001 vs 1992-1996. The incidences of NBI at the paediatric ICU (PICU), paediatric wards and paediatric surgery departments (PSD) were 24.1, 2.8 and 2.5/1000 patients, with an increase in NBI cases at PICU and PSD during 1997-2001 vs 1992-1996. Of 661 pathogens, Gram-negative, Gram-positive and fungal organisms were isolated in 54.3%, 36.6% and 9.1% of cases, respectively. Enterobacteriaceae (34.6% of all isolates) were the most frequently isolated Gram-negative organisms. Enterococcus spp., coagulase-negative staphylococci and Staphylococcus aureus (9.5% of all isolates each) were the most frequently isolated in Gram-positive organisms. A significant increase was recorded in the incidence of NBI caused by Streptococcus pneumoniae and Pseudomonas spp. A significant decrease in the susceptibility of Enterobacteriaceae spp. to piperacillin, ceftazidime, gentamicin and ceftriaxone was recorded during the study period. 33 (8.9%) patients with NBI died.

A 7-year study of bloodstream infections in an English children?s hospital

Knowledge of the pattern of bloodstream infection (BSI) can help determine antibiotic prescribing policy and infection control procedures. Data on 2364 consecutive episodes of BSI at Birmingham Children's Hospital over 7 years were collected prospectively. A total of 1224 (51.8%) episodes were community-acquired, but only 281 (11.9%) were in previously healthy children. Intravascular devices (IVDs) were the most common source of infection, accounting for 48.9% of episodes. Gram-positive, gram-negative and anaerobic bacteria accounted for 66.2%, 31.3% and 0.4% of isolates, and 2.2% were yeasts. Coagulase-negative staphylococci, Staphylococcus aureus and enterococci accounted for over 50% of all isolates. Of these, only enterococci were predominantly hospital-acquired. Neisseria meningitidis was the most common cause of community-acquired BSI in previously healthy children. Of cases of meningococcaemia, 55.6% were diagnosed by PCR alone. Antibiotic resistance, especially in Enterobacteriaceae, S. aureus and enterococci, was more common than in earlier studies of BSI in children, and varied between specialties. The overall mortality rate directly attributable to infection was 2.4%, but was higher in neonates (6.2%) and in previously healthy children with community-acquired infections (5.3%). Intravascular devices have emerged as the commonest source of bloodstream infection in children, leading to marked similarities in the species distribution of blood culture isolates across specialties other than General Paediatrics, and explaining the low overall mortality rate. Antibiotic resistance was found frequently in most commonly isolated pathogens, but differences between specialties suggest the existence of local risk factors, some of which might be amenable to infection control interventions.

Catheter design influences recurrence of catheter-related bloodstream infection in children with cancer.

Multiple studies have demonstrated that catheter-related bloodstream infections (CRBI) can be successfully treated without catheter removal (in situ therapy), but there is insufficient information available to determine if catheter design can influence the eradication of bacteremia or recurrence. Bacteremic episodes in patients at St Jude Children's Research Hospital between January 1996 and May 2001 were identified and patient records were reviewed. A total of 172 unique episodes of CRBI were identified. In situ therapy resulted in successful eradication of bacteremia in 87% of the episodes. Bacteremia recurred in 10% of the episodes. Although catheter design (Hickman and Broviac versus totally implantable central venous catheter) did not influence short-term eradication of bacteremia, totally implantable central venous catheters were significantly associated with recurrence of bacteremia (odds ratio, 10; 95% confidence interval, 3.1 to 33.3). In a multivariable analysis, this association between catheter design and recurrence remained statistically significant after adjustment for other factors that influenced recurrence in this study (isolation of coagulase-negative staphylococci and inadequate duration of initial antibiotic therapy). This study demonstrates that patients with CRBI with a totally implantable central venous catheter in place are more likely to develop recurrent bacteremia. Management strategies to prevent recurrence in this setting should be explored.

Central venous catheter techniques in infants and children

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors. Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists. Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.

Nosocomial infections after cardiac surgery in infants and children: incidence and risk factors

This prospective study was undertaken to determine the spectrum, sites and main risk factors for hospital-acquired infections (HAI) in our paediatric cardiothoracic intensive care unit (PCICU), and to determine the main organisms causing bloodstream infection in this setting. All patients admitted between January and December 1999 were prospectively followed for the development of HAI. To define risk factors, patients were grouped by age, complexity score, length of stay in PCICU, and whether the patient's chest was open or closed postoperatively. Three hundred and thirty-five patients underwent cardiac surgery. Fifty-five patients acquired 69 HAIs (HAI patient rate 16.4%). The most common HAI were bloodstream and surgical wound infection in 10 and 8%, respectively. The main causative organisms were Klebsiella spp.,Enterobacter spp. and Pseudomonas spp. in 22, 17 and 16% of episodes, respectively.Staphylococcus spp. accounted for 16% of episodes. The main risk factors for developing HAI were: neonatal age [P <0.05, odds ratio (OR): 5.89, 95% confidence interval (CI): 2.96–11.58] prolonged PCICU stay (P<0.05, OR: 6.82, 95% CI: 3.37–14.48), open chest postoperatively (P<0.05, OR: 3.44, 95% CI: 1.31–8.52) and high complexity score (P<0.05, OR: 4.03 95% CI: 1.87–8.43). The main causative organisms of bloodstream infections in children hospitalized in the PCICU differ from those in adult and pediatric general intensive care units (ICUs) and include mainly Gram-negative bacilli. High complexity score, neonatal age, prolonged ICU stay, and open chest postoperatively are risk factors of HAI in this patient population.

Rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit patients.

The objective of this study was to determine the rate, risk factors, and outcomes of nosocomial primary bloodstream infection in pediatric intensive care unit (PICU) patients. Prospective cohort study. This study was performed at St Louis Children's Hospital, a 235-bed academic tertiary care center with a combined 22-bed medical and surgical PICU. Subjects for this study were patients admitted to the PICU between September 1, 1999, and May 31, 2000. None. Patients were monitored for the development of nosocomial bloodstream infections from the day of PICU admission until 48 hours after PICU discharge. Of 911 patients, 526 (58%) were male and 674 (74%) were white. Congenital heart disease (29%), lung disease (25%), and genetic syndrome (18%) were common. There were 65 episodes of primary bloodstream infection in 57 patients; 5 were polymicrobial and 7 patients had multiple bloodstream infections. Coagulase-negative Staphylococcus was the leading cause of bloodstream infection (n = 28), followed by Enterobacter cloacae (n = 8). The rate of bloodstream infection was 13.8 per 1000 central venous catheter days. In multiple logistic regression analysis, patients with bloodstream infection were more likely to have multiple central venous catheters (adjusted odds ratio [aOR]: 5.7; 95% confidence interval [CI]: 2.9-10.9), arterial catheters (aOR: 5.5; 95% CI: 1.8-16.3), invasive procedures performed in the PICU (aOR: 4.0; 95%CI: 2.0-7.8), and be transported out of the PICU (aOR: 3.4; 95% CI: 1.8-6.7) to the radiology or operating room suites. Severity of illness as measured by admission Pediatric Risk of Mortality score, underlying illnesses, and medications were not associated with increased risk of nosocomial bloodstream infection. Conclusions This study identified a high rate of bloodstream infection among St Louis Children's Hospital PICU patients. Risk factors for bloodstream infection were related more to process of care than to severity of illness. Additional research is needed to develop interventions to reduce nosocomial bloodstream infections in children.

Incidence rates of bloodstream infections in children with long-term central venous catheters at Instituto Nacional do Câncer, Brazil (1995 to 2001)

Incidence rates of bloodstream infections in children with long-term central venous catheters at Instituto Nacional do Câncer, Brazil (1995 to 2001)

CDC catheter guidelines aim to cut bloodstream infections in children

Most bloodstream infections in infants and children, as well as adults, are related to the use of intravascular catheters. To address this problem, the U.S. Centers for Disease Control and Prevention (CDC) is revising guidelines on preventing catheter-related infections to include pediatric

Bloodstream infections in children with cancer: a multicentre surveillance study of the Italian Association of Paediatric Haematology and Oncology

A one-year prospective, multicentre surveillance study on aetiology, main clinical features and outcome of bloodstream infections in children with cancer was conducted in 18 paediatric haematology centres belonging to the Italian Association for Paediatric Haematology and Oncology. A total of 191 bloodstream infections were reported during the study period. Of them, 123 (64%) occurred in neutropenic and 68 (36%) in non-neutropenic patients. Gram-positive cocci caused 45% (85/191) of the episodes, gram-negative rods 41% (78/191), and fungi 9% (18/191). The remaining 5% (10/191) of the episodes were poly-microbial infections. A total of 204 pathogens were isolated (46% gram-positive cocci; 44% gram-negative rods; and 10% fungi). The aetiologic distribution was similar among neutropenic and non-neutropenic patients. A correlation between the infection and the presence of an indwelling central venous catheter was found in 20% (23/114) of the episodes among neutropenic patients and in 55% (23/62) among non-neutropenic patients. Gram-negative micro-organisms were isolated in an unusually high proportion of catheter-related infections (48%). The overall mortality rate from any cause within 30 days from the first positive blood culture was 11%, and was higher among patients who were neutropenic at the onset of the infection than among those who were not neutropenic (15 versus 4%, P=0.03). In addition, the mortality was significantly higher in recipients of bone marrow transplantation than in patients with acute leukaemia or solid tumour (21, 11 and 6%, respectively) and was also higher in fungaemias and poly-microbial infections (22 and 30%) than in single gram-positive and gram-negative bacteraemias (11 and 6%).

#668 Bloodstream infections in children with cancer are on the rise

#668 Bloodstream infections in children with cancer are on the rise

Bloodstream infections in children with cancer are on the rise. 730

Over the past decade the majority of bloodstream infections in children with cancer have been due to gram positive organisms. We recently noted that bloodstream infections in children with cancer at the University of Rochester appeared to occur more frequently and that there was an increase in the number of gram negative infections. To investigate this observation, we retrospectively reviewed the microbiology logs and the medical records of children with cancer treated from 1991-1996. A bloodstream infection was defined as an episode of fever with at least one positive culture of blood. If a common organism was isolated, at least 2 positive cultures within 48 hours were required to fulfill entry criteria. There were 155 bloodstream infections in 108 children treated from 1991-6. Forty-nine infections occurred in 38 children from 1991-3; 106 infections occurred in 70 children from 1994-6. The proportion of children on active treatment who had bloodstream infections was significantly greater in the 1994-6 group than in the 1991-3 group: 70/131(53%) versus 38/133 (28%) (p<.001). In the earlier group, 17 of the 49 infections (35%) were due to gram negative bacilli, while in the later group, 51 of 106 episodes (48%) were caused by gram negative organisms (p=.15). Twenty-eight of 49 children (57%) in the 1991-3 group had gram positive infections compared to 44/106 (42%) in the 1994-6 group (p=.10). Sixty-five percent of infections in the early group occurred in children whose absolute neutrophil counts were ≥500/μl; 60% of the episodes in the later group were associated with an ANC≥500/μl. There were no differences between the 2 groups with respect to race, the proportion of episodes which occurred as outpatients, proportion of definite or probable catheter-related infections, proportion of patients with other foci of infection, and proportion of patients on intensive chemotherapy protocols. We conclude that there has been a sharp rise in bloodstream infections in children being treated for cancer, that part of this rise is due to the increased number of gram negative infections, and that it does not appear to be due to changes in intensity of chemotherapy regimens. Other possibilities for this increase such as the increasing reliance on home care and needleless catheter systems must be explored.

Detection of bloodstream infections in children

A critical responsibility of the clinical microbiology laboratory serving clinicians who care for infected children is accurate and timely detection of bacteremia. Blood culture protocols which are suitable for processing adult specimens are not necessarily the first choice for processing pediatric specimens. In this review, the following aspects of detection of bacteremia in children are covered: obtaining blood culture specimens from children, including skin disinfection, specimen volume and timing of specimen collection; the array of blood culture methods available, focusing upon conventional, radiometric, infrared spectroscopic and manometric broth cultures, as well as biphasic agar/broth and lysis direct plating techniques: the strengths and weaknesses of the various methods; and recommendations to laboratories for selection of a blood culture method based upon the laboratory's staffing level.