Viral Lower Respiratory Tract Research Articles

A study on aetiology and outcomes of viral lower respiratory tract infections in hospitalized children from South India

Introduction: Viral respiratory infection is a common cause of morbidity and mortality in children, especially those less than 5 years old. Objectives: To study the aetiology and seasonal variation of viral lower respiratory tract infection (LRTI) in hospitalized children and to assess the morbidity and mortality. Method: A retrospective cohort study was done on children, aged 1 month to 16 years, admitted in G. Kuppuswamy Naidu Memorial hospital, a tertiary care hospital in Coimbatore, South India. Case records of children hospitalized with features of LRTI, for whom respiratory viral panel was sent, were retrospectively reviewed and were analysed from July 2017 to June 2018. The aetiology of viral infection, age wise distribution, severity of illness and seasonal variation were studied. Multiplex PCR panel was done from either throat swab or nasopharyngeal aspirate in 69 children admitted with a clinician diagnosis of LRTI. Results: Respiratory viruses were identified in 33 (47.8%) of the 69 children. Respiratory syncytial virus (RSV), Influenza viruses A and B, parainfluenza virus and boca virus were the common viruses isolated from hospitalized children with LRTI. RSV and bocavirus were common among children less than 2 years old. RSV infection began in July, peaked during September and October and continued till January. Influenza virus was common among children more than 2 years and occurred between September and March. Conclusions: RSV, Influenza A and B viruses, parainfluenza virus and bocavirus were the common viruses isolated from hospitalized children with LRTI. RSV infection peaked from September to October whilst influenza virus infection peaked from January to March. Sri Lanka Journal of Child Health, 2020; 49(3): 218-222

6 Factors associated with treatment failure of high flow nasal cannula (HFNC) among children with bronchiolitis: a single centre retrospective study

Abstract Background Bronchiolitis is the most common viral lower respiratory tract infection in children under two years of age and is the leading cause of hospital admission for children under the age of one year. Respiratory support for bronchiolitis with high flow nasal cannula (HFNC) is increasingly being used outside of critical care areas and in community hospitals. It is important to understand the patient factors associated with HFNC treatment failure in order to identify which patients are at higher risk for requiring escalation of respiratory support and transfer to a pediatric critical care centre. Objectives The primary objective of this study was to evaluate the patient characteristics that are associated with HFNC treatment failure in bronchiolitis. Design/Methods We completed a retrospective review of patients under 24 months of age with a clinical diagnosis of bronchiolitis admitted to a single tertiary level children’s hospital for supportive management with HFNC between January 2014 and December 2018. Patients who were mechanically ventilated or on non-invasive positive pressure ventilation prior to the initiation of HFNC during their hospital stay were excluded. HFNC treatment failure was the primary endpoint of the study, with treatment failure defined as escalation to non-invasive positive pressure or invasive mechanical ventilation. Multivariable logistic regression analysis was used to identify the patient demographic, clinical, and biochemical parameters associated with HFNC failure. Results Four hundred and thirty-five patient charts were identified, of which 208 patients met inclusion criteria for the study. Of these patients, 61 (29%) were classified as HFNC treatment failures. The likelihood of failing HFNC support was reduced with older age (OR 0.89; 95% CI 0.81, 0.97; p= 0.011) and greater time spent on HFNC (OR 0.94; 95% CI 0.92, 0.96; p<0.001). Patients with a Modified Tal score greater than 5 at 4 hours of HFNC treatment had a greater likelihood of failing HFNC support (OR 2.81; 95% CI 1.04, 7.64; p= 0.042). Conclusion This was the first study to examine predictors of HFNC failure among Canadian children with bronchiolitis. We found that patient age, time spent on HFNC, and severity of bronchiolitis as defined using a Modified Tal score were associated with HFNC failure. These patient factors should be considered when initiating HFNC for bronchiolitis, and may identify patients at risk for escalation of respiratory support, warranting earlier referral to pediatric critical care centres.

The Etiology of Viral Lower Respiratory Tract Infections at a Tertiary Hospital in Jordan over Five Years

Background
 Lower respiratory tract infection (LRTI) is the most common condition treated in primary care and is considered the third leading cause of death worldwide. The objective of our study is to determine the etiological agents that cause viral LRTI in Jordan, aiming to help physicians to choose the appropriate treatment strategy.
 Materials and Methods 
 We conducted a retrospective study on patients who were admitted with the diagnosis of LRTI between January, 2011 and January, 2016. We used Fast-track Diagnostics (FTD)® Respiratory 21 Kit (Fast-track Diagnostics, Luxembourg) real-time PCR to determine the viral etiology of LRTI, and we investigated pandemic H1N1 2009 swine flu virus using rapid test PCR.
 Results 
 This study involved 495 patients with a mean age of 57.79 ± 18.43 years. The causative agents were identified in 157 patients out of 495 patients (31.7%). FTD real-time PCR was done for 170 patients, and the test was positive for seasonal Influenza A virus in 7.1% of patients, influenza B in 4.1%, RSV in 4.7%, metapneumovirus in 4.1%, adenovirus in 4.1%, corona 229E/NL63 in 4.1%, parainfluenza virus in 7.6%, and rhinovirus in 3.5%. The percent of cases who were positive for pandemic H1N1 2009 swine flu virus was 4.2%. The rate of ICU admission was 16.8%, and the mortality rate of LRTI was as low as 3.64%.
 Conclusions
 Viral LRTI is more common in winter season in Jordan, especially in January. Remarkably, Influenza A and Parainfluenza viruses were the main viral causative agents for LRTI in our study.

Procalcitonin-Guided Therapy for Reduction of Antibiotic Use in Patients with Bronchiolitis

Objective Procalcitonin (PCT)-guided treatment could reduce antibiotic use in viral lower respiratory tract infections. We evaluated the impact of PCT-guided treatment on antibiotic use in patients hospitalized with bronchiolitis. Study Design A total of 100 patients aged 1 to 24 months old who were hospitalized with bronchiolitis were included in the study. Patients were randomized into two groups: PCT-guided group received an antibiotic treatment based on PCT levels and control group received an antibiotic treatment according to the physician decision. Results Antibiotic use on first day in the PCT-guided group (12%) was found to be statistically significantly lower than in the control group (80%) (p = 0.001; p < 0.05; relative risk [RR]: 29.33; 95% confidence interval [CI]: 9.77–88.03). On the third day, antibiotic use was statistically significantly lower in the PCT-guided group (16%) than in the control group (40%) (p = 0.014; p < 0.05; RR: 3.5; 95% CI: 1.36–9). Conclusion We suggested that PCT guidance will have important contributions to reduce antibiotic use in children with bronchiolitis. Particularly in countries with higher antibiotic prescription rates, this strategy may have implication for reducing the development of antibiotic resistance and side effects due to disturbance of microbiota.

ANTIBIOTIC USE FOR INPATIENT BRONCHIOLITIS: DID NATIONAL GUIDELINES CHANGE PRACTICE?

Abstract BACKGROUND Millions of infants and young children are affected by bronchiolitis annually around the globe. This viral lower respiratory tract infection often results in hospital admissions, thus impacting the cost of the healthcare system. Because of its heterogeneous clinical presentation, inpatient management practices amongst paediatricians varies widely. The publication of national guidelines by the Canadian Paediatric Society (CPS) in 2014 was aimed at decreasing the use of unnecessary investigations and therapies for inpatient management of bronchiolitis. OBJECTIVES To evaluate the levels of antibiotic prescriptions and supportive investigations for inpatient management of bronchiolitis before and after the publication of national guidelines. DESIGN/METHODS This study is a single-centre retrospective chart review of inpatients with confirmed cases of bronchiolitis. We included children with no other relevant co-morbidities, aged 1- 24 months, who were admitted from November 2011 – October 2016. We excluded those who were born less than 35 weeks gestational age and patients with chronic complex medical problems. Our inclusion and exclusion criteria mirrored those used in the CPS guidelines. Those admitted prior to December 2014 were analysed in the pre-guidelines cohort and the remaining were placed in the post-guidelines cohort. The main outcome was antibiotic prescription during the hospital stay. Secondary outcomes included the frequency of chest x-rays, nasopharyngeal swabs, and blood cultures. RESULTS 131 patients were included in the first (pre-guideline) cohort and 71 in the second (post- guideline) cohort. The overall initiation of antibiotics was almost equal in both cohorts, regardless of whether a chest x-ray was ordered (p=1.000). There was no significant difference in the number of chest x-rays ordered between cohorts (p=0.099). The percentage of patients discharged on antibiotics were significantly lower in the second cohort (p=0.018). More antibiotics were discontinued after a viral cause was isolated in the second cohort (p=0.001). The gender distribution, mean age and mean length of stay were almost equivalent between the cohorts. CONCLUSION Our study did not show a significant change in antibiotic prescription despite the release of national guidelines. We found that isolating a viral aetiology often leads to the discontinuation of antibiotics. This study emphasizes the need for local antimicrobial stewardship initiatives to reduce the use of unnecessary antibiotics.

Comparison of clinical features between respiratory syncytial virus and human rhinovirus lower respiratory tract infection in infants between 2013-2015 in Suzhou

Objective To analyze the clinical features of infants infected by respiratory syncytial virus (RSV) or human rhinovirus (HRV) in lower respiratory tract in Suzhou area based on the month age and the month of the year. Methods From January 2013 to December 2015, 2 206 nasopharyngeal aspirates specimens were collected from the infants with lower respiratory tract infection. Direct immunofluorescence assay was performed to test RSV.Reverse transcription-polymerase chain reaction(RT-PCR) method was used to test HRV.The medical history was collected and pulmonary function tests were performed in some infants who were infected with RSV and HRV. Results In 2 206 cases, total RSV positive rate was 19.90%(439/2 206 cases) and simple RSV infection positive was detected in 399 cases. Total HRV positive rate was 14.14%(312/2 206 cases), in which simple HRV infection positive was detected in 250 cases and the detection rate of RSV was significantly higher than that of HRV(χ2=25.88, P 1-2 month, >2-3 month and >3-4 months respectively.Up to the age of 4 months old, the detection rate decreased gradually, and with the increase of age and the detection rate in >7-8 month group was only 10.96%(16/146 cases). The detection rate of HRV was 0(0/12)and 9.40%(44/468 cases) in the age group of 28 d-1 month, >1-2 month, respectively. After 2 months age old, the detection rate fluctuation ranged from 13.22% to 16.67%.The incidence rate of severe RSV infection was 12.30%(54/439 cases) and the incidence rate of severe HRV infection was 5.13%(16/312 cases). Increased respiratory rate was more common in patients with severe RSV infection while severe HRV infection in infants were accompanied by multiple lobar involvement.After RSV infection, the incidence rate of pulmonary function damage was 89.03%(276/310 cases). After HRV infection, 89.27%(183/205 cases)of the infants suffered from pulmonary function damage. Both RSV and HRV infection might cause pulmonary function damage. Conclusions RSV and HRV are the major pathogens in infants of Suzhou areas. The incidence of RSV-induced wheezing is significantly higher than that of HRV. RSV is detected positive mainly in winter and early spring and the infants within 4-month old are susceptible population.HRV is detected positive mainly in June, July and September and the infants older than 2 months are susceptible population. The incidence of severe RSV infection is significantly higher than that of HRV. Severe RSV infection may cause increased respiratory rate and severe HRV infection mainly cause multiple lobar involvement. RSV and HRV infection may cause pulmonary function damage. Key words: Infants; Respiratory syncytial virus; Human rhinovirus

VIRUSES OF THE PARVOVIRIDAE FAMILY: MOLECULAR GENETICAL ASPECTS OF REPRODUCTION AND MEDICAL IMPORTANCE

Discovery of new parvoviruses led to taxonomical structure and the nomenclature of the Parvoviridae family reevaluation. There are two subfamilies: Densovirinae and Parvovirinae. Densovirinae subfamily consists of viruses of arthropoda. The Parvovirinae subfamily includes eight genuses of vertebrate animals viruses. In this review parvoviruses which are of interest to practical health care will be considered. Data on molecular and biological and virological characteristics of viruses, epidemiological and clinical features of the infections caused by these viruses are submitted. Parvoviruses whichare interesting for human health care belong to five genuses: Bocaparvovirus, Dependoparvovirus, Erythroparvovirus, Protoparvovirus and Tetraparvovirus. The most known person pathogenic parvovirus is the Primate erythroparvovirus 1 virus which was earlier called by Human parvovirus B19. It was discovered in 1975. It relates to the Erythroparvovirus genus. In this review the main attention is paid to less known viruses of this family. In viral lower respiratory tract infections structure the leading place is taken by Human Bocavirus — Primate bocaparvovirus 1 and Primate bocaparvovirus 2 relating to the Bocaparvovirus genus. In 2005, the virus of human, Primate tetraparvovirus 1, was discovered which belongs to the genus Tetraparvovirus. Clinically acute form of a tetraparvoviral infection is a top and lower respiratory tract and an alimentary tract disease. The virus possesses teratogenic action. Protoparvovirus genus representatives cause an alimentary tract disease also. Two species, pathogenic for the person are described. Bufavirus (Primate protoparvovirus 1) was found in 2012. Tuzavirus (Primate protoparvovirus 2, Tusavirus 1) was highlighted in 2014. Rodent protoparvovirus 1 which consist of rodents viruses is very interesting species for therapy of the human. Viruses of this species are capable to infect a wide range of human cancer cells, have the expressed carcinolytic properties and are perspective for treatment of person with a cancer. The human virus of the Dependoparvovirus genus called Human adeno-associated virus was discovered in 1965 in the drugs of an adenovirus. This virus isn’t associated with any disease however the virus can be located in a certain locus of the 19th human chromosome and is a perspective candidate like a vector for the treatment of genetic diseases.

Maternal Traumatic Stress and Infant Bronchiolitis

Introduction: Bronchiolitis, a viral lower respiratory tract infection, affects 20-30% of infants and is a leading cause of hospitalizations. Identifying and mitigating risk factors has public heal...

Protein conformation in a vaccine matters

Protein conformation in a vaccine matters

Chronic respiratory morbidity following viral lower respiratory tract infections in prematurely born infants

Human meta-pneumovirus (hMPV) and rhinovirus (RV) lower respiratory tract infections (LRTIs) may result in acute symptoms similar to those of respiratory syncytial virus (RSV) LRTI. We, therefore, tested the hypothesis that other viral LRTI, as RSV LRTI, will increase healthcare utilization and chronic respiratory morbidity in prematurely born infants. One hundred and twelve prematurely born infants were followed prospectively. Hospital admissions and general practitioner (GP) attendances were recorded and cough and wheeze documented by diary card. Nasopharyngeal aspirates (NPA) were obtained for every LRTI and analyzed to identify RSV (A and B), hMPV, RV, parainfluenza (1 and 2) and influenza (A and B) viruses. Eighty-four infants suffered 126 LRTIs; 94 viruses (41 RSV, 36 RV, seven hMPV, five parainfluenza (1, 2 or 3) and five influenza (A or B) viruses) were identified from 82 of the 126 NPAs. Compared to the no viral LRTI group, infants with only RSV infection had more (P =0 .038) and longer (P =0 .045) hospital admissions, more GP attendances (P =0 .024), more cough (P =0 .030) and wheeze at follow up (P =0 .018). If infants with dual infections are also considered, however, infants with a hMPV LRTI, with or without other viral RNA being detected, compared to the no viral group, had more hospital admissions (P =0 .005), longer admissions ( P< 0.001), more GP visits (P =0 .029), more days of cough (P =0 .008) and more days of wheeze (P =0 .004). RSV and possibly hMPV, but not RV, LRTI increase healthcare utilization and respiratory morbidity in prematurely born infants.

Release of High-Mobility Group Box-1 (HMGB1) in the Airways of Children with Viral Lower Respiratory Tract Infections

Release of High-Mobility Group Box-1 (HMGB1) in the Airways of Children with Viral Lower Respiratory Tract Infections

Is radiological appearance of lower respiratory tract infection due to respiratory syncytial virus a predictor of clinical outcome?

Objective: Respiratory syncytial virus (RSV) lower respiratory tract infection is the most common viral infection in childhood. RSV-infected infants demonstrate various radiographic findings. The aim of the study is to evaluate whether assessment of radiological characteristics of lower tract infection due to RSV may be a predictor of clinical outcome in newborns.Methods: The study included 36 newborn infants hospitalized for lower tract infection. In order to detect RSV, RSV Respi-Strip (Coris Bioconcept Organization) test kits were used on admission. Chest X-rays and clinical characteristics of the study group were reviewed.Results: Of 36 patients hospitalized for lower tract infection from October 2012 to April 2013, 18 (50%) newborns were infected with RSV. The study included 36 neonates. Patients with RSV-positive infants at admission had greater need for respiratory support, supplemental oxygen and prolonged stay in the NICU. Newborns with an atelectasis pattern on admission chest radiograph had greater at RSV-positive infants.Conclusion: Chest radiological patterns with lower respiratory tract infection in newborn infants due to RSV are a predictor of clinical outcome.

Relation between pulse oximetry and clinical score in infants with acute bronchiolitis

Background: Bronchiolitis is inflammation of the bronchioles, the smallest air passages of the lungs. It is the most common severe viral lower respiratory tract infection of infancy. Clinical diagnosis remains the most important tool for diagnosis. Clinical diagnosis would be supplemented by pulse oximetry but pulse oximetry may not be always available. Aims & Objective: To study Relation between SPO2 (oxygen saturation) and clinical score in children with acute bronchiolitis patients less than 12 months of age. Materials and Methods: This was the cross sectional observational study done in paediatric department of Jhalawar medical college, Jhalawar. One hundred and forty two infants were evaluated by the single paediatrician. Modified Tal’s clinical score and SPO2 of the patient were recorded. Bonferroni analysis was used using Graph pad 5 prism software for statistical analysis. Results: The mean (± SD) SpO2 value was 98.2 ± 1.3% for children with clinical scores of 2–5 (n = 32); 95.2 ± 0.9% for those with scores of 6–7 (n = 84), and 92.3 ± 0.87% for children with scores of 8–10 (n = 26), (P < 0.001 by Bonferroni’s multiple comparison, when all two-way comparisons were done for each pair of results). The clinical score showed a good correlation with SpO2 [ r =−0.734(P < 0.0001)]. Conclusion: We conclude that Modified Tal’s clinical score can be used as a primary tool to confirm severity of hypoxemia in infants with acute bronchiolitis even if pulse oximetry is not available.

Defining the burden of respiratory syncytial virus infection

i l b e t o Respiratory syncytial virus (RSV) remains one of the great threats to child health associated with considerable acute and long-term morbidity.1 RSV is the main cause of viral lower respiratory tract infection (LRTI) in young children in both developed and developing countries, and worldwide almost 34 million new cases occur every year. In the United States, RSV is the most common cause of hospitalization in infants.2,3 In the developing world RSV accounts for 3.4 million hospitalizations for LRTI in children < 5 years of age.4 Nevertheless, the global burden of RSV extends well beyond hospitalization and into the outpatient setting.5,6 There are well-characterized risk factors for severe RSV disease including prematurity, chronic lung disease (CLD), congenital heart disease (CHD), trisomy 21, neuromuscular disorders or an immunocompromised state. In addition, recent studies have identified other conditions to be associated with an increased risk for severe RSV disease, such as chromosomal abnormalities or malformations of the upper airway. In reality, pediatricians are well aware that any ‘‘non-previously healthy infant’’ is actually at higher risk

Neonatal Lung Disease and Respiratory Failure

Neonatal Lung Disease and Respiratory Failure

Value of Chest Radiographic Pattern in RSV Disease of the Newborn: A Multicenter Retrospective Cohort Study

Respiratory syncytial virus (RSV) lower respiratory tract infection is the most common viral respiratory infection in infants. Several authors have sought to determine which risk factors are the best predictors for severe RSV disease. Our aim was to evaluate if a specific chest radiographic pattern in RSV disease can predict the disease severity. We conducted a multicenter retrospective cohort study in term and preterm neonates with confirmed lower respiratory tract RSV infection, admitted to neonatal intensive care units (NICU) from 2000 to 2010. To determine which factors independently predicted the outcomes, multivariate logistic regression analysis was performed. A total of 259 term and preterm neonates were enrolled. Patients with a consolidation pattern on the chest radiograph at admission (n = 101) had greater need for invasive mechanical ventilation (OR: 2.5; P = .015), respiratory support (OR: 2.3; P = .005), supplemental oxygen (OR: 3.0; P = .008), and prolonged stay in the NICU (>7 days) (OR: 1.8; P = .025). Newborns with a consolidation pattern on admission chest radiograph had a more severe disease course, with greater risk of invasive mechanical ventilation, respiratory support, supplemental oxygen, and prolonged hospitalization.

CT of Viral Lower Respiratory Tract Infections in Adults: Comparison Among Viral Organisms and Between Viral and Bacterial Infections

CT of Viral Lower Respiratory Tract Infections in Adults: Comparison Among Viral Organisms and Between Viral and Bacterial Infections

Dexamethasone in children mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus: A randomized controlled trial*

To determine the efficacy of dexamethasone in the treatment of mechanically ventilated children with respiratory syncytial virus-severe lower respiratory tract infection. International, multicenter, randomized, double-blind, placebo-controlled trial. Twelve pediatric intensive care units. Children (<2 yrs) mechanically ventilated for respiratory syncytial virus lower respiratory tract infection. Children were prestratified for severity of oxygen abnormalities on admission. Intravenous dexamethasone (0.6 mg/kg/day, 48 hrs) or placebo. A superiority approach was used in the subgroup of patients with mild oxygen abnormalities (arterial partial pressure of oxygen/fractional inspired oxygen concentration [PaO(2)/FIO(2)] >200 mm Hg and/or mean arterial pressure ≤10 cm H(2)O) and a noninferiority approach in those with severe oxygen abnormalities (PaO(2)/FIO(2) ≤200 mm Hg and mean arterial pressure >10 cm H(2)O). Primary outcome was the duration of mechanical ventilation. In the subgroup with mild oxygenation abnormalities, 45 of the 89 included patients received dexamethasone and 44 placebo; in the subgroup with severe oxygenation abnormalities, 28 of the 56 included patients received dexamethasone and 28 placebo. Baseline characteristics in both treatment arms were similar for both subgroups. After the third interim analysis, the trial was stopped early for futility taking the slow enrollment into account. At that time, the median duration (interquartile range) of mechanical ventilation was 137 (91-195) hrs in the dexamethasone- and 139 (117-188) hrs in the placebo-treated patients in the subgroup with mild oxygenation abnormalities (p = .6). In the subgroup with severe oxygenation abnormalities, it was 171 (136-212) hrs in the dexamethasone- and 170 (125-201) hrs in the placebo-treated patients (p = .6). In this prematurely ended trial in children mechanically ventilated for severe respiratory syncytial virus-lower respiratory tract infection, we found no evidence of a beneficial effect of dexamethasone in children with mild oxygenation abnormalities. Neither was evidence found that dexamethasone may prolong mechanical ventilation in those with severe oxygenation abnormalities.

Health Care–Associated Infections in Children

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

Special populations: Do we need evidence from randomized controlled trials to support the need for respiratory syncytial virus prophylaxis?

Congenital abnormalities and impaired mechanisms that govern the normal coordinated physiology of breathing, sucking, swallowing and airway clearance, place infants with underlying medical disorders at high risk for respiratory morbidity following respiratory syncytial virus (RSV) lower respiratory tract infection. The use of RSV prophylaxis in premature infants' ≤ 35 weeks gestational age, infants with chronic lung and hemodynamically significant heart disease is firmly established through randomized controlled clinical trials (RCT's). RSV prophylaxis in infants with serious medical illnesses must be justified based on emerging scientific literature and the overriding concept of achieving a balance between benefit and harm with treatment. This article will explore the current evidence for palivizumab prophylaxis in a variety of disorders and examine existing differences between pediatric advisory body recommendations and real world practice.