NOSOCOMIAL INFECTIONS IN PEDIATRICS

Dr. Sandip Gupta PGT, Pediatrics B.S.M.C.H.

DEFINITION

Nosocomial or Health care associated infections(HAI) are defined as any infection that was not present or incubating at the time of admission but occurred at 48hrs or more after hospital admission. Infections due to antibiotic-resistant organism is increasing specially in PICU.

Prevalence of HAI in pediatric patients ranges from 6 to12% in PICU & 10 to 25% in NICU*. Most common HAI are Catheter related blood stream infection(CR-BSI),Ventilator associated pneumonia(VAP), UTI.
*BanerjeeSN et al,Infect Control Hosp Epidemiol.2006;27(6):560-71

Nosocomial infections are even more alarming in the 21st century as antibiotic resistance spreads. Reasons why nosocomial infections are so common include:

hospitals house large numbers of people who are sick and whose immune systems are often in a weakened state; increased use of outpatient treatment means that people who are in the hospital are sicker on average; medical staff move from patient to patient, providing a way for pathogens to spread; many medical procedures bypass the body's natural protective barriers.

RISK FACTORS
Post-operative period Parenteral nutrition Longer duration or >7days of admission Use antimicrobial agents Invasive procedures Greater severity of illness

Source Of Nosocomial Infection :

Source

Endogenous Cause Self Infection Or Auto Infection

Exogenous Cause Cross Infection Or Environmental Infection

CATHETER RELATED BLOOD STREAM

INFECTION

Most common HAI. CR-BSI is either bactremia or fungemia documented with at least one peripherally obtained blood culture that is obtained from a vein not a catheter,clinial evidence of an infection , including a host response must be present that cannot be attribute to any source other than catheter.

NHNS(National healthcare safety network) data reveal a pooled mean of 2.9 BSI /1000 catheter- days.

Risk factors for BSI : multiple intravascular devices, longer duration of intravascular devices, extracorporeal life support, arterial catheter, packed R.B.C. tranfusion,, genetic syndromes. Organisms: MC is coagulase-negative Staph., Enterococcus, candida sp., serratia, S.aureus, pseudomonas, klebsiella, E.coli., acinobacter.

Indian study showed BSI were caused by isolates with increasing level of resistance.*
*Singhi S et al.nosocomial infection in a pediatric intensive care unit. Indian J pediatr.2008;75(1):25-30.

TREATMENT

Emperical t/t should consist gm ve & gm+ve cover.

IDSA2009 guidelines recommends vancomycin as gm+ve coverage & gm-ve should be based on local susceptibility. 4th gen cephalosporins ,carbepenems, blactam/blactamase are recommended. Aminoglycoside can be added in neutropenic pts , in sepsis, MDR gm-ve cases. Femoral lines-additional candida coverage. Descalate according to culture report. Duration may be 7 to 14 days, removal of infected catheter.

VENTILATOR-ASSOCIATED PNEUMONIA

CDC defines VAP as a new or progressive radiological infiltrate, consolidation, cavitation, pneumatocele (infants) that has persisted for at least 2 days plus any 2 of following: a temperature above 38.5c or below35c leucocyte count > 10000/mm3 or <5000/mm3 isolation of pathogenic bacteria from ET aspirates.

It has been shown that VAP rate is about 3 to 10% of ventilated pts in PICU & 6.2 to 32.3% in NICU.

NHSN data revealed a pooled mean of 2.1 VAP cases /1000ventilation days.

Risk factors include genetic syndrome , reintubation ,transport out of PICU, use of neuromuscular blockade agents, immunosupression, female gender, narcotic medication, presnce of enteral feeds. Longer duration of ventilation more the risk. Use of H2 blocker may help enteric bacteria to colonise UGI & predispose them to VAP.

Mc isolated organism in VAP pts were gm-ve including E.coli., Enterobacter sp., Serratia sp., Pseudomonas sp.,& mc gm+ve organism was S.aureus. About 38% of VAP pts had polymicrobial infectoions.

TREATMENT
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Single agents effective in VAP pts include carbepenems, cefepime, piperacillin-tazobactam. Floroquinones can also be used. Gm +ve coverage in form of vancomycin or linezolide can be added . Pts underlying disease, prior antimicrobial therapy , mental status, length of hospitalisation, result of respiratory aspirates, local antibiotic susceptibility pattern should all be considered. Duration : 5 to 7days for uncomplicated disease & longer for MDR organisms.

UTI

NHSN data revealed a pooled mean of 5UTI/1000 urinary catheter days.

Cystitis , pyelonephritis, & 2ndary BSI can occur in catheter related UTIs.
UTI in neoantal period is related to vescico -ureteric reflux. Urine from catheter is considered infected if colony counts are greater than 100,000cfu/ml. pts may or may not have pyuria.

Traditional features of dysuria , frequency, pelvic or flank pain, fever or chills are seldom found in ICU pts.

Mc pathogens are enteric gm-ve or perineal flora including enterobacter sp.& candida sp. Basic management of catheter associated UTIs is removal of catheter. Pts with complication of UTI such as pyelonephritis or BSI require systemic antimicrobials. Prior receipt of antibiotics may put the patient at risk of infection with resistant organisms.

At present there is no consensus on duration of therapy.

OTHERS

C.difficile mc cause of nosocomial infectious dirrhoea. Can cause pseudomembranous colitis. t/t includes discontinuation of precipitating antibiotics, oral metronoidazole, vancomycin can be used non responders. Surgical site infections , infections of vascular grafts, prosthetic valves, peritoneal catheters, VP shunts. General principles of surgical wound infections include source control with surgical drainage of localised infection, obtaining intra-operative cultures, use of appropriate antibiotics. In device related infections, surgical removal infected devices e.g. VPS externalisation, in addition to use of systemic infections.

DIFFICULT TO CONTROL INFECTIONS

Gm positive MRSA/VRSA VRE CLOSTRIDIUM DIFFICILE

ESBLs KPCs MDR A. baumanni

Gm negative

BUNDLED INTERVENTIONS FOR PREVENTION

Central venous line: Educate personnel about catheter insertion & care. Use chlorhexidine for preparation of insertion site. Maxium barrier precaution during insertion. Ask daily is the catheter really necessary.

VAP: elevate head end to 30-45 degrees. Give sedation vacation & asses readiness to extubate. Use peptic ulcer prophylaxis. DVT Prophylaxis.

Surgical site infection:

Give prophylactic antibiotic 1hr before &discontinue 24 hrs after. Limit hair removal.

UTI Place when absolutely nessecary. Use aseptic technique. Minimize manipulation & opening of the system. Remove as soon as possible.

PREVENTIVE MEASURES:
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Proper means of disinfection and sterilisation (physical, chemical and biological tests),

Disposable instruments (cost/effectiveness!),

Separation or/and exclusion of suspect sources (patients, visitors),

Strict rules in handling the bed clothes, meals and hospital wastes,
Hospital committee for nosocomial infections evidence, surveillance, Washing the hands between the contact with two different patients.

TAKE HOME MASSAGE

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Routine use of anti-microbial agents in hospitals creates selection pressure for the emergence of resistant strains.

Thorough hand washing and/or use of alcohol rubs by all medical personnel before each patient contact is one of the most effective ways to combat nosocomial infections.

More careful use of anti/microbial agents, such as antibiotics, is also considered vital.