Journal Reviews
August 1, 1999 3 minutes read
Journal Reviews
Richards MJ, Edwards JR, Culver DH, et al. Nosocomial infections in pediatric intensive care units in the United States. Pediatrics 1999; 103:e39.
A mean overall patient infection rate of 6.1% was found in this study of data collected between January 1992 and December 1997 from 61 pediatric intensive care units (PICUs) in the United States. The study used the standard surveillance protocols and nosocomial infection site definitions of the Centers for Disease Control and Prevention’s National Nosocomial Infections Surveillance system.
"Our analysis suggests that the epidemiology of nosocomial infections in PICUs differs from that seen in other critical care areas," the authors found. "The distribution of infection sites lies between what we have previously reported in neonatal ICUs and adult medical ICUs."
Primary bloodstream infections were the most common sites of infection, followed by pneumonia and urinary tract infections (UTIs). In adult medical ICUs, UTIs were most frequently reported. In neonatal ICUs, bloodstream infections were an even greater proportion of all infections than in pediatric units. "We saw a transition between the patterns with age, although bloodstream infections remain the most frequent nosocomial infections in adolescents," they conclude. Device-associated infection rates are the best rates currently available for comparisons between units, because they are not associated with length of stay, the number of beds in the hospital, or season.
Data on 110,709 patients with 6,290 nosocomial infections were analyzed. Primary bloodstream infections (28%), pneumonia (21%), and urinary tract infections (15%) were most frequent and were almost always associated with use of an invasive device. Primary bloodstream infections and surgical site infections were reported more frequently in infants aged two months or less than in older children. UTIs were reported more frequently in children more than five years old than in younger children. Coagulase-negative staphylococci (38%) were the most common bloodstream isolates, and aerobic gram-negative bacilli were reported in 15% of primary bloodstream infections. Pseudomonas aeruginosa was the most common species reported from pneumonia (22%) and Escherichia coli the most common from urinary tract infections (19%). Enterobacter species were isolated with increasing frequency from pneumonia and were the most common gram-negative isolates from bloodstream infections.
Rao VK, Iademarco EP, Fraser VJ, et al. Delays in the suspicion and treatment of tuberculosis among hospitalized patients. Ann Intern Med 1999; 130:404-411.
Nosocomial transmission of tuberculosis can result from delays in the suspicion and treatment of TB among hospitalized patients, the authors warn. Despite increased awareness of TB, delays in management appear to be common, due in part to a decline in TB expertise among physicians trained in the post-sanitarium era. Other studies have underscored that management errors are common and may contribute to the emergence of drug-resistant TB, they remind.
The authors found that over a three-year period at their hospital, 25 patients were identified by the infection control department as the source of TB exposures to 598 health care workers. "In these patients, a diagnosis of tuberculosis was not considered at admission and initiation of isolation and treatment was delayed," they noted. Delays in initiation of treatment were more common than delays in the initial suspicion of TB, but both types of delays were common, even in patients with disease that was confirmed by a positive smear.
"These delays illustrate a need for improved education of physicians about the benefits of early initiation of therapy for tuberculosis," they advise.
Researchers: Screen all admissions
To assist in clinical decision making, they recommend:
• All patients admitted to the hospital should undergo prompt assessment of their risk for active TB. The stringency of this assessment must be based on the prevalence of TB among hospital admissions.
• Patients in whom the diagnosis is suspected must be placed in respiratory isolation immediately, and diagnostic studies, including chest radiography, collection of sputum for acid-fast smear and culture, and tuberculin skin testing must be done in the first 24 hours of hospitalization.
• The timing of initiation of treatment is less straightforward and must rely on the clinical judgment of the treating clinician. However, certain guiding principles are applicable. Treatment for TB should be started immediately in all cases in which acid-fast organisms are present on smears unless infection with a non-TB mycobacterial species has been confirmed and the diagnosis of TB has otherwise been excluded.
• In addition, patients whose chest radiographs or symptoms are highly suggestive of TB should also begin antituberculous therapy while results of smears are awaited. In high-risk patients with negative smears, treatment should be continued until final culture results are available or further diagnostic studies are undertaken.
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