Carbapenem-resistant Klebsiella pneumoniae colonization in pediatric and neonatal intensive care units: risk factors for progression to infection

Abstract Background Little is known about factors associated with carbapenem-resistant Klebsiella pneumoniae infections in pediatric patients, who are initally colonized with carbapenem-resistant Klebsiella pneumoniae. Materials and methods A retrospective case–control study was conducted involving pediatric and neonatal intensive care units throughout a five-year period (January 2010–December 2014). Clinical and microbiological data were extracted from Hospital Infection Control Committee reports and patients’ medical records. Risk factors were assessed in carbapenem-resistant Klebsiella pneumoniae colonized patients who developed subsequent systemic infection (cases) and compared to carbapenem-resistant Klebsiella pneumoniae colonized patients who did not develop infection (controls). Results Throughout the study period, 2.6% of patients admitted to neonatal intensive care units and 3.6% of patients admitted to pediatric intensive care units had become colonized with carbapenem-resistant Klebsiella pneumoniae. After a mean of 10.6 ± 1.9 days (median: 7 days, range: 2–38 days) following detection of colonization, 39.0% of the carbapenem-resistant Klebsiella pneumoniae colonized patients in pediatric intensive care units and 18.1% of carbapenem-resistant Klebsiella pneumoniae colonized patients in neonatal intensive care units developed systemic carbapenem-resistant Klebsiella pneumoniae infection. Types of systemic carbapenem-resistant Klebsiella pneumoniae infections included bacteremia (n = 15, 62.5%), ventilator-associated pneumonia (n = 4, 16.6%), ventriculitis (n = 2, 8.3%), intraabdominal infections (n = 2, 8.3%), and urinary tract infection (n = 1, 4.1%). A logistic regression model including parameters found significant in univariate analysis of carbapenem resistant Klebsiella pneumoniae colonization and carbapenem resistant Klebsiella pneumoniae infection groups revealed underlying metabolic disease (OR: 10.1; 95% CI: 2.7–37.2), previous carbapenem use (OR: 10.1; 95% CI: 2.2–40.1), neutropenia (OR: 13.8; 95% CI: 3.1–61.0) and previous surgical procedure (OR: 7.4; 95% CI: 1.9–28.5) as independent risk factors for carbapenem-resistant Klebsiella pneumoniae infection in patients colonized with carbapenem-resistant Klebsiella pneumoniae. Out of 24 patients with carbapenem resistant Klebsiella pneumoniae infection, 4 (16.6%) died of carbapenem-resistant Klebsiella pneumoniae sepsis. Conclusion Asymptomatic colonization with carbapenem-resistant Klebsiella pneumoniae in intensive care units of pediatric departments should alert health care providers about forthcoming carbapenem-resistant Klebsiella pneumoniae infection. Those carbapenem-resistant Klebsiella pneumoniae colonized patients at risk of developing infection due to carbapenem-resistant Klebsiella pneumoniae may be targeted for interventions to reduce subsequent infection occurence and also for timely initiation of empirical carbapenem-resistant Klebsiella pneumoniae active treatment, when necessary.

Airway Pressure Release Ventilation: An Alternative Ventilation Mode for Pediatric Acute Hypoxemic Respiratory Failure.

Airway pressure release ventilation (APRV) is a relatively new mode of mechanical ventilation. The use of this model of ventilation in pediatrics has been limited. The authors describe their experience with this mode of ventilation in a series of pediatric hypoxemic respiratory failure patients. Three patients with acute hypoxemic respiratory failure (AHRF) were treated with APRV, when oxygenation did not improve with pressure control ventilation (PCV). The mean age of the patients was 5.8± 1.3 months. Fractional oxygen concentration decreased from 0.97±0.02 for PCV to 0.68±0.12 for APRV, peak airway pressure fell from 36.6±11.5 cm H2O for PCV to 33.3±5.7 cm H2O for APRV, mean airway pressure increased from 17.9±5.9 cmH2O for PCV to 27± 2.6 cmH2O for APRV and release tidal volume increased from 8.3±1.5 mL/kg for PCV to 13.2±1.1 mL/kg for APRV after 1 h. APRV may improve oxygenation in pediatric AHRF when conventional mechanical ventilation fails. The APRV modality may provide better oxygenation with lower peak airway pressure.