Petting Zoos as an Unsuspected Source of Pediatric Infections.

Children are at risk for infection following animal exposure at petting zoos owing to suboptimal hand hygiene and frequent hand-to-mucosal surface contact. Public health surveillance is limited, and infectious risk is likely underrecognized. Most reported infections are enteric. Here, we describe two children with unusual, nonenteric infections following petting zoo exposure.

Clostridioides difficile Infections in Inpatient Pediatric Oncology Patients: A Cohort Study Evaluating Risk Factors and Associated Outcomes.

BACKGROUND: Clostridioides difficile infection (CDI) is a significant source of morbidity in pediatric cancer patients. Few reports to date have evaluated risk factors and short-term outcomes for this population. METHODS: We retrospectively evaluated pediatric oncology admissions at St Louis Children's Hospital from 2009 to 2018. All inpatient cases of diagnosed initial CDI were identified. We aimed to investigate the prevalence of CDI and associated risk factors, including coadmission with another patient with CDI, and to evaluate short-term outcomes including length of stay and delays in subsequent scheduled chemotherapy. RESULTS: Review of 6567 admissions from 952 patients revealed 109 CDI cases (11.4% of patients). Patients with leukemia or lymphoma, compared to those with solid tumors, were more likely to have CDI (odds ratio [OR], 3 [95% CI, 1.4-6.6], and 3 [95% CI, 1.3-6.8], respectively). Autologous hematopoietic stem cell transplant (HSCT) was also a risk factor (OR, 3.5 [95% CI, 1.7-7.4]). Prior antibiotic exposure independently increased the risk for CDI (OR, 3.0 [95% CI, 1.8-4.8]). Concurrent admission with another patient with CDI also significantly increased the risk (OR, 84.7 [95% CI, 10.5-681.8]). In contrast to previous reports, exposure to acid-suppressing medications decreased the risk for CDI (OR, 0.5 [95% CI, .3-.7]). CDI was associated with increased length of stay (mean difference, 8 days [95% CI, 4.6-11.4]) and prolonged delays for subsequent chemotherapy (mean difference, 1.4 days [95% CI, .1-2.7]). CONCLUSIONS: CDI in pediatric oncology patients significantly prolongs hospitalization and delays chemotherapy treatment plans. Interventions to control CDI will improve the care of pediatric oncology patients.

Delayed Development of Coronary Artery Dilitation in Suspected Severe Acute Respiratory Syndrome Coronavirus 2 Multisystem Inflammatory Syndrome: More Research Needed.

Although significant disease burden in the severe acute respiratory syndrome coronavirus 2 pandemic has been relatively uncommon in children, worldwide cases of a postinfectious multisystem inflammatory syndrome in children and possible atypical Kawasaki-like disease attributing to severe acute respiratory syndrome coronavirus 2 infection have arisen. Original thinking for coronavirus disease-19 disease was that an overwhelming proinflammatory response drove disease pathogenesis. Emerging reports suggest that a robust immune suppression may be more relevant and predominant. Recently reported data on children with multisystem inflammatory syndrome in children have demonstrated a heterogeneity of immune phenotypes among these patients, with concern for a strong initial proinflammatory state; however, data are lacking to support this. Likewise, understanding development of certain clinical findings to changes in the immune system is lacking. CASE SUMMARY: We report a 12-year-old multiracial male with negative coronavirus disease-19 nasopharyngeal RNA polymerase chain reaction testing but positive severe acute respiratory syndrome coronavirus 2 serology, subsequent development of vasodilatory shock with myocardial depression, and subsequent delayed development of coronary artery dilatation after resolution of myocardial depression. Unlike previous reported cases of multisystem inflammatory syndrome in children, he exhibited profound lymphopenia without specific inflammatory cytokines elevations, whereas nonspecific markers (ferritin and C-reactive protein) were increased. He subsequently was discharged on day 12 of hospitalization with complete recovery. CONCLUSION: Our representative case of a patient with coronavirus disease-19-associated multisystem inflammatory syndrome in children without robust hyperinflammation and a delayed finding of coronary artery dilatation compared with reported case series highlights the need for further mechanistic understanding of coronavirus disease-19 disease and subsequent multisystem inflammatory syndrome in children or Kawasaki disease development. This report offers a number of disease mechanisms and clinical evolution considerations for further elucidation to guide development of potential therapies.

Vancomycin Concentrations in Paraspinal Muscles During Posterior Spinal Fusions for Neuromuscular Scoliosis.

STUDY DESIGN: Prospective consecutively enrolled cohort. OBJECTIVES: To evaluate paraspinal muscle concentration of intravenously administered vancomycin, at predetermined time points, during posterior spinal fusion (PSF) with instrumentation in neuromuscular scoliosis (NMS). SUMMARY: Surgical site infection (SSI) after PSF for NMS can be a devastating complication, which may lead to prolonged antibiotic use, multiple additional surgical procedures, pseudarthroses, and sepsis. Because of significant morbidity of SSIs in NMS, the prophylactic use of vancomycin has been adopted at our institution as standard wound prophylaxis, despite any high-level evidence of its efficacy. METHODS: A prospective study of 20 patients who underwent definitive PSF for NMS and received vancomycin infusion preoperatively per institutional protocol. Serum levels were obtained immediately after infusion, at surgical incision, and then at 1, 2, and 4 hours post incision. Muscle tissue samples were simultaneously obtained at incision and at 1, 2, and 4 hours post incision. Samples were analyzed by a validated liquid chromatography-tandem mass spectrometry method. RESULTS: 10 males and 10 females with a mean age of 14+11 years (9-20 years) received a mean infusion of 15.0 mg/kg vancomycin. Mean serum levels were 26.7 µg/mL after infusion, 18.1 at incision, 13.2 at 1 hour, 11.8 at 2 hours, and 7.6 at 4 hours post infusion. Mean muscle levels were 0.5 µg/mL at incision, 0.6 at 1 hour, 0.5 at 2 hours, and 0.7 at 4 hours post infusion. Mean serum levels reached minimum inhibitory concentration (MIC) for Staphylococcus aureus at incision and at all timepoints during surgery. Mean muscle vancomycin levels never reached MIC. No patients had any cardiac or kidney disease, and all patients had normal kidney function according to their preoperative laboratory values. CONCLUSIONS: Using accepted guidelines for the administration of intravenous vancomycin preoperatively, serum levels reached MIC at incision and at all timepoints tested during PSF for neuromuscular scoliosis. At no timepoint tested did muscle levels reach MIC. LEVEL OF EVIDENCE: Level II.

Use of Administrative Data for the Identificationof Laboratory-Confirmed Influenza Infection: The Validity ofInfluenza-Specific ICD-9 Codes.

We used Pediatric Health Information System data and laboratory records from 3 children's hospitals to determine whether administrative data accurately identify children with laboratory-confirmed influenza. Among 23 282 inpatients, diagnosis codes for influenza detected 73% of laboratory-confirmed influenza cases, whereas <1% of patients without a diagnosis code had laboratory-confirmed influenza.

Risk factors and outcomes of surgical site infection in children.

BACKGROUND: Indices for prediction of surgical site infection (SSI) are well documented in the adult population; however, these factors have not been validated in children. STUDY DESIGN: A retrospective case-control study was performed by examining the medical records of children (0 to 18 years) who developed an SSI within 30 days of selected class I and class II procedures at our institution from 1996 to 2008. Two controls were selected from among patients undergoing identical procedures within 12 months of each case. Statistical analysis was performed using Wilcoxon test for continuous and chi-square test for categorical variable. Factors thought a priori to be associated with risk of SSI and statistically significant variables from a univariate analysis were used to create a logistic regression model. RESULTS: Of 16,031 patients, 159 children (0.99%) developed an SSI. Univariate analysis showed race, postoperative location, skin preparation, urinary catheter, procedure duration, and implantable device as risk factors for development of an SSI. Independent predictors of SSI in multiple conditional logistic regression were age (adjusted odds ratio [aOR] 4.97 neonate vs adolescent; 95% CI 1.38 to 17.90), race (aOR 2.36 for African American vs white; 95% CI 1.32 to 4.18), postoperative location (aOR 6.55 ICU vs home; 95% CI 1.58 to 27.21), urinary catheter placement (aOR 3.56; 95% CI 1.50 to 8.48), and implantable device (aOR 3.05; 95% CI 1.14 to 8.21). Wound classification and antibiotic administration were not independent predictors of SSI. CONCLUSIONS: Postoperative location, urinary catheter insertion, and use of an implantable device are potentially modifiable risk factors for an SSI in children. The higher risk of SSI in younger patients and non-white race suggest a possible developmental, socioeconomic, or genetic marker for impaired host defense.

Methicillin-sensitive and methicillin-resistant Staphylococcus aureus: preventing surgical site infections following plastic surgery.

LEARNING OBJECTIVES: The reader is presumed to have a broad understanding of aesthetic surgical procedures. After studying this article, the participant should be able to: 1. Explain the microbiology of Staphylococcus species and discuss antibiotic resistance development in Staphylococcus species and assess how clinical outcomes are affected. 2. Identify the epidemiology of Staphylococcus carriers and the impact on the clinical practice and regulation. Practice effective measures that prevent surgical site infections. 3. Practice screening for and decolonizing of patients with methicillin-resistant Staphylococcus aureus (MRSA). Physicians may earn 2.5 AMA PRA Category 1 Credit by successfully completing the examination based on material covered in this article. The examination begins on page 245. As a measure of the success of the education we hope you will receive from this article, we encourage you to log on to the Aesthetic Society website and take the preexamination before reading this article. Once you have completed the article, you may then take the examination again for CME credit. The Aesthetic Society will be able to compare your answers and use this data for future reference as we attempt to continually improve the CME articles we offer. ASAPS members can complete this CME examination online by logging on to the ASAPS Members-Only Website (http://www.surgery.org/members) and clicking on "Clinical Education" in the menu bar. Staphylococcus aureus is the most common cause of surgical site infections (SSI), with both methicillin-sensitive and methicillin-resistant strains causing these infections. The incidence of methicillin-resistant S aureus (MRSA) has increased in the US over the past decade, largely due to the emergence of community-acquired MRSA (CA-MRSA). This article reviews the microbiology and epidemiology of methicillin-sensitive S aureus (MSSA) and MRSA, risk factors for surgical site infections among plastic surgery patients, the evidence supporting preoperative screening and decolonization measures to prevent surgical site infections caused by MRSA, recommendations for anti-microbial prophylaxis, and treatment recommendations for surgical site infections. Other proven methods of reducing SSI, including maintenance of normothermia during surgery, glucose control, cessation of nicotine use, and not shaving the surgical site preoperatively are discussed.

Effect of nosocomial infections due to antibiotic-resistant organisms on length of stay and mortality in the pediatric intensive care unit.

OBJECTIVE: To determine the prevalence, risk factors, and outcomes of nosocomial infection due to antimicrobial resistant bacteria in patients treated in the pediatric intensive care unit (PICU). DESIGN: Nested case-cohort study. Patient data were collected prospectively, and antimicrobial susceptibility data were abstracted retrospectively. SETTING: A large pediatric teaching hospital. PATIENTS: All PICU patients admitted from September 1, 1999, to September 1, 2001, unless they died within 24 hours after PICU admission, were 18 years old or older, or were neonatal intensive care unit patients receiving extracorporeal membrane oxygenation. RESULTS: A total of 135 patients with more than 1 nosocomial bacterial infection were analyzed; 52% were male, 75% were white, the mean Pediatric Risk of Mortality score was 10.5, and the mean age was 3.5 years. Of these patients, 37 (27%) had nosocomial infections due to antibiotic-resistant organisms. In univariate analysis, transplantation (odds ratio [OR], 2.83 [95% confidence interval (CI), 1.05-7.66]) and preexisting lung disease (OR, 2.63 [95% CI, 1.18-5.88]) were associated with nosocomial infections due to antibiotic-resistant organisms. Age, Pediatric Risk of Mortality score at admission, length of hospital stay before infection, and other underlying conditions were not associated with infections due to antibiotic-resistant organisms. Patients infected with antibiotic-resistant organisms had greater mean PICU lengths of stay after infection, compared with patients infected with antibiotic-susceptible organisms (22.9 vs 12.8 days; P=.004), and higher crude mortality rates (OR, 2.40 [95% CI, 1.03-5.61]). CONCLUSIONS: Identifiable risk factors exist for nosocomial infections due to antibiotic-resistant organisms. In univariate analysis, infections due to antibiotic-resistant bacteria are associated with increased length of stay in the PICU after onset of infection and increased mortality.

Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital.

OBJECTIVE: To determine the attributable cost and length of stay of intensive care unit (ICU)-acquired, catheter-associated bloodstream infections from a hospital-based cost perspective, after adjusting for potential confounders. DESIGN: Patients admitted to the ICU between January 19, 1998, and July 31, 2000, were observed prospectively for the occurrence of catheter-associated bloodstream infections. Hospital costs were obtained from the hospital cost accounting database. SETTING: The medical and surgical ICUs at a 500-bed suburban, tertiary care hospital. PATIENTS: Patients requiring central venous catheterization while in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured occurrence of catheter-associated bloodstream infection, in-hospital mortality rate, total ICU and hospital lengths of stay, and total hospital costs. Catheter-associated bloodstream infection occurred in 41 of 1,132 patients (3.6 cases per 1000 catheter days). Patients with catheter-associated bloodstream infection had significantly higher unadjusted ICU length of stay (median, 24 vs. 5 days; p < .001), hospital length of stay (median, 45 vs. 11 days; p < .001), mortality rate (21 [51%] vs. 301 [28%], p = .001), and total hospital costs (83,544 dollars vs. 23,803 dollars, p < .001). Controlling for other factors that may affect costs and lengths of stay, catheter-associated bloodstream infections resulted in an attributable cost of 11,971 dollars (95% confidence interval, 6,732 dollars-18,352 dollars), ICU length of stay of 2.41 days (95% confidence interval, 0.08-3.09 days), and hospital length of stay of 7.54 days (95% confidence interval, 3.99-11.09 days). CONCLUSIONS: Patients with catheter-associated bloodstream infection had significantly longer ICU and hospital lengths of stay, with higher unadjusted total mortality rate and hospital cost compared with uninfected patients. After adjusting for underlying severity of illness, the attributable cost of catheter-associated bloodstream infection was approximately 11,971 dollars.

Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: a 2-year prospective cohort study.

OBJECTIVE: The primary objective was to determine the rate of and risk factors for nosocomial primary bloodstream infection (BSI) in pediatric intensive care unit (PICU) patients in order to determine the validity of our previously published findings. The secondary objective was to analyze whether risk factors for primary BSI differed by organism type, particularly whether device use was more strongly associated with BSI due to gram-positive organisms. DESIGN: Prospective cohort study. SETTINGS: St. Louis Children's Hospital, a 235-bed academic tertiary care center with a 28-bed combined medical and surgical PICU. PATIENTS: PICU patients admitted between September 1, 1999, and September 1, 2001. OUTCOME MEASURES: Nosocomial primary BSIs. RESULTS: Of 2,310 patients, 55% were male, and 73% were white. There were 124 episodes of primary BSI in 87 patients (3.8%). Coagulase-negative Staphylococcus organisms were the leading cause of BSI (42 of 124 episodes). The rate of BSI was 9 BSIs/1,000 central venous catheter-days. Multiple logistic regression analysis showed that independent predictors of nosocomial primary BSI included higher number of arterial catheter-days (adjusted odds ratio [aOR], 5.7 per day of arterial catheterization; 95% confidence interval [CI], 3.4-9.8), higher number of packed red blood cell transfusions (aOR, 1.2; 95% CI, 1.1-1.4), and genetic syndrome (aOR, 4.7; 95% CI, 1.8-12). Severity of illness, underlying illnesses, and medications were not independently associated with increased risk of nosocomial BSI. CONCLUSION: Arterial catheter use and packed red blood cell transfusion are potentially modifiable risk factors for nosocomial primary BSI in PICU patients. Genetic syndromes may be markers for unrecognized immune defects that impair host defense against microorganisms.

Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients.

OBJECTIVE: To determine the attributable cost of nosocomial primary bloodstream infections (BSIs) in PICU patients. METHODS: A prospective cohort study was conducted of the PICU of the St Louis Children's Hospital, a 235-bed academic tertiary care center. All patients who were admitted to the PICU were included unless they met the following exclusion criteria: age >18 years, death within 24 hours of PICU admission, admission to the NICU service. Total and direct medical costs of PICU and hospital stay for patients with and without nosocomial primary BSI were measured. RESULTS: Fifty-seven children developed 65 episodes of primary BSIs during their PICU stay. The rate of BSI in this population was 13.8 per 1000 central venous catheter days. In multiple linear regression analysis, severity of illness as measured by the admission Pediatric Risk of Mortality Score III, congenital heart disease, underlying lung disease, ventilator days, transplant (solid organ and bone marrow), and nosocomial primary BSI were independent predictors of PICU direct costs. The direct cost of PICU admission for patients with nosocomial primary BSI was 45,615 dollars and for the patients without primary BSI was 6396 dollars. CONCLUSIONS: After controlling for age, severity of illness, underlying disease, and ventilator days, we found that the direct cost of PICU admission attributable to nosocomial primary BSI was 39,219 dollars. The prevention of these infections through specific interventions is likely to be cost-effective.

Survey of knowledge, beliefs, and practices of neonatal intensive care unit healthcare workers regarding nosocomial infections, central venous catheter care, and hand hygiene.

OBJECTIVE: To assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs). DESIGN: Self-administered survey. SETTING: A 55-bed NICU. PARTICIPANTS: NICU HCWs (N = 215). RESULTS: The response rate was 68%. Ninety-two percent knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. Ninety-five percent knew when to change gloves. Thirty-one percent knew the recommended duration for handwashing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and handwashing (99%) prevent nosocomial infection (NI). Sixty-seven percent used sterile barriers to insert CVCs, 76% reported wearing gloves, 81% reported routine handwashing, 35% knew that bacterial hand counts are higher with rings, 30% knew that long fingernails are associated with higher gram-negative bacterial hand contamination, and 35% knew that artificial fingernails are associated with higher gram-negative bacterial hand contamination. Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixty-one percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails. CONCLUSIONS: A disconnect existed between CVC knowledge and beliefs and practice. HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.

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

OBJECTIVE: 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. DESIGN: Prospective cohort study. SETTINGS: 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. PATIENTS: Subjects for this study were patients admitted to the PICU between September 1, 1999, and May 31, 2000. INTERVENTIONS: None. OUTCOME MEASURES: Patients were monitored for the development of nosocomial bloodstream infections from the day of PICU admission until 48 hours after PICU discharge. RESULTS: 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.

Ventilator-associated pneumonia in pediatric intensive care unit patients: risk factors and outcomes.

OBJECTIVES: To determine the rates, risk factors, and outcomes of ventilator-associated pneumonia in pediatric intensive care unit (PICU) patients. METHODS: A prospective cohort study was conducted at the St Louis Children's Hospital PICU on all patients who were admitted to the PICU from September 1, 1999, to May 31, 2000, except those who died within 24 hours, were > or =18 years of age, or were neonatal intensive care unit patients on extracorporeal membrane oxygenation. The primary outcome measured was the development of ventilator-associated pneumonia. Secondary outcomes were death and hospital and PICU length of stay. Multiple logistic regression analysis was performed to determine independent predictors for ventilator-associated pneumonia. RESULTS: There were 34 episodes of ventilator-associated pneumonia in 30 patients of 911 admissions (3.3%) and 595 (5.1%) mechanically ventilated patients. The mean ventilator-associated pneumonia rate was 11.6/1000 ventilator days. By logistic regression analysis, genetic syndrome (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.01-5.46), reintubation (OR: 2.71; 95% CI: 1.18-6.21), and transport out of the PICU (OR: 8.90; 95% CI: 3.82-20.74) independently predicted ventilator-associated pneumonia. CONCLUSIONS: Ventilator-associated pneumonia occurs at significant rates among mechanically ventilated PICU patients and is associated with processes of care. Additional studies are necessary to develop interventions to prevent ventilator-associated pneumonia.