Incidence, Risks, and Types of Infections in Pediatric Long-term Care Facilities.

Importance: The population of infants, children, and adolescents cared for at pediatric long-term care facilities is increasing in complexity and size and thus consumes substantial health care resources. Infections are a significant cause of morbidity and mortality in this population, but few recent data describe their incidence and effects. Objectives: To describe the types of infections diagnosed in residents of pediatric long-term care facilities, calculate infection rates, and identify risk factors for respiratory tract infections (RTIs). Design, Setting, and Participants: This prospective cohort study, which was part of a larger trial called Keep It Clean for Kids, was conducted from September 1, 2012, to December 31, 2015, at 3 pediatric long-term care facilities in New York. Residents of the facilities who were 21 years or younger and either residents or admitted during the study period (n = 717) were enrolled in the study. Medical records were reviewed to identify infections diagnosed by site clinicians. Main Outcomes and Measures: Incidence of infections, such as RTIs; skin and soft-tissue infections; chronic comorbid conditions, including neurologic and respiratory disorders; and device use, including gastrostomy tubes and tracheostomies, was determined. Risk factors for RTIs were assessed by generalized linear mixed method regression modeling. Results: The 717 residents had a median (interquartile range) age at enrollment of 2.6 (0.4-9.1) years; 358 (49.9%) were male. Four hundred twenty-eight residents (59.7%) had feeding tubes and 215 (30.0%) had tracheostomies. Most chronic comorbid conditions were musculoskeletal or ambulation (532 residents [74.2%]), neurologic (505 [70.4%]), respiratory (361 [50.3%]), and gastrointestinal (230 [32.1%]) disorders, and 460 residents (64.2%) had 4 or more chronic comorbid conditions. Site clinicians diagnosed 2052 infections during the 3-year study period. Respiratory tract infections were most common and were diagnosed in 1291 residents (62.9%). The overall infection rate was 5.3 infections per 1000 resident-days, and RTI rates were 3.3 infections per 1000 resident-days. Overall infection rates and rates of RTI, skin and soft-tissue infection, urinary tract infection, and bloodstream infection varied among the 3 sites. In the multivariable model, younger age (incidence rate ratio [IRR], 1.05; 95% CI, 1.03-1.06), increased number of chronic comorbid conditions (IRR, 1.12; 95% CI, 1.06-1.19), and the use of feeding tubes (IRR, 1.34; 95% CI, 1.03-1.64) and tracheostomies (IRR, 1.40; 95% CI, 1.17-1.69) were associated with RTIs. Conclusions and Relevance: In this study, RTIs were the most common infections diagnosed, but modifiable risk factors for RTIs were not identified. Future work should focus on optimizing infection prevention and control strategies to reduce infections, particularly RTIs, in the pediatric long-term care population.

Is hand hygiene frequency associated with the onset of outbreaks in pediatric long-term care?

BACKGROUND: Studies in adult long-term care facilities (LTCFs) have shown a correlation between hand hygiene (HH) and viral outbreak reduction, but no such studies have been conducted in pediatric LTCFs where the epidemiology of viral pathogens is different. METHODS: We compared electronically monitored facility-wide HH frequency in the weeks immediately prior to outbreaks of acute respiratory or gastrointestinal infections versus control weeks in a 137-bed pediatric LTCF from October 2012-August 2015. Control weeks were the 8-14 day (control 1) and 15-21 day (control 2) periods prior to the onset of each outbreak. RESULTS: There was no difference in HH frequency in the weeks leading up to the outbreaks versus control weeks (odds ratio [OR], 1.0; 95% confidence interval CI, 1.00-1.001 using control 1 and OR, 1.0; 95% CI, 1.00-1.001 using control 2). CONCLUSIONS: Our findings differed from those in adult LTFCs, possibly because of the greater contact between residents and staff in the pediatric setting, increased susceptibility to viral pathogens because of immunologic immaturity, or differences in the types of pathogens prevalent in each setting. Although HH may be important for limiting the number of residents infected during outbreaks, we found no association between HH frequency and subsequent outbreak onset.

Impact of Infection Prevention and Control Initiatives on Acute Respiratory Infections in a Pediatric Long-Term Care Facility.

We evaluated the collective impact of several infection prevention and control initiatives aimed at reducing acute respiratory infections (ARIs) in a pediatric long-term care facility. ARIs did not decrease overall, though the proportion of infections associated with outbreaks and average number of cases per outbreak decreased. Influenza rates decreased significantly. Infect Control Hosp Epidemiol 2016;37:859-862.

Direct costs of acute respiratory infections in a pediatric long-term care facility.

Acute respiratory tract infections (ARI) are a major burden in pediatric long-term care. We analyzed the financial impact of ARI in 2012-2013. Costs associated with ARI during the respiratory viral season were ten times greater than during the non-respiratory viral season, $31 224 and $3242 per 1000 patient-days, respectively (P < 0·001). ARI are burdensome for pediatric long-term care facilities not only because of the associated morbidity and mortality, but also due to the great financial costs of prevention.

Infection prevention and control practices in pediatric long-term care facilities.

Pediatric long-term care facilities (pLTCFs) provide for children with chronic, complex medical needs and therefore face unique challenges for infection prevention and control (IP&C). At a conference in 2012, pLTCF providers reported IP&C issues of greatest concern in a survey. Major concerns included the lack of IP&C best practice guidelines, multidrug-resistant bacteria, and viral respiratory infections. Best practice guidelines for IP&C specific to pLTCF populations should be developed and evaluated.

Epidemiology of human metapneumovirus in a pediatric long-term care facility.

BACKGROUND: Viral respiratory pathogens cause outbreaks in pediatric long-term care facilities (LTCFs), but few studies have used viral diagnostic testing to identify the causative pathogens. We describe the use of such testing during a prolonged period of respiratory illness and elucidate the epidemiology of human metapneumovirus (hMPV) at our LTCF. DESIGN: Retrospective study of influenza-like illness (ILI). SETTING: A 136-bed pediatric LTCF from January 1 through April 30, 2010. METHODS: The ILI case definition included fever, cough, change in oropharyngeal secretions, increase in oxygen requirement, and/or wheezing. RESULTS: During the study period, 69 episodes of ILI occurred in 61 (41%) of 150 residents. A viral pathogen was detected in 27 (39%) of the episodes, including respiratory syncytial virus (RSV) (n = 3), influenza A virus (not typed; n = 2), parainfluenza virus (n =2), adenovirus (n = 1), and hMPV (n = 19). Twenty-seven of the residents with ILI (44%) required transfer to acute care hospitals (mean length of hospitalization, 12 days; range, 3-47 days). Residents with tracheostomies were more likely to have ILI (adjusted odds ratio [OR], 3.99 [95% confidence interval {CI}, 1.87-8.53]; P = .0004). The mortality rate for residents with ILI was 1.6%. Residents with hMPV were younger (P = .03), more likely to be transferred to an acute care facility (OR, 3.73 [95% CI, 1.17-11.95]; P = .02), and less likely to have a tracheostomy (adjusted OR, 0.19 [95% CI, 0.047-0.757]; P = .02 ). DISCUSSION: Diverse pathogens, most notably hMPV, caused ILI in our pediatric LTCF during a prolonged period of time. Viral testing was helpful in characterizing the epidemiology of ILI in this population.