Use of the Pediatric Risk of Mortality score to predict nosocomial infection in a pediatric intensive care unit.

OBJECTIVE: To define infection rates in patients with Pediatric Risk of Mortality (PRISM) scores greater than and less than 10 on admission to the pediatric ICU (PICU). DESIGN: Descriptive. SETTING: An 18-bed PICU admitting patients of all ages except nonsurgical neonates; within a 585-bed tertiary care pediatric hospital. PATIENTS: Patients admitted to the PICU from July 1987 to February 1988 inclusive. Of 685 admitted, 480 were followed for greater than or equal to 72 hr. METHODS: The baseline state of the patients on admission was determined by a designated intensivist using the PRISM score. Other variables included age, length of stay, and hospital day of onset of infection. Infections were identified by a designated intensivist who undertook prospective daily bedside observation, chart, radiographic, and laboratory review. MEASUREMENTS AND MAIN RESULTS: Equal portions of patients had PRISM scores less than and greater than 10. Significantly more infections occurred in the high PRISM population (10.8% vs. 3.4%, p less than .001). This association held through age, service, and length of stay. Sensitivity, specificity, positive and negative predictive values of a PRISM score greater than 10 were 75%, 53%, 11%, and 97%, respectively. Bacteremias accounted for 36% of infections, skin/eye/drain site 22%, respiratory 16%, wound 15%, and urine 9%. The most prevalent organisms were coagulase-negative staphylococci (32%), Pseudomonas aeruginosa (23%), Candida sp. (20%), and S. aureus (9%). CONCLUSIONS: A PRISM score greater than 10 on PICU admission characterizes a population within the PICU at increased risk of infection. However, 93% of patients did not develop infection and thus, a negative predictive value of 97% yields little additional information.

The incidence of viral-associated diarrhea after admission to a pediatric hospital.

For determination of the incidence of viral-associated diarrhea after admission to a pediatric hospital, all patients admitted to general pediatrics, cardiology, and neurosurgery wards without diarrhea between January 1 and July 31, 1985 were followed 5 days per week for presence of diarrhea, etiologic agent, and possible risk factors. A total of 1,530 patients were followed for 3,642 days. Of these patients, 69 developed 80 nosocomial diarrhea episodes after 72 hours in hospital for a nosocomial diarrhea rate of 4.5 infected children per 100 admissions. Of 358 patients with an infected roommate, 37 (10.3%) developed nosocomial diarrhea. Etiologic agents recognized included rotavirus (43%), calicivirus (16%), astrovirus (14%), minreovirus (12%), adenovirus (8%), Salmonella sp. (4%), and parvo/picornavirus (3%). The nosocomial diarrhea rate by age was: 0-11 months, 8.8%; 12-35 months, 3.6%; and 36 months or more, 0.6%. The rate by length of stay was: 3-7 days, 8.4%; 8-14 days, 10.4%; 15-21 days, 7.9%; and 22 days or more, 8.8%, and by number of roommates/1,000 patient-days it was: 0-1, 15.7; 2 to 3, 27.7; and 4 or more, 45.2. Patients who acquired diarrhea were more likely to be diapered (9.6% vs. 1.8%, p less than 0.001). Playroom use was not significantly different in the two groups. A total of 64 patients developed diarrhea within 72 hours of admission (community diarrhea rate = 4.2). Nosocomial viral-associated diarrhea is almost exclusively a disease of diapered children less than age 36 months and occurs at any time during hospital stay. It is more common in multibed rooms, but does occur in single-bed rooms.

Early nosocomial infections in pediatric cardiovascular surgery patients.

All patients undergoing cardiovascular surgery between July 1, 1987 and February 29, 1988 were followed from admission to the pediatric ICU (PICU) daily by an intensivist/anesthetist. Patients were characterized by surgical procedure and PRISM score on ICU admission. Of 310 patients, 40 patients (nosocomially infected patient ratio 12.9) developed 78 infections (nosocomial infection ratio 25.2), of which 28% (n = 22) were wounds, within 2 months of surgery. Early wound infection followed 8% of closed, nonpump cases and 6.7% of open, pump cases. Wound infection was more likely if the sternum was open on the ward (elective or emergency) (27.6% open vs. 5.0% closed, p less than .001) or if the PRISM score was greater than or equal to 10 on PICU admission (10.7% greater than or equal to 10 vs. 2.3% less than 10, p less than .01). The causative agents in wound infections in closed cases were Staphylococcus aureus (70%) and coagulase negative staphylococci (CONS) (30%) while in open, pump cases the agents were CONS (33%), Pseudomonas aeruginosa (27%), Candida spp. (27%), and S. aureus (20%). Nonwound infections accounted for 72% of infections (n = 56). The number of bacteremias and other central and arterial line-related infections approximated wound infection in incidence at 6.8/100 patients. Wound infections are more likely if the sternum has been left open on the ward, if the patient has a high PRISM score on PICU admission, and after specific surgical procedures.

Evaluation of a new method of detection of nosocomial infection in the pediatric intensive care unit: the Infection Control Sentinel Sheet System.

To improve the efficiency of nosocomial infection detection, a highly structured system combining initial reporting by the bedside night nurse of symptoms possibly related to infection with follow-up by the infection control nurse (ICN) was developed: The Infection Control Sentinel Sheet System (ICSSS). Between July 1, 1987 and February 28, 1988, a prospective comparison of results obtained through ICSSS and daily bedside observation/chart review by a full-time trained intensivist was undertaken in the pediatric intensive care unit (PICU). Ratios of nosocomial infections and nosocomially-infected patients were 15.8 and 7.0 respectively among 685 admissions; included are seven infections identified only through the ICSSS so that the "gold standard" became an amalgamation of the two systems. The sensitivity for detection of nosocomially-infected patients by bedside observation/chart review and ICSSS was 100% and 87% respectively. The sensitivity for detection of standard infections (blood, wound and urine) was 88% and 85% respectively. The sensitivity for detection of nosocomial infections at all sites was 94% and 72% respectively. Missed infections were minor (e.g., drain, skin, eye), required physician diagnosis (e.g., pneumonia), were not requested on the sentinel sheet (SS) (e.g., otitis media), related to follow-up of deceased patients or were minor misclassifications or failures to associate with device (e.g., central-line related). Daily PICU surveillance by the ICN required only 20 minutes a day. The ICSSS appears highly promising and has many unmeasured benefits.

Epidemiologic study of 4684 hospital-acquired infections in pediatric patients.

During a 4-year period 4684 nosocomial infections occurred in a university pediatric hospital which admitted 78,120 patients (nosocomial infection rate (NIR) = 6.0). NIR varied from 0.17 to 14.0 on different wards or services; the highest rates (greater than or equal to 5.6) were found in the Neonatal Intensive Care Unit, infant neurosurgery, hematology/oncology, neonatal surgery, cardiology/cardiovascular surgery, Pediatric Intensive Care Unit and infant/toddler medicine areas. Infections were most common in patients less than or equal to 23 months (NIR = 11.5), were less common in the 2- to 4-year age group (NIR = 3.6) and occurred least frequently in patients greater than or equal to 5 years (NIR = 2.6). The median day of onset of infections was 15.3 days. The proportional frequencies of infections were: 35% gastrointestinal; 21% bacteremia; 16% respiratory (10% upper, 6% lower); 7% postoperative wound; 6% urinary tract; 5% skin (32% of these skin infections were related to intravascular lines); 5% eye; 3% cerebrospinal fluid; and 2% other. A similar proportional frequency of 379 infections in patients hospitalized for more than 100 days was observed. The etiologic agents were Gram-positive bacteria (50%), viruses (23%), Gram-negative bacteria (18%), fungi (4%) and mixed/other (5%).

Nosocomial infections in a pediatric intensive care unit.

In a prospective 30-month study of nosocomial infections in a pediatric ICU (PICU), the incidence, sites, and causes of infection were determined. Factors associated with increased risk of infection were investigated. In 1,388 patients who remained in the PICU for a minimum of 72 h, 116 infections occurred (6.1 infections/100 admissions). Primary bacteremias comprised 38% of PICU infections and lower respiratory infections comprised 15%. The remaining infections were divided equally among GI, skin, eye, upper respiratory, postoperative wounds, and other sites. Coagulase-negative staphylococci, Pseudomonas aeruginosa, and Staphylococcus aureus were the most prevalent pathogens. Surgical patients had similar rates of infection to medical patients. Patients in the first 2 yr of life, particularly those between 7 and 30 days of age, had the highest rate of infection. Onset of infection was more common after the first week in the PICU with 11% of patients staying 14 to 20 days, 27% of patients staying 21 to 27 days, 48% of patients staying 28 to 34 days, and 52% of patients staying more than 35 days before the onset of infection. The risk of nosocomial infection increases with arterial and central line use, prolonged intubation, ventilation, intracranial pressure monitoring, and paralysis.

Pathophysiology of the ciliary motility syndromes.

The ciliary motility syndromes are characterised by specific and genetically determined defects of cilia with resulting impairment of mucociliary defense mechanisms in the respiratory tract. The ciliary pathobiology, clinical observations, serial pulmonary function and chest radiographs are reviewed and correlated for a series of 33 patients with the ciliary motility syndromes, aged from 0.5 to 75 years. The clinical course and progressive nature of this disease emphasizes the importance of early and accurate diagnosis to prevent irreversible pulmonary damage.