Alexis Elward

Washington University in St. Louis, San Luis, Missouri, United States

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Publications (27)138.52 Total impact

  • Alexis Elward
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background: Central line associated bloodstream infection (CLABSI) rates in critically ill children are associated with increased morbidity and mortality. Decreasing the risk of CLABSI through successful implementation of central line (CL) insertion and maintenance bundles has been well documented. Given the proximity of the CL insertion site and intravascular (IV) tubing connections to the oropharyngeal and genitourinary regions, maintaining dry and intact CL dressings in children is problematic. By creating a dedicated CL dressing change team and increasing involvement of leadership in the details of CL care, a sustained decrease in the cardiac intensive care unit (CICU) CLABSI was seen. Methods: Creation and deployment of a CL dressing change team began July 2011. The CL dressing change team consisted of a group of experienced CICU staff nurses. The team members were responsible for changing all CL dressings following recommended maintenance guidelines. The bedside nurses were present during each dressing change which enhanced awareness and provided “just in time” education. The CICU utilized pictures of appropriate and inappropriate CL dressings as visual aids. The CICU medical director and nursing leadership began joint weekly rounds in June 2012 which reinforced and validated their commitment to decreasing CLABSI rates. Rounds included assessing the need for all IV lines, careful evaluation of the CL dressing, repositioning of the IV tubing away from the potential contamination sites, and separation of the tubing and stopcocks from these areas if change in position was not possible. If umbilical lines were present, the umbilical stump was evaluated for omphalitis. Results: (See Table 1) While not statistically significant (p = .065), CLABSI rates decreased 69.2% from 2010-2012. The median days between CLABSI increased from 32 in 2010 to 79 in 2012 (p=0.16) and year to date 2013 is 138. Table 1: 2010-2012 CICU CLABSI Data # CLABSI Device Days CLABSI Rate Device Utilization Ratio (DUR) NHSN Pooled mean NHSN DUR 2010 13 3310 3.9 0.69 2.1 0.69 2011 9 3430 2.6 0.83 1.6 0.70 2012 4 3836 1.0 0.89 Conclusion: Using dedicated staff members to manage CL dressing changes paired with consistent high level leadership involvement in CLABSI prevention can positively impact outcomes and decrease CLABSI rates.
    IDWeek 2013 Meeting of the Infectious Diseases Society of America; 10/2013
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    ABSTRACT: BACKGROUND: Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children. METHODS: In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393). FINDINGS: 1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02). INTERPRETATION: Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated. FUNDING: Sage Products, US National Institutes of Health.
    The Lancet 01/2013; DOI:10.1016/S0140-6736(12)61687-0 · 45.22 Impact Factor
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    ABSTRACT: We conducted a 2-sample pharmacokinetic study of oseltamivir in 12 premature infants. Oseltamivir 1 mg/kg/dose twice daily in infants <38 weeks postmenstrual age (n = 8) resulted in oseltamivir carboxylate exposure comparable to previously published pediatric data, which helps prospectively validate this regimen. Oseltamivir 3 mg/kg/dose once daily in premature infants >38 weeks postmenstrual age (born prematurely but chronologically past term, n = 4) resulted in similar oseltamivir and oseltamivir carboxylate exposure. Although these results suggest persistence of immature renal function in this subgroup, further pharmacokinetic/pharmacodynamic description is required to confirm the appropriateness of this regimen.
    The Journal of Infectious Diseases 07/2012; 206(6):847-50. DOI:10.1093/infdis/jis471 · 5.78 Impact Factor
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    ABSTRACT: Background: Recent studies suggest that daily CHG baths may reduce the incidence of bacteremia in adult intensive care units (ICU). Our objective was to determine if daily bathing with 2% CHG impregnated cloths compared with standard bathing practices would reduce bacteremia in critically ill children. Method: We performed an unmasked, controlled, cluster-randomized crossover trial in 10 ICUs at 5 academic medical centers. Patients more than 2 months of age with an expected duration of stay of more than two days were eligible. The primary outcome was bacteremia defined as any positive blood culture and included those due to commensal organisms. The main secondary outcome was central line-associated bloodstream infections (CLABSI). Planned efficacy (per protocol [PP]) and effectiveness (intent to treat [ITT]) analyses were performed. The treatment effect was estimated by adjusted incidence rate ratios (IRR) at the patient-level (patient IRR) and the ICU-level (ICU IRR). Result: 4,961 patient visits were randomized: 2422 to treatment and 2525 to control. There were 133 episodes of bacteremia of which 42 were CLABSI. There was a 35% decrease in the incidence of bacteremia in patients receiving treatment (PP; IRR 0.65, 95%CI 0.44-0.97) and a trend toward a reduction in incidence of bacteremia in ICUs receiving treatment (PP; IRR 0.66, 95%CI 0.43-1.01). A similar, but not statistically significant, treatment effect was seen in the ITT analysis (patient IRR 0.70, 95%CI 0.43-1.13; ICU IRR 0.69, 95%CI 0.41-1.18). There was not a statistically significant decrease in the incidence of CLABSI in patients or ICUs receiving treatment in the PP or ITT analyses ([PP; patient IRR 0.72, 95%CI 0.37-1.37, ICU IRR 0.72, 95%CI 0.36-1.42]; [ITT, patient IRR 0.55, 95%CI 0.25-1.17, ICU IRR 0.55, 95%CI 0.25-1.21]). There was no difference in the proportion of bacteremias due to Gram positive organisms in the treatment and control groups (0.57 and 0.71, p=.14). Conclusion: Daily CHG bathing reduces bacteremia in critically ill children. As CLABSIs become less frequent, larger studies may be needed to confirm our observed but not statistically significant reduction in CLABSI.
    Infectious Diseases Society of America 2011 Annual Meeting; 10/2011
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    ABSTRACT: Indices for prediction of surgical site infection (SSI) are well documented in the adult population; however, these factors have not been validated in children. 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. 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. 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.
    Journal of the American College of Surgeons 03/2011; 212(6):1033-1038.e1. DOI:10.1016/j.jamcollsurg.2011.01.065 · 4.45 Impact Factor
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    ABSTRACT: The incidence of Clostridium difficile infection (CDI) is increasing. Multicenter studies of CDI have been limited by the lack of valid case-finding tools. To facilitate pediatric studies of CDI, we constructed a case-finding tool using administrative data. A cross-sectional study was performed using the Pediatric Health Information System database and microbiologic data from 4 member hospitals. Using patients with laboratory-confirmed CDI as the standard, we determined the sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of an ICD-9-CM code for identifying children with laboratory-confirmed CDI. We identified 109 patients with laboratory-confirmed CDI and 119 patients with CDI ICD-9-CM code. The sensitivity, specificity, PPV, and NPV were 80.73%, 99.89%, 73.95%, and 99.92%, respectively, for this comparison. The addition of a billing charge for both C. difficile laboratory test and treatment medication to the ICD-9-CM code increased the specificity and PPV, but resulted in a slight decrease in the sensitivity and NPV. The use of administrative data for identifying pediatric cases of CDI was also compared with that of chart review, and was found to be a stronger surrogate for identifying cases of CDI when compared with microbiology data alone. These results demonstrate that the use of administrative data for CDI is a reliable and accurate method for identifying pediatric patients with CDI. The use of administrative data could facilitate the completion of larger studies due to its greater accessibility and reduced costs.
    The Pediatric Infectious Disease Journal 11/2010; 30(3):e38-40. DOI:10.1097/INF.0b013e3182027c22 · 3.14 Impact Factor
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    ABSTRACT: To identify opportunities to safely reduce antibiotic use in critically ill children with moderately severe respiratory failure. Prospective observational. Four pediatric intensive care units at three American tertiary care children's hospitals. Children aged 2 months to 18 yrs who were mechanically ventilated, had an abnormal chest radiograph, and for whom the attending physicians had initiated antibiotics for presumed bacterial pneumonia. Nonbronchoscopic bronchoalveolar lavage. Eligible children were subjected to nonbronchoscopic bronchoalveolar lavage within 12 hrs of initiating antibiotics. The concentration of bacteria in the lavage fluid was determined by quantitative assay, and the diagnosis of pneumonia was confirmed if >10 (4)pathogenic bacteria/mL were cultivated. Twenty-one subjects were enrolled, in whom 20 nonbronchoscopic bronchoalveolar lavage procedures were completed. Six of 20 subjects had nonbronchoscopic bronchoalveolar lavage results confirmatory of bacterial pneumonia, three additional subjects had bacteria isolated at concentrations below levels conventionally used to diagnose bacterial pneumonia, and the remaining 11 demonstrated no growth. Clinical parameters reflective of severity of disease and laboratory parameters reflective of systemic and local inflammation were tested for their association with a positive nonbronchoscopic bronchoalveolar lavage, but none was demonstrated. Eleven of 20 mechanically ventilated children treated with antibiotics for presumed infectious pneumonia had undetectable concentrations of bacteria in their lower respiratory tract, and three others had organisms present at low concentrations, suggesting that opportunities exist to reduce antibiotic exposure in this population.
    Pediatric Critical Care Medicine 10/2010; 12(3):282-5. DOI:10.1097/PCC.0b013e3181f39f0e · 2.33 Impact Factor
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    ABSTRACT: We surveyed members of the Society for Healthcare Epidemiology of America to assess current practice with regard to identifying and eradicating methicillin-resistant Staphylococcus aureus (MRSA) colonization in the neonatal intensive care unit (NICU). Although most respondents (86%) screened patients for MRSA colonization, variation existed in the number of anatomic sites sampled and in the use of culture at NICU admission, empirical institution of isolation precautions, and MRSA decolonization therapy. Evidence-based prevention strategies for MRSA transmission and infection are needed.
    Infection Control and Hospital Epidemiology 07/2010; 31(7):766-8. DOI:10.1086/653615 · 3.94 Impact Factor
  • Conference Paper: Alexis Elward
    Alexis Elward
    Fifth Decennial International Conference on Health-Care Related Infections 2010; 03/2010
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    ABSTRACT: Background: The incidence of Clostridium difficile infection (CDI) is increasing among children. Epidemiologic studies using administrative data can be an efficient method to study CDI in children. However, the use of ICD-9 codes to identify cases of CDI has not been validated using multi-center pediatric data. We determined the sensitivity, specificity, positive (PPV), and negative predictive value (NPV) of an ICD-9 code for identifying pediatric patients with laboratory confirmed CDI. Methods: Hospitalized pediatric patients with laboratory confirmed CDI were identified at 4 US children’s hospitals from May to October 2007. The Pediatric Health Information System (PHIS) database was queried to obtain all patients discharged with the ICD-9 code for CDI (008.45) during the study period. We further refined the definition of CDI by adding data on the presence of a charge for a C. difficile laboratory test and a prescription for CDI treatment. Using the list of patients with laboratory confirmed C. difficile as the gold standard, the sensitivity, specificity, positive, and negative predictive value of administrative data were calculated. Results: We identified 109 patients with laboratory confirmed CDI and 119 patients with a CDI ICD-9-CM code at discharge during the study period. The results are shown below in Table 1. Sensitivity, Specificity, PPV, and NPV of the ICD-9-CM code for CDI Sensitivity Specificity PPV NPV ICD-9 code 80.7% 99.8% 73.9% 99.9% ICD-9 code plus test 79.8% 99.9% 81.3% 99.9% ICD-9 code plus test and treatment 76.1% 99.9% 83.0% 99.9% Conclusions: This study demonstrates that the ICD-9 code for CDI is a reliable and accurate method to identify children with CDI. Using sequentially applied codes for C. difficile testing or treatment improves the positive predictive value of the code. This is the first multi-center pediatric study to provide evidence for the use of administrative data in identifying hospitalized pediatric patients with CDI.
    Infectious Diseases Society of America 2009 Annual Meeting; 10/2009
  • Alexis M Elward, Joanne M McAndrews, V Leroy Young
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    ABSTRACT: 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.
    Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 05/2009; 29(3):232-44. DOI:10.1016/j.asj.2009.01.010 · 2.03 Impact Factor
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    ABSTRACT: We sought to define the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal colonization in the St Louis pediatric population. Children from birth to 18 years of age presenting for sick and well visits were recruited from pediatric practices affiliated with a practice-based research network. Nasal swabs were obtained, and a questionnaire was administered. We enrolled 1300 participants from 11 practices. The prevalence of methicillin-resistant S aureus nasal colonization varied according to practice, from 0% to 9% (mean: 2.6%). The estimated population prevalence of methicillin-resistant S aureus nasal colonization for the 2 main counties of the St Louis metropolitan area was 2.4%. Of the 32 methicillin-resistant S aureus isolates, 9 (28%) were health care-associated types and 21 (66%) were community-acquired types. A significantly greater number of children with community-acquired methicillin-resistant S aureus were black and were enrolled in Medicaid, in comparison with children colonized with health care-associated methicillin-resistant S aureus. Children with both types of methicillin-resistant S aureus colonization had increased contact with health care, compared with children without colonization. Methicillin-sensitive S aureus nasal colonization ranged from 9% to 31% among practices (mean: 24%). The estimated population prevalence of methicillin-sensitive S aureus was 24.6%. Risk factors associated with methicillin-sensitive S aureus colonization included pet ownership, fingernail biting, and sports participation. Methicillin-resistant S aureus colonization is widespread among children in our community and includes strains associated with health care-associated and community-acquired infections.
    PEDIATRICS 06/2008; 121(6):1090-8. DOI:10.1542/peds.2007-2104 · 5.30 Impact Factor
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    ABSTRACT: Background: Neonatal Intensive Care Unit (NICU) pts are at increased risk for nosocomial primary bloodstream infection (BSI). Few studies have addressed attributable charges, length of stay (LOS), and mortality associated with BSI in this population. Methods: This study was conducted at a 235-bed children’s hospital. All patients discharged from the NICU in 2004-2006 who remained for >48 hours were eligible for study inclusion. BSI were identified by hospital infection control. ICD-9 diagnosis and CPT codes were used to create comorbidity and procedure variables. Charge data were inflation adjusted to 2006 dollars. Total charges and LOS were natural log-transformed to achieve a normal distribution and were used as the dependent variables in separate multivariate ordinary least squares models to determine attributable hospital cost and LOS associated with BSI. Mortality was the dependent variable in a Cox regression model with BSI as a time-dependent predictor. Results: 1711 pts were included in the analysis; 160 (9%) had a BSI. Of these, 20 (13%) had two BSI and 19 (12%) had > 3. BSI was an independent predictor of charges, LOS, and mortality (p < .001) in all 3 multivariate models. After controlling for 21 other significant predictors of cost (adjusted R2 = 0.749), the attributable charge of one BSI was $14,976 (95% CI: $7,564 - $23,227). Two BSI increased charges to $36,915 (95% CI: $19,930 - $58,418) and > 3 BSI was $60,333 (95% CI: $23,172 - $114,545). BSI also increased LOS after adjusting for 14 other predictors (adjusted R2 = 0.638). The LOS attributed to one BSI was 6 days (95% CI: 4 - 9 days) and multiple BSI was 20 days (95% CI: 13 - 30 days). BSI increased the hazard of mortality by 2.89 fold (95% CI 1.74 - 4.82) after adjusting for 8 other factors in the multivariate model. Conclusion: BSI significantly increased cost of hospitalization, LOS, and mortality in NICU pts. Focused interventions are needed to reduce primary BSI in this population.
    Infectious Diseases Society of America 2007 Annual Meeting; 10/2007
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    ABSTRACT: Background: Educational programs have not resulted in sustained improvement in hand hygiene adherence by healthcare workers (HCWs). We performed a multidisclinary intervention using front line staff to improve hand hygiene. Methods: Hand hygiene upon room exit was observed between 12/05- 1/ 07 at a 235 bed children’s hospital on 5 units: a procedure center (APC), an ambulatory wound care center (PAWS), a surgical floor, neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU). Adherence to hand hygiene was defined as use of alcohol foam or antibacterial soap and water immediately upon room exit. Only completely observed events were analyzed. The primary outcome was the adherence to hand hygiene practices by healthcare workers before and after the formation of a multidisciplinary team of front line staff at SLCH in 7/ 06. The team developed monthly hospital-wide activities and games, staff badges inviting parents to remind HCWs to perform hand hygiene (“Ask me”), posters and educational video sessions to improve hand hygiene. Results: 8261 HCW-patient interactions were observed ; 7410 (89.7%) were completely observed. 3046 (41.1%) of completely observed events occurred before 7/1/06. Preintervention the adherence to hand hygiene was 54.8% versus a rate of 78.1% postintervention (OR: 2.9; 95% CI 2.6-3.2). In multivariate analysis, the following were independent predictors of hand hygiene: postintervention period (OR 3.2; 95% CI 2.9-3.6) , type of HCW, unit and isolation status of patient (OR: 1.7; 95% CI 1.3-2.0). Respiratory Therapists (OR: 4.0; (95% CI 2.9-5.6) and nurses (OR: 2.2; 95% CI 1.9-2.6), were more likely than physicians to practice hand hygiene. Monthly rates of hand hygiene have remained at 91% 11/06-3/07. Conclusion: The multidisciplinary team intervention adopted at the SLCH was an effective method for improving sustained adherence to hand hygiene among health care workers.
    Infectious Diseases Society of America 2007 Annual Meeting; 10/2007
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    ABSTRACT: Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.
    Clinical Microbiology Reviews 08/2007; 20(3):409-25, table of contents. DOI:10.1128/CMR.00041-06 · 16.00 Impact Factor
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    ABSTRACT: 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). Nested case-cohort study. Patient data were collected prospectively, and antimicrobial susceptibility data were abstracted retrospectively. A large pediatric teaching hospital. 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. 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]). 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.
    Infection Control and Hospital Epidemiology 04/2007; 28(3):299-306. DOI:10.1086/512628 · 3.94 Impact Factor
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    ABSTRACT: 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. 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. The medical and surgical ICUs at a 500-bed suburban, tertiary care hospital. Patients requiring central venous catheterization while in the ICU. None. 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). 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.
    Critical Care Medicine 09/2006; 34(8):2084-9. DOI:10.1097/01.CCM.0000227648.15804.2D · 6.15 Impact Factor
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    ABSTRACT: To determine the source of an outbreak of Salmonella javiana infection. Case-control study. A total of 101 culture-confirmed cases and 540 epidemiologically linked cases were detected between May 26, 2003, and June 16, 2003, in hospital employees, patients, and visitors. Asymptomatic employees who had eaten in the hospital cafeteria between May 30 and June 4, 2003, and had had no gastroenteritis symptoms after May 1, 2003, were chosen as control subjects. A 235-bed academic tertiary care children's hospital. Isolates from 100 of 101 culture-confirmed cases had identical pulsed-field gel electrophoresis patterns. A foodhandler with symptoms of gastroenteritis was the presumed index subject. In multivariate analysis, case subjects were more likely than control subjects to have consumed items from the salad bar (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.3-12.1) and to have eaten in the cafeteria on May 28 (aOR, 9.4; 95% CI, 1.8-49.5), May 30 (aOR, 3.6; 95% CI, 1.0-12.7), and/or June 3 (aOR, 4.0; 95% CI, 1.4-11.3). Foodhandlers who worked while they had symptoms of gastroenteritis likely contributed to the propagation of the outbreak. This large outbreak was rapidly controlled through the use of an incident command center.
    Infection Control and Hospital Epidemiology 07/2006; 27(6):586-92. DOI:10.1086/506483 · 3.94 Impact Factor
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    Alexis M Elward, Victoria J Fraser
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    ABSTRACT: 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. Prospective cohort study. St. Louis Children's Hospital, a 235-bed academic tertiary care center with a 28-bed combined medical and surgical PICU. PICU patients admitted between September 1, 1999, and September 1, 2001. Nosocomial primary BSIs. 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. 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.
    Infection Control and Hospital Epidemiology 07/2006; 27(6):553-60. DOI:10.1086/505096 · 3.94 Impact Factor