[show abstract][hide abstract] 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.
[show abstract][hide abstract] 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.
[show abstract][hide abstract] ABSTRACT: To identify opportunities to safely reduce antibiotic use in critically ill children with moderately severe respiratory failure.
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. · 2.35 Impact Factor
[show abstract][hide abstract] 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. · 4.02 Impact Factor