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Risk Factors for Nosocomial Primary Bloodstream Infection in Pediatric Intensive Care Unit Patients: a 2-Year Prospective Cohort Study Alexis M

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Risk Factors for Nosocomial Primary Bloodstream Infection in Pediatric Intensive Care Unit Patients: a 2-Year Prospective Cohort Study Alexis M Washington University School of Medicine Digital Commons@Becker Open Access Publications 2006 Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: A 2-year prospective cohort study Alexis M. Elward Washington University School of Medicine in St. Louis Victoria J. Fraser Washington University School of Medicine in St. Louis Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs Part of the Medicine and Health Sciences Commons Recommended Citation Elward, Alexis M. and Fraser, Victoria J., ,"Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: A 2-year prospective cohort study." Infection Control and Hospital Epidemiology.,. 553-560. (2006). https://digitalcommons.wustl.edu/open_access_pubs/905 This Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Open Access Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact [email protected]. Risk Factors for Nosocomial Primary Bloodstream Infection in Pediatric Intensive Care Unit Patients: A 2‐Year Prospective Cohort Study • Author(s): Alexis M. Elward , MD and Victoria J. Fraser , MD Reviewed work(s): Source: Infection Control and Hospital Epidemiology, Vol. 27, No. 6 (June 2006), pp. 553-560 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/505096 . Accessed: 15/04/2012 18:42 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. The University of Chicago Press and The Society for Healthcare Epidemiology of America are collaborating with JSTOR to digitize, preserve and extend access to Infection Control and Hospital Epidemiology. http://www.jstor.org infection control and hospital epidemiology june 2006, vol. 27, no. 6 original article Risk Factors for Nosocomial Primary Bloodstream Infection in Pediatric Intensive Care Unit Patients: A 2-Year Prospective Cohort Study Alexis M. Elward, MD; Victoria J. Fraser, MD 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. Infect Control Hosp Epidemiol 2006; 27:553-560 Bloodstream infection (BSI) is the most frequent nosocomial primary BSI. Some studies have been limited because of a infection reported in pediatric intensive care unit (PICU) short duration of arterial catheterization among participants patients.1-4 Central venous catheter (CVC)–associated BSI and small sample size. rates in PICUs range from 7.7 to 46.9 infections per 1,000 We performed a 2-year prospective cohort study to deter- CVC-days.4-9 These rates are comparable to BSI rates found mine the rate of and risk factors for nosocomial BSI in PICU in burn units and neonatal intensive care units.6 Coagulase- patients in order to enlarge our study population and validate negative staphylococci are the most common pathogens iden- the previously published analysis of data from the first 9 tified among patients with catheter-related BSI (38% of ep- months of the study.4 In addition, we analyzed whether risk isodes), although gram-negative rods are isolated in 25% of factors for BSI due to gram-negative pathogens differed from PICU bacteremia cases.2 Several studies have shown an as- risk factors for BSI caused by coagulase-negative staphylo- sociation between BSI and mortality in PICU patients in uni- cocci, with the specific goal of determining whether device variate analysis.3,4,10 The mean attributable cost of BSI in the use was more strongly associated with BSI due to gram-pos- PICU ranges from $39,000 to $50,000 per patient.11-13 itive organisms. Several studies involving PICU patients have sought to determine risk factors for nosocomial primary BSI.1,3,4,14,15 methods Longer duration of CVC use,3,14 increased number of CVCs Setting used,14 arterial catheter use,1,3 and receipt of extracorporeal membrane oxygenation,14 dialysis,14 total parenteral nutri- This study was performed at St. Louis Children’s Hospital, a tion,3 and mechanical ventilation1,3 are each associated with 235-bed teaching hospital affiliated with Washington Uni- From the Departments of Pediatrics (A.M.E.) and Internal Medicine (V.J.F.), Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri. Received November 11, 2005; accepted February 23, 2006; electronically published May 31, 2006. ᭧ 2006 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2006/2706-0004$15.00. 554 infection control and hospital epidemiology june 2006, vol. 27, no. 6 versity School of Medicine (St. Louis). St. Louis Children’s ceived) were obtained from the blood bank and from indi- Hospital is located in the St. Louis metropolitan area and has vidual medical records. Lung disease was defined as a history a referral base in southeastern Missouri and southwestern of restrictive or obstructive pulmonary disease (including Illinois with a 483-km (300-mile) radius. St. Louis Children’s asthma, bronchopulmonary dysplasia, and cystic fibrosis) or Hospital has a combined medical and surgical PICU with 22 chronic hypoxemia or hypercapnia requiring administration beds. Six beds were added after construction of a new facility of oxygen or mechanical ventilation at home, as documented in 2000. There are approximately 1,400 admissions to the in the admission history and during physical examination. PICU per year. In the new facility, patient rooms are separated Congenital heart disease was defined as abnormal cardiac by walls rather than curtains, and each room has a sliding anatomy at birth, including an abnormal number of cham- glass door and a sink placed next to the door. There were 12 bers, an intracardiac shunt, or abnormally structured circu- sinks and 22 beds in the old facility. lation, valves, or coronary arteries. Developmental delay was defined as a significant lag in development or an inability to Patients attain normal developmental milestones, and genetic syn- Subjects for this study were patients admitted to the PICU drome was defined as a chromosomal abnormality or cluster between September 1, 1999, and September 1, 2001. We ex- of physical findings consistent with a recognized genetic syn- cluded patients who were older than 18 years of age, who drome, as documented in the medical record. Transfusion died within 24 hours after admission, or who were from the was defined as receipt of packed red blood cells, platelets, neonatal intensive care unit and receiving extra corporeal fresh frozen plasma, or cryoprecipitate at any time during membrane oxygenation in the PICU. Approval for this study the PICU stay. Transport out of the PICU was defined as was obtained from the Washington University School of Med- physical movement of the patient from the PICU to another icine institutional review board. A waiver of written informed location, such as the operating room or radiology unit. consent was granted because of the observational nature of Only events that occurred before the development of nos- this study. ocomial BSI (ie, use of an arterial catheter and/or a CVC, receipt of medication and/or total parenteral nutrition, trans- Data Collection port out of the PICU, and receipt of a transfusion) were entered into the multiple logistic regression
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