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Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.
We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case–control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.
In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37–3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32–12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0–48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6–9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9–315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.
Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.
The objectives of this study were (1) to develop and validate a simulation model to estimate daily probabilities of healthcare-associated infections (HAIs), length of stay (LOS), and mortality using time varying patient- and unit-level factors including staffing adequacy and (2) to examine whether HAI incidence varies with staffing adequacy.
The study was conducted at 2 tertiary- and quaternary-care hospitals, a pediatric acute care hospital, and a community hospital within a single New York City healthcare network.
All patients discharged from 2012 through 2016 (N = 562,435).
We developed a non-Markovian simulation to estimate daily conditional probabilities of bloodstream, urinary tract, surgical site, and Clostridioides difficile infection, pneumonia, length of stay, and mortality. Staffing adequacy was modeled based on total nurse staffing (care supply) and the Nursing Intensity of Care Index (care demand). We compared model performance with logistic regression, and we generated case studies to illustrate daily changes in infection risk. We also described infection incidence by unit-level staffing and patient care demand on the day of infection.
Most model estimates fell within 95% confidence intervals of actual outcomes. The predictive power of the simulation model exceeded that of logistic regression (area under the curve [AUC], 0.852 and 0.816, respectively). HAI incidence was greatest when staffing was lowest and nursing care intensity was highest.
This model has potential clinical utility for identifying modifiable conditions in real time, such as low staffing coupled with high care demand.
Background: Measles can cause miscarriages and preterm birth in nonimmune pregnant women. During the 2018–2019 measles outbreak in New York, a woman with measles delivered an extremely low birth weight preterm infant at our Women and Children’s Hospital. We describe our measles preparedness strategies and infection prevention and control (IPC) management relevant to congenital measles. Methods: Because of the measles outbreak, in Q4 2018, IPC verified measles immunity in all obstetric and pediatric staff, per state regulations, and recommended determining the measles immune status of all pregnant women. To prevent measles exposure, visitor restrictions for the neonatal intensive care unit (NICU) were implemented (May 2019); only 3 visitors were permitted for each infant, including parents. All visitors had to provide written documentation of immunity to measles, regardless of epidemiologic risk factors or receive an MMR vaccine prior to visiting. New York state and New York City health departments performed measles diagnostic testing for maternal and infant specimens. Results: Our hospital was informed of the imminent transfer of a woman in preterm labor with suspected measles. To avoid any exposure, the mother was masked in the ambulance bay and taken by commandeered elevator to the obstetrical operating room suite, which was cleared of other patients. She delivered by C-section and was transferred to an airborne infection isolation (AII) room. The 25-week-gestation infant was transported by isolette to the NICU and was placed on AII. Testing confirmed measles in the mother (measles PCR- and IgM-positive) and congenital measles in the infant (Table 1). The mother was allowed to visit the NICU when her respiratory symptoms and rash resolved, as confirmed by her provider, ~10 days after discharge. The infant never developed a rash, pneumonia, or neurologic findings. AII was discontinued on day of life 61 in consultation with the health departments. The infant was discharged at ~36 weeks gestation. No secondary cases of measles occurred among patients, visitors, or staff. Conclusions: We safely cared for an extremely preterm infant with congenital measles. Laboratory testing suggested prolonged presence of measles virus, but it is unknown how long an infant in the NICU should remain on AII. The current Council of State and Territorial Epidemiologists case definition for measles requires the presence of rash. This case provides support to revise this case definition if laboratory findings are consistent with congenital measles.
Background: As many as 40% of infants aged ≤12 months and 10%–28% of children aged 13–24 months are colonized by Clostridioides difficile. The IDSA and the SHEA recommend that testing should never be routinely recommended for infants ≤12 months of age and should not be routinely performed for children 1–2 years of age unless other causes are excluded. We report implementation of C. difficile diagnostic stewardship at 2 children’s hospitals. Methods: We implemented age-based restrictions for C. difficile testing at hospital A (∼200-bed, free-standing, children’s hospital) and hospital B (∼100-bed children’s hospital within a larger hospital). Both sites are part of the same multicampus institution, and both used nucleic acid amplification testing to detect C. difficile throughout the study. In May 2018, we implemented an electronic order set for C. difficile that provided alerts to avoid testing young infants and patients with recent use of laxatives, stool softeners, or enemas, but providers could order C. difficile testing at their discretion. In October 2018, we implemented a more restrictive diagnostic stewardship algorithm for C. difficile. No testing was allowed for infants aged ≤12 months. Approval pediatric infectious diseases staff was required to test children aged 13–24 months. Pathology resident approval was required to test children aged ≥24 months who had received laxatives, stool softeners, or enemas within ≤24 hours. Clinical microbiology laboratory supervisors reinforced rejection of nondiarrheal stool specimens for testing. Providers at both campuses were informed about the new testing guidelines by e-mail. We compared the number of tests sent and positive cases of healthcare facility-onset C. difficile (HO-CDI) by age strata before and after the implementation of the restrictive testing algorithm. Results: After the intervention, the number of tests in infants significantly declined; 2 infants aged ≤12 months and 4 infants aged 13–24 months were tested for C. difficile (Table). After the intervention, the number of tests per month declined at hospital A, as did the number of HO-CDI cases at both hospitals. Rejections of nondiarrheal stools significantly increased after the intervention (P < .001). Conclusions:C. difficile diagnostic stewardship for children was successfully implemented using a rule-based alert system in the electronic health record. This intervention was associated with a reduced number of tests sent and cases of HO-CDI. This strategy was cost-saving and prevented misdiagnosis, unnecessary antibiotic therapy, and overestimation of HO-CDI rates.
Background: In the past few decades, the epidemiology of Clostridioides difficile infection (CDI) has evolved. Given recent changes in the incidence of CDI and prevention efforts, we investigated temporal changes over a period of 8 years (2009–2016) in the incidence of and risk factors for CDI. Methods: Both pediatric and adult inpatients discharged from hospitals in metropolitan New York City were included. Individual and environmental (eg, pharmacological) risk factors were identified through a matched case-control by the length of stay at a ratio of 1:4. A Cochran–Armitage test or Mann-Kendall test was used to investigate trends of incidence and risk factors. Results: During the study period, 6,038 of 694,849 (0.87%) patients had a positive test for C. difficile during their hospitalization. Of these, 2,659 of 6,038 (44.04%) were identified as hospital-acquired CDI (HA-CDI) and just over half (3,379 of 6,038, 55.96%) were identified as community-acquired CDI (CA-CDI). There were no trends in total CDI incidence rates; rather, we detected downward trends in HA-CDI and upward trends in CA-CDI (Ptrend < .05). Younger patients and patients with lower risk of illness had HA-CDI over time (Ptrend < .05). Antibiotics were administered to more patients over time and in longer cumulative days (+3% and +3.1% per year). We detected a reduction in the receipt of high-risk antibiotics in all cohorts (−0.12% per year) and a decrease in cumulative days of high-risk antibiotics in the cohort with HA-CDI (−1.1% per year). When stratified by the type of high-risk antibiotics, the use of carbapenem, cephalosporins, clindamycin, and monobactam increased (+0.53%, +1.8%, +0.5%, and +0.39% per year, respectively), whereas the use of broad-spectrum penicillins and glycylcycline significantly decreased over time in all cohorts (−1.8% and −0.22% per year). Among the cohorts with HA-CDI, only cephalosporins showed a significant upward trend (+ 5.7% per year) and only fluoroquinolones showed a significant downward trend (−2.2% per year). Lastly, a reduction of proton pump inhibitors and an increased use of histamine-2 blockers were detected in all cohorts (−3.8% and +7.3% per year) (all Ptrend < .05). Conclusions: Although the incidence of HA-CDI decreased, more effort to decrease all antibiotics use and cumulative days should be emphasized as part of antibiotic stewardship. The downward trends of high-risk antibiotics might have been associated with the decrease in the trend of HA-CDI; however, the impact of the trends of risk factors on the trend of HA-CDI should be further investigated.
Background:Pseudomonas aeruginosa is an important nosocomial pathogen associated with intrinsic and acquired resistance mechanisms to major classes of antibiotics. To better understand clinical risk factors for drug-resistant P. aeruginosa infection, decision-tree models for the prediction of fluoroquinolone and carbapenem-resistant P. aeruginosa were constructed and compared to multivariable logistic regression models using performance characteristics. Methods: In total, 5,636 patients admitted to 4 hospitals within a New York City healthcare system from 2010 to 2016 with blood, respiratory, wound, or urine cultures growing PA were included in the analysis. Presence or absence of drug-resistance was defined using the first culture of any source positive for P. aeruginosa during each hospitalization. To train and validate the prediction models, cases were randomly split (60 of 40) into training and validation datasets. Clinical decision-tree models for both fluoroquinolone and carbapenem resistance were built from the training dataset using 21 clinical variables of interest, and multivariable logistic regression models were built using the 16 clinical variables associated with resistance in bivariate analyses. Decision-tree models were optimized using K-fold cross validation, and performance characteristics between the 4 models were compared. Results: From 2010 through 2016, prevalence of fluoroquinolone and carbapenem resistance was 32% and 18%, respectively. For fluoroquinolone resistance, the logistic regression algorithm attained a positive predictive value (PPV) of 0.57 and a negative predictive value (NPV) of 0.73 (sensitivity, 0.27; specificity, 0.90) and the decision-tree algorithm attained a PPV of 0.65 and an NPV of 0.72 (sensitivity 0.21, specificity 0.95). For carbapenem resistance, the logistic regression algorithm attained a PPV of 0.53 and a NPV of 0.85 (sensitivity 0.20, specificity 0.96) and the decision-tree algorithm attained a PPV of 0.59 and an NPV of 0.84 (sensitivity 0.22, specificity 0.96). The decision-tree partitioning algorithm identified prior fluoroquinolone resistance, SNF stay, sex, and length-of-stay as variables of greatest importance for fluoroquinolone resistance compared to prior carbapenem resistance, age, and length-of-stay for carbapenem resistance. The highest-performing decision tree for fluoroquinolone resistance is illustrated in Fig. 1. Conclusions: Supervised machine-learning techniques may facilitate prediction of P. aeruginosa resistance and risk factors driving resistance patterns in hospitalized patients. Such techniques may be applied to readily available clinical information from hospital electronic health records to aid with clinical decision making.
Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.
Retrospective case-control study.
Four academic medical centers.
Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.
Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.
Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).
Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.
To describe changes in the environmental microbiota of a new neonatal intensive care unit (NICU) and potential implications for infection prevention and control (IPC) efforts.
Prospective observational study.
A newly constructed level IV neonatal cardiac intensive care unit (NCICU) before and after patient introduction and the original NICU prior to patient transfer.
Environmental samples were obtained from the original NICU prior to patient transfer to a new NCICU. Serial sampling of patient rooms and provider areas of the new NICU was conducted immediately prior to patient introduction and over an 11-month study period. Microbiota at each sampling point were characterized using Illumina sequencing of the V3/V4 region of the 16S rRNA gene. Microbiota characteristics (α and β diversity and differential abundance) were compared based on time, location, and clinical factors (room-level antibiotic use and patient turnover).
An immediate increase in the environmental differential abundance of gut anaerobes were seen after patient introduction. There was an increase in the relative abundance of Staphylococcus spp, Klebsiella spp, Pseudomonas spp, and Streptococcus spp over time. The new NCICU consistently showed more diverse microbiota and remained distinct from the original NICU. The microbiota of the provider areas of the NCICU eventually formed a cluster separate from the patient rooms. Patient turnover increased room-level microbiota diversity.
Microbiota characteristics of the new NICU were distinct from the original ICU despite housing similar patients. Patient and provider areas developed distinct microbiota profiles. Non–culture-based methods may be a useful adjunct to current IPC practice.
Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI.
Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors.
Five urban, academic medical centers, part of the New York City Clinical Data Research Network.
Potential patients were age <22 years who were seen between October 2010 and September 2015.
In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1–6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics.
Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.
Given recent changes in the epidemiology of Clostridioides difficile infection (CDI) and prevention efforts, we investigated temporal changes over a period of 11 years (2006–2016) in incidence and risk factors for CDI.
Retrospective matched case-control study.
Pediatric and adult inpatients (n = 694,849) discharged from 3 hospitals (tertiary and quaternary care, community, and pediatric) in a large, academic health center in New York City.
Risk factors were identified in cases and controls matched by length of stay at a ratio of 1:4. A Cochran–Armitage or Mann-Kendall test was used to investigate trends of incidence and risk factors.
Of 694,849 inpatients, 6,038 (0.87%) had CDI: 44% of these cases were hospital acquired (HA-CDI) and 56% were community acquired (CA-CDI). We observed temporal downward trends in HA-CDI (−0.03% per year) and upward trends in CA-CDI (+0.04% per year). Over time, antibiotics were administered to more patients (+3% per year); the use of high-risk antibiotics declined (–1.2% per year); and antibiotic duration increased in patients with HA-CDI (+4.4% per year). Fewer proton-pump inhibitors and more histamine-2 blockers were used (−3.8% and +7.3% per year, respectively; all Ptrend <.05).
Although the incidence of HA-CDI decreased over time, CA-CDI simultaneously increased. Continued efforts to assure judicious use of antibiotics in inpatient and community settings is clearly vital. Measuring the actual the level of exposure of an antibiotic (incidence density) should be used for ongoing surveillance and assessment.
Little is known about prescribers’ attitudes regarding clinical nurses and antimicrobial stewardship. We conducted focus groups of prescribers and inquired about attitudes regarding nurses and stewardship. During 6 focus groups, prescribers were receptive to nursing involvement in stewardship activities, but noted structural barriers and knowledge gaps that should be addressed.
The costs of antimicrobial stewardship programs (ASPs) in children’s hospitals have not been described previously. We assessed ASP costs using an online survey administered to ASP leaders at U.S. children’s hospitals. ASP costs varied from $17,000 to $388,500 annually (median, $187,400). Overall costs were not correlated with hospital size.
To determine the association between state legal mandates for data submission of central line–associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) with process and outcome measures.
Participants. National sample of level II/III and III NICUs participating in National Healthcare Safety Network (NHSN) surveillance.
State mandates for data submission of CLABSIs in NICUs in place by 2011 were compiled and verified with state healthcare-associated infection coordinators. A web-based survey of infection control departments in October 2011 assessed CLABSI prevention practices, ie, compliance with checklist/bundle components (process measures) in ICUs including NICUs. Corresponding 2011 NHSN NICU CLABSI rates (outcome measures) were used to calculate standardized infection ratios (SIRs). Association between mandates and process and outcome measures was assessed by multivariable logistic regression.
Among 190 study NICUs, 107 (56.3%) were located in states with mandates, with mandates in place >3 years in 52 (49%). More NICUs in states with mandates reported ≥95% compliance to at least 1 CLABSI prevention practice (52.3%–66.4%) than NICUs in states without mandates (28.9%–48.2%). Mandates were predictors of ≥95% compliance with all practices (odds ratio, 2.8; 95% confidence interval, 1.4–6.1). NICUs in states with mandates reported lower mean CLABSI rates in the ≤750-g birth weight group (2.4 vs 5.7 CLABSIs/1,000 central line–days) but not in others. Mandates were not associated with SIR <1.
State mandates for NICU CLABSI data submission were significantly associated with ≥95% compliance with CLABSI prevention practices, which declined with the duration of mandate but not with lower CLABSI rates.
Infect Control Hosp Epidemiol 2014;35(9):1133-1139
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