Tuesday, February 7, 2023
HomePediatrics: General MedicineHospital-Acquired Infections

Hospital-Acquired Infections

Practice Essentials

Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common types are bloodstream infection (BSI), pneumonia (eg, ventilator-associated pneumonia [VAP]), urinary tract infection (UTI), and surgical site infection (SSI).

Risk factors for catheter-associated BSI in neonates include the following
:

Catheter hub or exit-site colonization

Catheter insertion after the first week of life

Duration of parenteral nutrition

Extremely low birth weight (< 1000 g) at catheter insertion

In the pediatric ICU, neutropenia, prolonged catheter dwell time (>7 days), percutaneously placed central venous lines, and frequent manipulation of lines have been identified as risk factors for catheter-associated BSI

Risk factors for candidemia in neonates include the following
:

Gestational age of less than 32 weeks

5-minute Apgar scores below 5

Shock, disseminated intravascular coagulation

Prior intralipid use

Parenteral nutrition, central venous line placement

H2 blocker administration

Intubation

Hospital stay longer than 7 days

Risk factors for VAP in pediatric patients include the following
:

Reintubation

Genetic syndromes

Immunodeficiency, immunosuppression

Prior BSI

Risk factors for hospital-acquired UTI in pediatric patients include the following
:

Bladder catheterization

Prior antibiotic therapy

Cerebral palsy

The source of infection may be suggested by the instrumentation, as follows:

Endotracheal tube: Sinusitis, tracheitis, pneumonia

Intravascular catheter: Phlebitis, line infection

Foley catheter: UTI

Patients with pneumonia may have the following:

Fever, cough, purulent sputum

Abnormal chest auscultatory findings (eg, decreased breath sounds, crackles, wheezes)

Patients with UTI may have the following:

Fever or normal temperature

Tenderness, suprapubic (cystitis) or costovertebral (pyelonephritis)

Cloudy, foul-smelling urine

See Clinical Presentation for more detail.

Diagnosis

Because not all bacterial or fungal growth on a culture is pathogenic and because such growth may reflect simple microbial colonization, interpretation of cultures should take into account the following:

Clinical presentation of the patient

Reason for obtaining the test

Process by which the specimen was obtained

Presence or absence of other supporting evidence of infection

Methods used to diagnose and characterize BSIs include the following:

Suspected catheter-associated BSI: Differential time to positivity of paired blood cultures (simplest)
; quantitative culture of blood obtained from the catheter and peripheral vein; quantitative culture of catheter segment

Suspected fungal infection: Fungal cultures, detection of (1,3)-β-D-glucan and galactomannan

Possible thrombosis or vegetations: Imaging studies such as echocardiography

Immunocompromised patients: Occasional special studies (eg, cultures for Nocardia, atypical mycobacteria, cytomegalovirus [CMV], and CMV antigenemia)

Tests used to identify pneumonia include the following:

Acute-phase reactants

Oxygen saturation and hemodynamic studies

Chest radiography

Sputum Gram stain and culture (if necessary, samples can also be obtained through bronchoalveolar lavage or thoracocentesis)

Rapid diagnostic tests (eg multiplex PCR capable of identifying multiple pathogens in a specimen)

Urinalysis and urine culture, along with clinical findings, are essential for differentiating between asymptomatic bacteriuria, cystitis, and pyelonephritis. The following factors should be kept in mind in the interpretation of urine cultures:

Number of colonies and species isolated

Method of sample collection

Time from collection to laboratory processing

Sex of the patient

Previous antibiotic use

Most experts recommend imaging studies in evaluating children with first-time UTI.

See Workup for more detail.

Management

Medical care includes supportive care addressing shock, hypoventilation, and other complications, along with empiric broad-spectrum antimicrobial therapy.

Management of BSI may include the following:

Line removal as appropriate

Antibiotic therapy covering gram-positive and gram-negative organisms, started empirically and then tailored according to specific susceptibility patterns

Antifungal therapy as appropriate

Antiviral therapy as appropriate

Prevention through use of catheter disinfection caps

Management of pneumonia includes the following:

Initial empiric broad-spectrum antibiotic therapy, later streamlined on the basis of identified organisms and susceptibilities, with attention to the risk of multidrug-resistant (MDR) pathogens

Antiviral medications against influenza for symptomatic patients and patients with immunodeficiency or chronic lung diseases to limit morbidity and mortality

Management of UTI includes the following:

Removal of indwelling catheters if possible

Empiric antibiotic and antifungal therapy

Management of SSI includes the following:

Surgical debridement

Antibiotic therapy

See Treatment and Medication for more detail.

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