Critical Care Medicine
- 1. Description of the problem
- 2. Emergency Management
- 3. Diagnosis
- 4. Specific Treatment
- 5. Disease monitoring, follow-up and disposition
Special considerations for nursing and allied health professionals.
What's the evidence?
Pediatric hospital acquired infections (HAI)
Hospital associated infections
Healthcare associated infections
Catheter-associated blood stream infection (CA-BSI)
Central line associated blood stream infection (CLA-BSI)
Ventilator-associated pneumonia (VAP)
Ventilator associated lower respiratory infection (VALORI)
Catheter-associated urinary tract infection (CA-UTI)
Surgical site infection (SSI)
1. Description of the problem
What every clinician needs to know
Blood stream infection0.0
Blood stream infection (BSI) is the most common hospital-associated infection (HAI) in the pediatric ICU. National Healthcare Safety Network (NHSN) data reports overall 2.9 BSI/1000 central venous line in pediatrics critical care units. The lowest rate occurred in purely pediatric medical ICUs (1.3 BSI/1000 device days), compared to 3.0 in combined medical-surgical ICUs and 3.3 in pediatric cardiac ICUs. Only adult burn units report higher BSI rates than pediatric ICUs.
Rates are higher in pediatric hematology oncology patients with temporary lines compared to those with permanent lines, 4.6 and 2.3, respectively.
There are several classifications of BSI. A catheter-related BSI (CR-BSI) requires culture positivity from the catheter followed by a positive peripherally obtained culture. Catheter-associated BSI (CA-BSI) is a less rigid definition in that it that the catheter needs to be in more than 48 hours prior to drawing the culture and there must be compelling clinical evidence (fever, chills, hypotension) that the CVL is the source.
Another classification, known as central line–associated laboratory-confirmed BSI (LC-BSI) has been in use since January 2008. LC-BSI is an HAI in which the patient has a recognized pathogen cultured from one or more blood cultures, and the organism cultured from blood is not related to an infection at another site.
For surveillance purposes, a central line is defined as a vascular infusion device that terminates at or close to the heart or in one of the great vessels. The following are considered great vessels for the purpose of reporting central-line infections and counting central-line days in the NHSN system: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins and common femoral veins. Neither the location of the insertion site nor the type of device may be used to determine if a line qualifies as a central line. An introducer or cordis is considered a central line.
Infection control specialists may report the following data:
CA-BSI rate per 1,000 CVL-days – For this metric, each day with a CVL is counted as 1, no matter how many lumens or how many separate catheters the patient has. Aslakson et al recently reported their findings on counting multiple catheters as individual lines in the determination of line days; as such, a patient with two CVLs in situ on the same day would be counted as 2 CVL-days compared to the traditional 1 line-day. This strategy has not yet been incorporated in the CDC guidelines.
Days between infections
Care bundles are recommended to impact the incidence of nosocomial infections. Care bundles are groupings of best practices that individually can improve care, yet when applied together result in substantially greater improvement. The science supporting the bundle components is sufficiently established to be considered standard of care. For BSI, elements of the bundle may include:
- Insertion items:
Educate staff on indications and care of CVL site and devices.
Dedicated catheter insertion/procedure cart – this will facilitate having all needed materials at the time of insertion.
Chlorhexidine skin antisepsis is preferred. Prepare clean skin with a greater than 0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Chlorhexidine is not recommended for use in infants under 2 months of age.
Maximal barrier precautions – using sterile drapes to cover the patient.
Empowering all clinical staff to stop the line insertion process if insertion guidelines are not adhered to appropriately.
Optimal catheter site selection. In adult patients, femoral vein catheterization is to be avoided, but in pediatrics there is no association of femoral catheterization and infection.
- Line maintenance items:
Standardized maintenance practices.
Prepackaged dressing change kits available on unit with standardized procedures for each dressing change – no element gets left out because it could not be located.
Standardized time intervals between dressing changes – usually 7 days unless the dressing has become soiled or moist.
Standardized IV administration set changes. Studies suggest that IV administration sets may be continued safely for up to 7 days if (a) used in conjunction with antiseptic catheters; or (b) if fluids that enhance microbial growth (e.g. parenteral nutrition, fat emulsions or blood) have not been used. When a fluid that enhances microbial growth is infused, more frequent administration set changes are indicated.
Daily review of line necessity with prompt removal of unnecessary lines.
Ventilator associated pneumonia
Ventilator-associated pneumonia (VAP) is reported as the number of infections per 1000 ventilator-days (vent-days). In pediatrics, the overall rate of VAP is 1.7 VAP/1000 vent-days, with a range of 0.6 in pediatric cardiac ICUs to 2.3 in pediatric medical ICUs. The CDC defines VAP using three definitions: PNU1, clinically defined pneumonia; PNU2, pneumonia with specific laboratory findings; PNU3, pneumonia in immunocompromised patients. The majority of pediatric VAP are diagnosed using the PNU1 criteria, although the new PNU2 and PNU3 are more stringent.
Children developing a VAP have a 4-fold increase in PICU and hospital length of stay.
Components of the VAP bundle may include:
Head of bed elevation 30-45 degrees; 15-30 degrees for infants.
Ulcer prophylaxis with an H2 blocker, proton pump inhibitor, or sucralfate. If patient is receiving full enteral (gastric) feedings, then ulcer prophylaxis may not be necessary.
Daily sedation holiday.
Daily paralytic holiday.
Daily assessment of readiness to extubate.
Proper care and maintenance of the ventilator circuit.
Catheter-associated urinary tract infection (CA-UTI)
Catheter-associated urinary tract infections (CA-UTI) are less common in children than in adults in an ICU. Only indwelling catheters are counted; external catheters (“condom catheters”) are not. Overall, the incidence of CA-UTI is 4.2/1000 device days, which is surprisingly lower than that observed at regular pediatric inpatient care areas, where a range of 6.7-7.2 is observed.
Surgical site infection
Surgical site infection (SSI) rate is reported as the number of infections per 100 procedures.
Blood stream infections
Fever, chills, hypotension. Hypothermia, apnea and/or bradycardia if under 12 months old.
Fever, tachypnea, increased work of breathing, increased FiO2, increased ventilator rate, purulent sputum.
Catheter-associated urinary tract infection
Fever, chills, hypotension, dysuria, vomiting, burning or tenderness in the suprapubic region.
Surgical site infection
Fever, chills, hypotension, erythema of site, purulent drainage from site, wound dehiscence.
Key management points
Blood stream infections
The most commonly reported causative pathogens remain coagulase-negative staphylococci, Staphylococcus aureus, enterococci, and Candida spp. (Wisplinghoff 2004) Gram negative bacilli accounted for 19% and 21% of CLABSIs reported to CDC. (Gaines 2009) and the Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database, respectively. (Wisplinghoff 2004)
Antibiotics should be initiated even if cultures are not yet obtained.
Catheter-associated urinary tract infection
Device removal may be key to successful treatment of the CA-UTI. Enterococcus is a common pathogen in children with indwelling catheters.
Surgical site infection
Wound integrity needs to be assessed by the surgical team. Wound debridement may be needed. Indwelling artificial materials may need removal.
2. Emergency Management
Appropriate antibiotics are indicated. Severely affected patients may need vasopressor support and/or an increase in mechanical ventilation support.
Stabilizing the patient
Severely affected patients may need vasopressor support and/or an increase in mechanical ventilation support.
For coagulase-negative Staphylococcus: remove the catheter and treat with systemic antibiotics 5-7 days. If endocarditis or septic thrombi are suspected, removal of the catheter is paramount; treat with a prolonged course of antibiotics, 4-8 weeks depending upon diagnosis.
In general, antibiotics are not required if the positive culture comes via the CVL and the peripheral culture is negative, as long as the CVL is removed.
Antibiotics, typically vancomycin plus a 3rd generation cephalosporin, are given. If the patient is immunocompromised or if there is a high risk of aspiration, use of piperacillin-tazobactam in lieu of cephalosporin for anaerobic coverage may be indicated. Once culture results are known, the antibiotic regimen should be adjusted according to the pathogen and the sensitivities. If Staph is sensitive to clindamycin, then it should replace vancomycin.
Appropriate antibiotics are indicated. Severely affected patients may need vasopressor support and/or an increase in mechanical ventilation support. Remove the indwelling catheter if clinically feasible.
Appropriate antibiotics are indicated. Severely affected patients may need vasopressor support and/or an increase in mechanical ventilation support. Exploration and debridement of the wound may be needed.
Methods to confirm the diagnosis
Obtain a blood culture from the suspect line and a peripheral blood culture.
White blood cell count (WBC) and differential.
Quantitative catheter tip culture. This microbiologic test is not done at all facilities and has limitations based upon the skill of the person retrieving the catheter and the laboratory technician setting up the plate. It is not recommended.
Chest radiograph demonstrating new infiltrate.
Abnormal (purulent) or increased sputum production.
Sputum culture: blind, protected specimen brush, bronchoalveolar lavage (BAL), quantitative.
A blind culture is easily obtained by passing a sterile suction catheter down the endotracheal tube and suctioning sputum into a sterile trap. Bacteriostatic saline should not be used to augment specimen recovery as it will inhibit any bacterial growth. The specimen obtained through this blind technique requires no special equipment or skills, but can be affected by bacteria adhering to the sides of the endotracheal tube. Thus a false positive culture may result. Similarly, since the specimen is being obtained from relatively high in the tracheobronchial tree and is undirected, it may not result in a specimen from an affected region of the lung.
A protected specimen brush can be used to obtain a culture. In this procedure a small sterile brush encased within a suction catheter is passed to a level below the endotracheal tube, either blindly or under bronchoscopic direction. The inner, protected brush is deployed and brought back into the catheter, thus keeping it ‘protected’ from flora in the endotracheal tube. As with the blind specimen, one cannot be certain that the brush gets a sample from an affected region.
Bronchoalveolar lavage (BAL) requires technical training in bronchoscopy, and thus an appropriately trained practitioner may not be available at all times to perform the procedure. A benefit of BAL is that the specimen can be obtained from a selected region of the lung.
White blood cell count elevation and differential shift.
Urinalysis, specifically to determine the presence of nitrites or leukocyte esterase. Microscopic evaluation will determine the presence of bacteruria by Gram stain or pyuria.
Site culture can result in contamination of the swab with adjacent skin flora. Expression of purulent material or probing the wound with a swab may increase yield of the pathogen.
White blood cell count and differential.
Confirming the diagnosis
Criteria for diagnosing an HAI generally require that the patient has been in the hospital or exposed to the device (catheter) for at least 48 hours before symptoms began. Criteria for each HAI depend upon age and a constellation of findings and culture results.
A diagnosis of BSI, VAP, CA-UTI or SSI is based on the definitions/criteria currently in use from NHSN and the CDC.
Other possible diagnoses
Sepsis from another source such as pneumonia, abscess, or surgical site.
Progression of community-acquired pulmonary process.
Unusual organism, such as Legionella, Aspergilla.
Bladder catheter causing trauma to bladder (cystitis) or urethra.
Poor wound healing.
Reaction to sutures.
Blood cultures done via the catheter in question and subsequently from a peripheral site.
Lavage specimen culture. Cultures may be negative if patient has already been on antibiotics.
Lung biopsy: definitive, but rarely done since the procedure is so invasive.
Post-mortem: gold standard, but obviously undesirable and not helpful in treatment selection.
Urine culture obtained via catheter.
Deep wound culture.
4. Specific Treatment
First line therapy in the ICU typically includes use of vancomycin and a third-generation cephalosporin. Therapy should be tailored as blood culture results are obtained.
IV antibiotic: typically vancomycin. Nafcillin or clindamycin should replace vancomycin if culture and sensitivities demonstrate efficacy.
Consider catheter removal if the infection does not clear. Although rarely the choice in adults, in children, given the greater difficulty with CVL placement, occasionally a CA-BSI can be treated by infusing the antibiotic via the suspect catheter lumen. If the infection does not clear in 3 days, the catheter should be removed.
IV antibiotics are given; typically cephalosporin and vancomycin or clindamycin, if susceptibilities are known.
A carbapenem should be used if the patient is immunocompromised.
Catheter removal as soon as clinically possible.
Escherichia coli is the most common bacterial cause of UTI, but in patients with indwelling catheters Enterococcus is prevalent. Gram-negative bacterial pathogens include Klebsiella, Proteus, Enterobacter and Citrobacter. Gram-positive bacterial pathogens include Staphylococcus saprophyticus, Enterococcus and Staphylococcus aureus.
In the critically ill child with possible CA-UTI, ampicillin and gentamicin or a 3rd or 4th generation cephalosporin should be used. Ampicillin is given due to the high incidence of enterococcal infection.
IV antibiotic; typically vancomycin.
Vancomycin dosing by age
|Premature (<1.2 kg)||15 mg/kg q24h|
|Premature (<1.2-2 kg)||15 mg/kg q12-18h|
|Full term (≥36 wks)||15-20 mg/kg q12h|
|Infants (>4 w - 1 y)||20 mg/kg q8-12h|
|Children (1-16 y)||20 mg/kg to 1 gram q8h|
|Adults (>16-65 y)||1 gram q8-12h|
|Cystic fibrosis||20 mg/kg q8h (max: 1 gram initially)|
When first-line therapy is ineffective
Vancomycin is first line; this may be changed to nafcillin if methicillin sensitive coagulase negative or positive Staphylococcus. Add a 3rd generation cephalosporin for immunocompromised hosts.
For coagulase negative Staphylococcus, 5-7 days of therapy after catheter removal should be adequate. If the catheter is maintained and culture clears, then antibiotics should continue for 10-14 days.
For a patient with no known risk factors for a drug resistance, a 3rd generation cephalosporin, ampicillin-sulbactam, or levofloxacin may be used. IV antibiotic selection for the critically ill would typically involve a 3rd generation cephalosporin and vancomycin, or clindamycin, if susceptibilities are known. A carbapenem should be used if the patient is immunocompromised.
Addition of ampicillin and an aminoglycoside, if not already in the regimen.
Ampicillin (100 mg/kg/day IV divided in four doses).
Gentamicin (7.5 mg/kg/day divided in three doses).
Cefotaxime (150 mg/kg per day IV divided in three doses).
Ceftriaxone (50-100 mg/kg per day IV).
Cefepime (100 mg/kg per day divided in two doses for children weighing 40 kg or less, maximum daily dose 1 g; 500 mg twice per day for children weighing more than 40 kg).
Vancomycin, clindamycin, piperacillin-tazobactam and an aminoglycoside are usually given in varying combinations depending upon the surgical site and underlying pathology.
Enterococcus: Remove catheter. Treat for 10-14 days.
Ampicillin susceptible: ampicillin +/- gentamicin
Ampicillin resistant/vancomycin susceptible: vancomycin +/- gentamicin
Ampicillin resistant/vancomycin resistant: linezolid or daptomycin
Gram negative: Remove catheter. Treat 10-14 days.
E. coli or Klebsiella:
ESBL positive: carbapenem; ciprofloxacin.
ESBL negative: 3rd generation cephalosporin, ciprofloxacin.
Enterobacter or Serratia marsescens: carbapenem; ciprofloxacin.
Pseudomonas: 4th generation cephalosporin or carbapenem or piperacillin-tazobactam; +/- aminoglycoside.
Staph aureus bacteremia, in particular, may progress to endocarditis. Obtain an echocardiogram to assess for endocarditis a few days to 1 week after infection is diagnosed to evaluate for valvular vegetations or regurgitation.
If bacteremia does not clear after 72 hours of appropriate antibiotics and catheter removal, look for sites of seeding from the primary infection, or other sources of infection. Treatment in this case should be prolonged for several weeks. Consider evaluation for osteomyelitis or other seeded sites and/or abscesses. Consider evaluation for secondary infection of foreign material/devices.
Carbapenem for possible anaerobic infection.
Vancomycin or linezolid for methicillin-resistant Staphylococcus.
Cefipime or ceftazidime for possible pseudomonal infection.
Consider aerosolized antibiotics such as colistin or aminoglycosides for refractory pneumonia.
Patient with persistent fever after 24-48 hours of treatment may have a resistant E coli or enterococcus.
CA-UTI caused by Pseudomonas aeruginosa or other multidrug-resistant, gram-negative bacteria may be treated with ciprofloxacin.
Antibiotic coverage should be determined by pathogen, sensitivities and surgical site.
5. Disease monitoring, follow-up and disposition
If the catheter is removed and the infection does not clear from the blood, or the elevation in WBC or inflammatory markers does not improve, suspect:
Phlebitis (warmth, tenderness, erythema or palpable venous cord); bacteremia or sepsis from a primary site.
Pulmonary status continues to worsen despite adequate antibiotic coverage.
Fever, WBC elevation or hypotension persists for more than 24 hours after initiation of therapy. A renal ultrasound can evaluate for renal abscess.
Fever, WBC elevation or hypotension persists.
Consider follow-up blood culture if symptoms persist.
Echocardiogram if Staph aureus.
None specific. If clinical status is improving, a follow-up radiograph is not necessary.
Repeat urine culture is not considered necessary.
Surgical follow up.
The most common nosocomial pathogens may well survive or persist on surfaces for months and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed. Most gram-positive bacteria, such as Enterococcus spp. (including vancomycin resistant enterococcus (VRE)), Staphylococcus aureus (including MRSA) or Streptococcus pyogenes, survive for months on dry surfaces.
Many gram-negative species, such as Acinetobacter spp., Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, or Shigella spp., survive for months. However, a few others, such as Bordetella pertussis, Haemophilus influenzae, Proteus vulgaris or Vibrio cholerae persist only for days. Mycobacteria, including Mycobacterium tuberculosis, and spore-forming bacteria, including Clostridium difficile, survive for months on surfaces. Candida albicans survives up to 4 months on surfaces.
Most viruses from the respiratory tract, such as corona, coxsackie, influenza, SARS or rhino virus, can persist on surfaces for a few days. Viruses from the gastrointestinal tract, such as astrovirus, HAV, polio- or rotavirus, persist for approximately 2 months. Blood-borne viruses, such as HBV or HIV, can persist for more than 1 week. Herpes viruses, such as CMV or HSV type 1 and 2, have been shown to persist from only a few hours to up to 7 days.
Healthcare associated infections (HAI) refer to infections caused by a wide variety of common and unusual bacteria, viruses, and fungi during the course of receiving medical care. Care in an ICU very often exposes the patient to invasive devices, and the patient may be in a state of immunodysfunction, which increases the risk for infection. HAI related to medical care can be devastating and even deadly. As we acknowledge our ability to prevent HAIs, these infections are increasingly unacceptable.
In 1986, the Centers for Disease Control (CDC) and the National Nosocomial Infections Surveillance (NNIS) began tracking pediatric infection information. Similar to the NNIS system, the National Healthcare Safety Network (NHSN) member facilities voluntarily report their HAI surveillance data for aggregation into a single national database. Facilities are provided assistance in developing surveillance and analysis methods that permit timely recognition of patient safety problems and prompt intervention with appropriate measures.
Of 1,545 hospitals contributing to the NHSN database, 38 are children’s hospitals. Overall, 163 pediatric cardiac, medical and medical-surgical ICUs contributed to the 2009 report, which included data from 2006-2008. Data is collected for the following purposes:
Estimation of the magnitude of HAIs.
Monitoring of HAI trends.
Facilitation of interfacility and intrafacility comparisons with risk-adjusted data that can be used for local quality improvement activities.
Effective surveillance may aid in identification of differences in practice, techniques, procedures and processes that result in differing infections rates. For more information about how to collect surveillance data, go to www.cdc.gov/ncidod/dhqp/pdf/surveillance/OutlineForHAISurveillance.pdf. Surveillance requires professionals trained in data collection and interpretation. Infection control data collection is time-consuming and costly due to the need to review various kinds of data, such as culture reports, radiograph reports, nursing flow sheets and laboratory data. The Joint Commission (TJC) requires compliance with CDC guidelines.
Infection rate data needs to be shared among the entire care team; making results known to the front lines of care allows infection risks to be assessed, changes implemented, and results comprehended by the bedside team.
Important factors to keep in mind
Major mechanism of patient-to-patient transmission is carriage of organism on hands of health care workers.
Transmission from environmental surfaces or by airborne route may occur (IV intubated patients or in burn units).
S. aureus(including MRSA) can survive on dry inanimate surfaces for 7 days to 7 months, based on six citations in systematic review.
Modes of transmission of contamination of catheters
Migration of organisms from the skin surface along the surface of the catheter.
Direct contamination of the catheter by contact with hands or contaminated devices (tubing caps, connectors) or infusate fluids.
Hematogenous seeding from another location.
Overall the rates of BSI as HAI have been reduced drastically through a number of quality improvement strategies aimed at improving catheter placement and maintenance procedures and processes. As a result, the NNIS reported 6.6 BSI/1000 CVL days in 2004; by 2009, that rate had decreased to fewer than 3 BSI/1000 CVL-days.
Potential methods to impact BSI rates
In contrast to adults, studies in pediatric patients have demonstrated that femoral catheters have a low incidence of mechanical complications and might have an equivalent infection rate to that of non-femoral catheters.
Use a short peripheral catheter for an infusion anticipated to run fewer than 6 days.
Use of ultrasound decreases the number of skin punctures that could impact development of local infection or hematoma.
Daily CHG bathing may reduce infections.
Use of sutureless securement devices.
Use of antibiotic impregnated catheters did not decrease the incidence of CA-BSI but did delay the time to infection to 18 days vs 5 days for the non-impregnated devices.
Consider use prophylactic antimicrobial lock solution in patients with long-term catheters who have a history of multiple BSI despite optimal maximal adherence to aseptic technique.
Routine replacement of CVLs is discouraged.
Guide wire exchanges should be avoided.
Use of a VAP bundle has been shown to significantly the incidence of VAP and the subsequent mortality related to VAP.
Normalization of vital signs and white blood cell count.
Blood culture sterility.
Complications to keep in mind
Clearing of chest radiograph.
Improvement in ventilator settings and lessened FiO2 requirement.
Decreased sputum production
Complications to be kept in mind
Development of ARDS
Antibiotic duration depends in large part on the clinical improvement and the organism. For an uncomplicated VAP, 7 days of therapy should be adequate. If Pseudomonas is isolated then a longer course -- about 14 days -- is given. Staph aureus pneumonia is treated for about 21 days. If no organism is isolated from the culture and the patient is improving after 3 days of empiric therapy antibiotics may be discontinued.
Complications to be kept in mind
Secondary sepsis (urosepsis)
Long term, if infection is untreated, it may lead to:
End-stage renal dysfunction
Resolution of local erythema, induration and warmth.
Complications to be kept in mind
Infection of retained hardware.
Elward found that the attributable direct costs of a child incurring a BSI was $39,219. In a prospective study of children undergoing cardiac surgery, the development of a BSI resulted in increased ICU stay (6 days no BSI vs. 23 days BSI), longer hospital LOS (11 days no BSI vs. 34 days BSI), and mortality (2% no BSI vs. 11% BSI). (Elella 2009)
VAP is unfortunately and significantly associated with increased PICU length of stay, mechanical ventilator days and mortality rates. In a retrospective review of pediatric VAP, the mean hospital length of stay (LOS) for VAP patients was 26.5 +/-13.1 days, compared with 17.8 +/- 4.7 days for non-VAP patients (p=.032). The hospital LOS attributable to VAP was 8.7 days. The attributable VAP costs were $51,157.
Another study reported similar findings of increased PICU length of stay ((VAP19.5+/-15.0 vs non-VAP 7.5+/-9.2, P< .001); ventilator days (VAP16.3+/-14.7 vs non-VAP 5.3+/-8.4, P< .001); mortality (VAP 19.1% vsnon-VAP 7.2%, P= .01).
Special considerations for nursing and allied health professionals.
What's the evidence?
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