Elisabeth Esteban

The impact of a quality improvement intervention to reduce nosocomial infections in a PICU.

Objective: To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes. Design: Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up. Setting: A 14-bed medical and surgical PICU in a university hospital for children. Interventions: The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing nosocomial infections. Measurements and Main Results: We included 851 patients in the preintervention period, 822 in the intervention period, and 940 in the long-term follow-up period. Compared with the preintervention period, in the intervention period, the rates of central line–associated bloodstream infection decreased from 8.1 to 6/1,000 central venous catheter-days (p = 0.640), ventilator-associated pneumonia decreased from 28.3 to 10.6/1,000 days’ ventilation (p = 0.005), and catheter-associated urinary tract infection decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). Multivariable logistic regression found that nosocomial infections was independently associated with increased mortality (odds ratio, 2.35 [95% CI, 1.02–5.55]; p = 0.046). Compared with the preintervention period, in the long-term follow-up period, central line–associated bloodstream infection decreased to 4.6/1,000 central venous catheter-days (p = 0.205); ventilator-associated pneumonia decreased to 9.1/1,000 ventilation-days (p = 0.001), and catheter-associated urinary tract infection decreased to 5.2/1,000 urinary catheter-days (p < 0.001). Hospital length of stay (14.45 days; p = 0.048) and mortality (3.2%; p = 0.058) also decreased. Conclusions: A multifaceted quality improvement intervention reduced nosocomial infection rates, hospital length of stay, and mortality in our PICU. The effects of the intervention were sustained over time.

Immunomodulation in Sepsis: The Role of Endotoxin Removal by Polymyxin B-Immobilized Cartridge

Severe sepsis results in high morbidity and mortality. Immunomodulation strategies could be an adjunctive therapy to treat sepsis. Endotoxin is a component of gram-negative bacteria and plays an important role in the pathogenesis of septic shock when it is recognized by immune cells. Removal of endotoxin could be an effective adjunctive approach to the management of sepsis. Devices to adsorb endotoxin or inflammatory cytokines have been designed as a strategy to treat severe sepsis, especially sepsis caused by gram-negative bacteria. Polymyxin B-immobilized cartridge has been successfully used to treat patients with sepsis of abdominal origin. Although this cartridge was conceived to adsorb endotoxin, several other immunological mechanisms have been elucidated, and this device has also yielded promising results in patients with nonseptic respiratory failure. In this paper, we summarize the immune modulation actions of Polymyxin B-immobilized cartridge to explore its potential usefulness beyond endotoxin elimination.

Severe enterovirus disease in febrile neonates

INTRODUCTION Fever in newborn infants may be due to an invasive infection with potential morbidity and mortality. Our aim was to describe the characteristics and outcome of group of febrile neonates with severe enterovirus infection compared to a group of neonates with severe bacterial infection. PATIENTS AND METHODS Prospective study including all neonates (<29 days old) admitted to a teaching hospital for fever (>38 degrees C), with positive bacterial cultures or enterovirus detection in sterile samples, from September 2003 to December 2004. Clinical information, analytical data at admission (complete leukocyte count and C-reactive protein concentrations), blood, urine, and cerebrospinal fluid culture results, molecular detection of enterovirus by polymerase chain reaction (PCR), and outcome were recorded. RESULTS Invasive bacterial infections were observed in 62 patients: urinary tract infection (n=57, including 8 cases of bacteremia), sepsis (n=3), and meningitis (n=2). Molecular tests for enterovirus were positive in 10 patients. C-reactive protein values were significantly higher in neonates with bacterial infection than in those with enterovirus infection (62,3 versus 9mg/L, P=0,008). Two patients with Streptococcus agalactiae meningitis, 1 with Staphylococcus aureus sepsis and 3 with enterovirus infection (manifested as myocarditis, hepatitis, and meningoencephalitis) required admission to the pediatric intensive care unit. Among these, 1 newborn with S. agalactiae and 2 of the 3 with enterovirus infection died. CONCLUSIONS In our series, enterovirus infection was an important cause of severe invasive disease. Specific viral diagnosis can contribute to the management of febrile neonates.

Polymerase chain reaction for diagnosis and serogrouping of meningococcal disease in children.

A prospective study was performed including all children younger than 18 years with the clinical diagnosis of invasive meningococcal disease (IMD) hospitalized at the University Hospital Sant Joan de Déu in Barcelona, Spain, from January 2001 to December 2006. During the study period, 168 meningococcal disease cases were reported. Microbiologic confirmation was obtained in 118 cases. Forty-six (38.9%) of 118 cases were only detected by polymerase chain reaction (PCR); 6 patients were culture positive and PCR negative (5%). Serogroup B predominated in the 6-year period with 83.1% of the strains. A significant decrease in serogroup C was observed in the last 3 years of the study (P=0.029), and less common serogroups, such as serogroup A and W135, emerged. Serogroup distribution of patient diagnoses only by real-time PCR showed a similar distribution: serogroup B, 85.7%; serogroup C, 7.1%; and nontypeable serogroups, 7.1%. In conclusion, real-time PCR is more rapid and sensitive than culture for diagnosis and serogrouping of IMD.

Glutamine effects on heat shock protein 70 and interleukines 6 and 10: Randomized trial of glutamine supplementation versus standard parenteral nutrition in critically ill children.

BACKGROUND & AIMS To determine whether glutamine (Gln) supplementation would have a role modifying both the oxidative stress and the inflammatory response of critically ill children. METHODS Prospective, randomized, double-blind, interventional clinical trial. Selection criteria were children requiring parenteral nutrition for at least 5 days diagnosed with severe sepsis or post major surgery. Patients were randomly assigned to standard parenteral nutrition (SPN, 49 subjects) or standard parenteral nutrition with glutamine supplementation (SPN + Gln, 49 subjects). RESULTS Glutamine levels failed to show statistical differences between groups. At day 5, patients in the SPN + Gln group had significantly higher levels of HSP-70 (heat shock protein 70) as compared with the SPN group (68.6 vs 5.4, p = 0.014). In both groups, IL-6 (interleukine 6) levels showed a remarkable descent from baseline and day 2 (SPN: 42.24 vs 9.39, p < 0.001; SPN + Gln: 35.20 vs 13.80, p < 0.001) but only the treatment group showed a statistically significant decrease between day 2 and day 5 (13.80 vs 10.55, p = 0.013). Levels of IL-10 (interleukine 10) did not vary among visits except in the SPN between baseline and day 2 (9.55 vs 5.356, p < 0.001). At the end of the study, no significant differences between groups for PICU and hospital stay were observed. No adverse events were detected in any group. CONCLUSIONS Glutamine supplementation in critically-ill children contributed to maintain high HSP-70 levels for longer. Glutamine supplementation had no influence on IL-10 and failed to show a significant reduction of IL-6 levels.

Bronchiolitis Score of Sant Joan de Déu: BROSJOD Score, validation and usefulness

To validate the bronchiolitis score of Sant Joan de Déu (BROSJOD) and to examine the previously defined scoring cutoff. Patients and Methods: Prospective, observational study. BROSJOD scoring was done by two independent physicians (at admission, 24 and 48 hr). Internal consistency of the score was assessed using Cronbachs α. To determine inter‐rater reliability, the concordance correlation coefficient estimated as an intraclass correlation coefficient (CCC) and limits of agreement estimated as the 90% total deviation index (TDI) were estimated. An expert opinion was used to classify patients according to clinical severity. A validity analysis was conducted comparing the 3‐level classification score to that expert opinion. Volume under the surface (VUS), predictive values, and probability of correct classification (PCC) were measured to assess discriminant validity. Results: About 112 patients were recruited, 62 of them (55.4%) males. Median age: 52.5 days (IQR: 32.75–115.25). The admission Cronbachs α was 0.77 (CI95%: 0.71; 0.82) and at 24 hr it was 0.65 (CI95%: 0.48; 0.7). The inter‐rater reliability analysis was: CCC at admission 0.96 (95%CI 0.94–0.97), at 24 h 0.77 (95%CI 0.65–0.86), and at 48 hr 0.94 (95%CI 0.94–0.97); TDI 90%: 1.6, 2.9, and 1.57, respectively. The discriminant validity at admission: VUS of 0.8 (95%CI 0.70–0.90), at 24 h 0.92 (95%CI 0.85–0.99), and at 48 hr 0.93 (95%CI 0.87–0.99). The predictive values and PCC values were within 38–100% depending on the level of clinical severity. Conclusion: There is a high inter‐rater reliability, showing the BROSJOD score to be reliable and valid, even when different observers apply it. Pediatr Pulmonol. 2017;52:533–539.

Adrenomedullin is a useful biomarker for the prognosis of critically ill septic children

AIM To measure midregional pro-adrenomedullin (MR-pro-ADM) in critically ill septic patients to determine its prognostic usefulness as compared with other used biomarkers in pediatric intensive care units, C-reactive protein (CRP) and procalcitonin (PCT). MATERIALS & METHODS Prospective observational study conducted on 95 patients. RESULTS Mean levels of MR-pro-ADM were significantly higher when patients needed mechanical ventilation (3.2 ± 4.3 vs 1.6 ± 2.4) and inotropes (4.4 ± 5.2 vs 1.3 ± 1.2). Receiver operating characteristic curves of mortality were higher for MR-pro-ADM (cut-off value of 2.2). This marker showed higher positive predictive prognostic value than PCT and CRP (31 vs 21.6% and 15.8%, respectively). CONCLUSION MR-pro-ADM levels are good indicators of disease severity and show better reliability than PCT and CRP for predicting in-hospital mortality.

A multifaceted educational intervention shortened time to antibiotic administration in children with severe sepsis and septic shock: ABISS Edusepsis pediatric study

Elisabeth Esteban, Sylvia Belda, Patricia García‐Soler, Antonio Rodríguez‐Núñez, Cristina Calvo, Javier Gil‐Anton, Amaya Bustinza, María‐Isabel Iglesias‐Bouzas, Montserrat Pujol‐Jove, Juan Carlos deCarlos, Juan‐Pablo García‐Iñiguez, Antonio Pérez‐Iranzo, Cinta Téllez, Irene Ortiz, Rosalía Pérez, Vanesa Bonil, Sonia Brió, Andrés Concha, José‐Domingo López, Vega Murga, Jose‐Carlos Flores, Alberto Trujillo, Aida Felipe, Clara Abadesso, María Pino, José León, María‐Carmen Martínez, Fernando Gómez, Rut Pérez‐Montejano, Rocío Tapia, Iolanda Jordan and Ricard Ferrer

Noninvasive Respiratory Support During Pediatric Ground Transport: Implementation of a Safe and Feasible Procedure

BACKGROUND: The purpose of this work was to determine the safety and feasibility of noninvasive support in children with acute respiratory failure (ARF) during interhospital ground transport. METHODS: This was a prospective, single-center observational clinical study in the pediatric transport unit of a tertiary-care pediatric hospital. We included all subjects with ARF transported from November 2010 to March 2013. A specific noninvasive support protocol was used for all cases. Transport ventilators used were the Crossvent 2+ and Oxylog 3000; interfaces were an oronasal mask, nasopharyngeal tube, or nasal prongs. RESULTS: A total of 288 children diagnosed with ARF were transported. Fifty-four subjects (19%) were transported with invasive ventilation, 50 with CPAP, 58 with NIV, and 126 (44%) with oxygen cannula or nebulization. The median age was 3.4 months (interquartile range 1.2–17 months). ARF was mainly due to bronchiolitis (58%), asthma (15%), and pneumonia (15%). Stabilization time, which is defined as the time between the arrival in the parking lot of the referring hospital and departure, was lower with noninvasive support than with invasive ventilation (median 48 min vs 83 min, P < .001). Median transport time was 35 min (interquartile range 20–65). Noninvasive ventilation and oronasal interface use rose progressively during the study period (P < .001 for the NIV and P < .036 for the interface). One complication was observed: One subject required intubation during transport. Evolution of subjects transferred while receiving noninvasive support was recorded in the receptor hospitals: 21% of subjects were intubated, and 55% continued with NIV. CONCLUSIONS: NIV seems to be a safe and feasible technique during pediatric ground transport. Careful patient selection, adequate material, and a well-trained transport team are crucial to minimize risks to the patient.

Sex differences in children with severe health conditions: causes of admission and mortality in a pediatric intensive care unit

Based on the existing sex differences in mortality rates in children, we would like to explore whether girls and boys respond differently under severe health conditions, in terms of mortality and cause of admission.