Gordon Hutcheon

Epidemiology of Human Metapneumovirus in a Pediatric Long-Term Care Facility

BACKGROUND Viral respiratory pathogens cause outbreaks in pediatric long-term care facilities (LTCFs), but few studies have used viral diagnostic testing to identify the causative pathogens. We describe the use of such testing during a prolonged period of respiratory illness and elucidate the epidemiology of human metapneumovirus (hMPV) at our LTCF. DESIGN Retrospective study of influenza-like illness (ILI). SETTING A 136-bed pediatric LTCF from January 1 through April 30, 2010. METHODS The ILI case definition included fever, cough, change in oropharyngeal secretions, increase in oxygen requirement, and/or wheezing. RESULTS During the study period, 69 episodes of ILI occurred in 61 (41%) of 150 residents. A viral pathogen was detected in 27 (39%) of the episodes, including respiratory syncytial virus (RSV) (n = 3), influenza A virus (not typed; n = 2), parainfluenza virus (n =2), adenovirus (n = 1), and hMPV (n = 19). Twenty-seven of the residents with ILI (44%) required transfer to acute care hospitals (mean length of hospitalization, 12 days; range, 3-47 days). Residents with tracheostomies were more likely to have ILI (adjusted odds ratio [OR], 3.99 [95% confidence interval {CI}, 1.87-8.53]; P = .0004). The mortality rate for residents with ILI was 1.6%. Residents with hMPV were younger (P = .03), more likely to be transferred to an acute care facility (OR, 3.73 [95% CI, 1.17-11.95]; P = .02), and less likely to have a tracheostomy (adjusted OR, 0.19 [95% CI, 0.047-0.757]; P = .02 ). DISCUSSION Diverse pathogens, most notably hMPV, caused ILI in our pediatric LTCF during a prolonged period of time. Viral testing was helpful in characterizing the epidemiology of ILI in this population.

Infection prevention and control practices in pediatric long-term care facilities

Pediatric long-term care facilities (pLTCFs) provide for children with chronic, complex medical needs and therefore face unique challenges for infection prevention and control (IP&C). At a conference in 2012, pLTCF providers reported IP&C issues of greatest concern in a survey. Major concerns included the lack of IP&C best practice guidelines, multidrug-resistant bacteria, and viral respiratory infections. Best practice guidelines for IP&C specific to pLTCF populations should be developed and evaluated.

Incidence, Risks, and Types of Infections in Pediatric Long-term Care Facilities

Importance The population of infants, children, and adolescents cared for at pediatric long-term care facilities is increasing in complexity and size and thus consumes substantial health care resources. Infections are a significant cause of morbidity and mortality in this population, but few recent data describe their incidence and effects. Objectives To describe the types of infections diagnosed in residents of pediatric long-term care facilities, calculate infection rates, and identify risk factors for respiratory tract infections (RTIs). Design, Setting, and Participants This prospective cohort study, which was part of a larger trial called Keep It Clean for Kids, was conducted from September 1, 2012, to December 31, 2015, at 3 pediatric long-term care facilities in New York. Residents of the facilities who were 21 years or younger and either residents or admitted during the study period (n = 717) were enrolled in the study. Medical records were reviewed to identify infections diagnosed by site clinicians. Main Outcomes and Measures Incidence of infections, such as RTIs; skin and soft-tissue infections; chronic comorbid conditions, including neurologic and respiratory disorders; and device use, including gastrostomy tubes and tracheostomies, was determined. Risk factors for RTIs were assessed by generalized linear mixed method regression modeling. Results The 717 residents had a median (interquartile range) age at enrollment of 2.6 (0.4-9.1) years; 358 (49.9%) were male. Four hundred twenty-eight residents (59.7%) had feeding tubes and 215 (30.0%) had tracheostomies. Most chronic comorbid conditions were musculoskeletal or ambulation (532 residents [74.2%]), neurologic (505 [70.4%]), respiratory (361 [50.3%]), and gastrointestinal (230 [32.1%]) disorders, and 460 residents (64.2%) had 4 or more chronic comorbid conditions. Site clinicians diagnosed 2052 infections during the 3-year study period. Respiratory tract infections were most common and were diagnosed in 1291 residents (62.9%). The overall infection rate was 5.3 infections per 1000 resident-days, and RTI rates were 3.3 infections per 1000 resident-days. Overall infection rates and rates of RTI, skin and soft-tissue infection, urinary tract infection, and bloodstream infection varied among the 3 sites. In the multivariable model, younger age (incidence rate ratio [IRR], 1.05; 95% CI, 1.03-1.06), increased number of chronic comorbid conditions (IRR, 1.12; 95% CI, 1.06-1.19), and the use of feeding tubes (IRR, 1.34; 95% CI, 1.03-1.64) and tracheostomies (IRR, 1.40; 95% CI, 1.17-1.69) were associated with RTIs. Conclusions and Relevance In this study, RTIs were the most common infections diagnosed, but modifiable risk factors for RTIs were not identified. Future work should focus on optimizing infection prevention and control strategies to reduce infections, particularly RTIs, in the pediatric long-term care population.

Developing Case Definitions for Health Care–Associated Infections for Pediatric Long-Term Care Facilities

Health care–associated infections (HAIs) are a leading cause of morbidity, hospitalizations in acute care, mortality, and increased health care costs among residents of long-term care facilities (LTCFs). Children residing in pediatric LTCFs (pLTCFs) have chronic medical conditions, which may increase their risk for HAIs. In addition, group activities are used daily in pLTCF for rehabilitation, socialization, and education, involving a large interdisciplinary care team and volunteers. These unique features of pLTCFs coupled with residents’ young age and vulnerability to infection can facilitate transmission and lead to outbreaks. Standardized surveillance case definitions are an integral part of infection prevention and control for HAI. In 1991, McGeer et al published HAI surveillance case definitions for LTCFs providing care to elderly residents. In 2012, the Society for Healthcare Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention (CDC) published updated HAI surveillance definitions for adults in LTCFs, but noted that definitions should be created for the pLTCF population. We performed a pilot study to assess the utility of the SHEA/CDC surveillance case definitions for children in pLTCFs.

Direct Costs of Acute Respiratory Infections in a Pediatric Long Term Care Facility

Acute respiratory tract infections (ARI) are a major burden in pediatric long‐term care. We analyzed the financial impact of ARI in 2012–2013. Costs associated with ARI during the respiratory viral season were ten times greater than during the non‐respiratory viral season,

Impact of Infection Prevention and Control Initiatives on Acute Respiratory Infections in a Pediatric Long-Term Care Facility

31 224 and

Is hand hygiene frequency associated with the onset of outbreaks in pediatric long-term care?

3242 per 1000 patient‐days, respectively (P < 0·001). ARI are burdensome for pediatric long‐term care facilities not only because of the associated morbidity and mortality, but also due to the great financial costs of prevention.

Implementation of an Electronic Hand Hygiene Monitoring System in Pediatric Long-term Care Facilities

We evaluated the collective impact of several infection prevention and control initiatives aimed at reducing acute respiratory infections (ARIs) in a pediatric long-term care facility. ARIs did not decrease overall, though the proportion of infections associated with outbreaks and average number of cases per outbreak decreased. Influenza rates decreased significantly. Infect Control Hosp Epidemiol 2016;37:859-862.

Epidemiology of Healthcare-associated Infections in Pediatric Long-term Care Facilities

Background Studies in adult long-term care facilities (LTCFs) have shown a correlation between hand hygiene (HH) and viral outbreak reduction, but no such studies have been conducted in pediatric LTCFs where the epidemiology of viral pathogens is different. Methods We compared electronically monitored facility-wide HH frequency in the weeks immediately prior to outbreaks of acute respiratory or gastrointestinal infections versus control weeks in a 137-bed pediatric LTCF from October 2012-August 2015. Control weeks were the 8-14 day (control 1) and 15-21 day (control 2) periods prior to the onset of each outbreak. Results There was no difference in HH frequency in the weeks leading up to the outbreaks versus control weeks (odds ratio [OR], 1.0; 95% confidence interval CI, 1.00-1.001 using control 1 and OR, 1.0; 95% CI, 1.00-1.001 using control 2). Conclusions Our findings differed from those in adult LTFCs, possibly because of the greater contact between residents and staff in the pediatric setting, increased susceptibility to viral pathogens because of immunologic immaturity, or differences in the types of pathogens prevalent in each setting. Although HH may be important for limiting the number of residents infected during outbreaks, we found no association between HH frequency and subsequent outbreak onset.

Attributable Costs of Acute Respiratory Infections in a Pediatric Long-Term Care Facility

ISSUE: Central Line-Associated Bloodstream Infections (CLABSIs) result in increased morbidity, mortality, and length of stay in Neonatal Intensive Care Unit (NICU) patients. The CLABSI rates in a level II and III NICUwere consistently greater than 5.4 (CLABSI/1000 device days) and peaked at a rate of 10.7 in 2010. To address this problem an “Aim for Zero” task force was created which included nurses, directors, infection control, and physicians, and implemented a central line team. PROJECT: The task force and central line team analyzed all bloodstream infections in the NICU. In September 2010 the line team began training with evidence based practice techniques for the care of all umbilical, peripherally inserted, and operating room inserted central catheters. Daily rounding and assessment of these lines was implemented as well as strict sterile insertion practices, dressing maintenance, daily sterile fluid changes, and a timely removal process. Sterile injection ports were added to all lines and a 30 second scrub with 3% chlorahexadine was performed prior to every access. The line team was officially launched in November, 2010. RESULTS: Immediately after implementing changes CLABSI rates dropped significantly. From December 2010 through November 2013 the NICU units recorded 25,000 central line days and 132,546 patient days and had a CLABSI rate of 0.65. Our longest CLABSI free stretch was 304 days ending in October of 2013. Our peripherally inserted and umbilical lines remain CLABSI free to date. It is important to note that our data is accurate as we do not use any maneuvers to avoid National Healthcare Safety Network (NHSN) CLABSI criteria.