Mònica Balaguer

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.

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.

Morbidity and mortality risk factors of pertussis in pediatrics.

Journal of Infection - In Press.Proof corrected by the author Available online since mardi 27 septembre 2016

Time of parenteral nutrition in paediatric critical care patients, prior nutritional status probably makes the difference?

It is well known that a delay in nutrient administration in the critical patient leads to a poor prognosis (1-4). It can induce an increase in nosocomial infections, mechanical ventilation duration, intensive care unit (ICU) length of stay (LOS), and mortality. In paediatrics there are only few clinical trials that have systematically analysed the importance of good nutrition in the pediatric critical patient’s outcome (5).

O.32. Epidemiología y hallazgos clínicos de la sepsis neonatal tardía en la unidad de cuidados intensivos pediátricos (UCIP)

Introduccion La sepsis neonatal es una causa importante de morbimortalidad neonatal. El estudio de factores de riesgo y el uso de medidas profilacticas han conseguido disminuir las sepsis precoces. Esto no se ha visto reflejado del mismo modo en las sepsis tardias que suelen generar ingreso en UCIP. Objetivos 1) Revisar la incidencia y epidemiologia de esta patologia. 2) Valorar la presencia de posibles factores de riesgo. Material y metodos Estudio descriptivo retrospectivo de 23 pacientes afectados de sepsis neonatal tardia ingresados entre 1998 y junio 2005 en nuestra unidad. Criterios de inclusion: se considero sepsis tardia a toda infeccion bacteriana sistemica, documentada por un hemocultivo positivo, a partir del septimo dia de vida, en paciente previamente sano. Se excluyeron las sepsis nosocomiales. Variables: edad, sexo, factores de riesgo, clinica al ingreso, ventilacion mecanica, inotropicos, pruebas diagnosticas, tratamiento empirico utilizado, cambios de antibioterapia y evolucion. Resultados Se seleccionaron 23 pacientes, 12 ninos (52,1%). La edad media al ingreso fue de 25,3 dias (DS ± 11). Correspondieron al 0,33% de los ingresos/ano y un 7,5% de los ingresos por sepsis al ano. Existieron factores de riesgo prenatal y connatal en 14 casos (66,6%). No existio relacion entre la presencia de factores de riesgo y sepsis posterior. La clinica de inicio mas frecuente fue la fiebre en 13 casos (56,5%). En todos los pacientes se realizo analitica, sedimento y hemocultivo. Se evidencio leucopenia en 17 pacientes (73,9%) y aumento de la PCR inicial en nueve (9%). No existieron diferencias estadisticamente significativas respecto a la presencia de leucopenia y mayor gravedad clinica. Se realizo puncion lumbar en 21 pacientes (91,3%), fue positiva en 10 casos (43,4%). La pauta antibiotica empirica mas utilizada fue la cefotaxima en 18 pacientes (85,7%) seguida de cefotaxima y ampicilina en 11 (47,8%). Se aislo germen en 19 casos (82,6%), el mas frecuente fue el S. agalactiae en 13 (61,9%), seguido de E. coli en tres (13,4%). No se detectaron resistencias a los antibioticos testados en ningun caso, pero se cambio de antibiotico en 12 pacientes (57,1%) por sensibilidad del germen. Fallecieron 6 pacientes (26%), en los primeros 3 dias del ingreso y todos presentaban meningitis. La estancia media en la UCIP fue de 6,9 dias (DE ± 7,3 dias). Conclusiones No se evidenciaron diferencias significativas respecto a la existencia de factores de riesgo y sepsis: la sepsis neonatal tardia en pacientes previamente sanos es poco predecible. La clinica fue inespecifica al inicio incluso en los casos de meningitis asociada. El SBG sigue siendo el germen mas frecuentemente aislado. Dado que no existieron resistencias antibioticas, cabria esperar mas cambios a antibioticos de menor espectro. La mortalidad fue del 26%, todos ellos con meningitis, falleciendo a las pocas horas del ingreso. La presencia de meningitis es un signo de mal pronostico (60% fallecidos).

Kinetics of Procalcitonin in Pediatric Patients on Extracorporeal Membrane Oxygenation

Objectives: To assess the kinetics of procalcitonin (PCT) and C-reactive protein (CRP) in pediatric patients who required extracorporeal membrane oxygenation (ECMO) and to analyze its relationship with morbidity and mortality. Patients and methods: Prospective observational study including pediatric patients who required ECMO. Both PCT and CRP were sequentially drawn before ECMO (P0) and until 72 hours after ECMO. Results: A total of 40 patients were recruited. Two cohorts were established based on the value of the P0 PCT (>10 ng/mL). Comparing the kinetics of PCT and CRP in these cohorts, the described curves were the expected for each clinical situation. The cutoff for P0 PCT to predict multiple organ dysfunction syndrome was 2.55 ng/mL (sensibility 83%, specificity 100%). Both PCT and CRP did not predict risk of neurologic sequelae or mortality in any group. Conclusions: Procalcitonin does not seem to be modified by ECMO and could be a good biomarker of evolution.

Immune response in RSV bronchiolitis: The key to more effective therapeutic interventions

Respiratory syncytial virus (RSV) is among the primary pathogens of bronchiolitis. The mortality rate among hospitalized children with RSV bronchiolitis is approximately 1 to 3%. As reported by various authors, the severity of this viral disease is linked to immune response. Thus, it is important that treatment for RSV bronchiolitis be immunologically targeted. The virus activates intracellular signaling in respiratory epithelial cells via receptors known as Toll-like receptors. After this stimulation, primary RSV infection generates a mixed Th1/Th2 response, which is regulated by gamma interferon. An exacerbated Th2 response would lead to a more severe infection. Herein we review the immunologic mechanisms behind RSV bronchiolitis in order to correlate each treatment with a corresponding immunological response.