Susan E. Coffin

Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary, Introduction, and accompanying editorial for additional discussion. 1. Burden of HAIs caused by MRSA in acute care facilities a. In the United States, the proportion of hospital-associated S. aureus infections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% of S. aureus infections in hospitals. b. Although the proportion of S. aureus –associated HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line–associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001. Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission. c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care.

Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.

Immune dysregulation in severe influenza

Among previously healthy children with severe influenza, the mechanisms leading to increased pathology are not understood. We hypothesized that children with severe influenza would have high levels of circulating cytokines. To examine this, we recruited patients with severe influenza and examined plasma cytokine levels as well as the ability of peripheral blood cells to respond to stimuli. Ten patients with severe influenza were enrolled during the 2005–2007 influenza seasons. We evaluated plasma cytokine levels, circulating NK cells, and responses to TLR ligands during the illness. We compared these patients with five patients with moderate influenza, six patients with respiratory syncytial virus (RSV), and 24 noninfected controls. Patients with influenza showed depressed responses to TLR ligands when compared with RSV patients and healthy controls (P<0.05). These normalized when retested during a convalescent phase. Plasma levels of IL‐6, IL‐12, and IFN‐γ were elevated in influenza patients compared with controls (P<0.05). A compromised ability to produce TNF‐α was reproduced by in vitro infection, and the magnitude of the effect correlated with the multiplicity of infection and induction of IFN regulatory factor 4 expression. Aberrant, systemic, innate responses to TLR ligands during influenza infection may be a consequence of specific viral attributes such as a high inoculum or rapid replication and may underlie the known susceptibility of influenza‐infected patients to secondary bacterial infections.

Infection Due to Moraxella osloensis: Case Report and Review of the Literature

We describe the successful treatment of Moraxella osloensis bacteremia in a 2-year-old boy who presented with fever, petechial rash, and exacerbation of reactive airway disease. We also review the 12 cases previously reported in the literature.

Health Care Worker Exposures to Pertussis: Missed Opportunities for Prevention

OBJECTIVE: Pediatric health care workers (HCWs) are at particular risk for pertussis exposure, infection, and subsequent disease transmission to susceptible patients. This cross-sectional study describes the epidemiology of occupational exposures to pertussis and identifies factors that may inform interventions to promote effective implementation of infection prevention and control (IPC) guidelines. METHODS: We abstracted data from occupational health (OH) and IPC records for pertussis cases that resulted in an exposure investigation in a large quaternary pediatric care network, January 1, 2002 to July 18, 2011. We calculated the frequency of occupational exposures and measured associated characteristics. To assess the frequency of potential missed exposures, we reviewed electronic health record (EHR) data identifying laboratory-confirmed pertussis cases not documented in OH or IPC records. RESULTS: A total of 1193 confirmed HCW pertussis exposures were associated with 219 index cases during the study period. Of these, 38.8% were infants <6 months old and 7 were HCWs. Most (77.5%) of exposures occurred in the emergency department or an ambulatory site; 27.0% of exposures occurred after documented initiation of IPC precautions. We identified 450 laboratory-confirmed pertussis cases through EHR review, of which 49.8% (N = 224) had no OH or IPC investigation. The majority of uninvestigated cases (77.2%) were from ambulatory sites. CONCLUSIONS: Occupational exposures to pertussis occur frequently in pediatric health care settings despite appropriate IPC guidelines. Interventions are needed to ensure consistent implementation of IPC practices and timely identification and reporting of pertussis index cases to prevent HCW exposures and potential transmission to patients.

Severe Complications in Influenza-like Illnesses

OBJECTIVE: Data on complications from upper respiratory infection are limited. We examined development of severe complications in children presenting to the emergency department (ED) for moderate to severe influenza-like illness (ILI). METHODS: Prospective cohort study of children 0 to 19 years presenting to a tertiary care childrens hospital ED during peak respiratory viral seasons from 2008 to 2010. Subjects included had moderate to severe ILI, defined by performance of venipuncture and nasopharyngeal multiplex polymerase chain reaction for respiratory viruses. Severe complications (respiratory failure, encephalopathy, seizures, pneumonia, bacteremia, death) were prospectively determined. Risk factors for severe complications were collected, including demographics, comorbidities, and household exposures. RESULTS: There were 241 enrolled subjects with median age of 27.4 months (interquartile range 8.9–68.5); 59.3% were boys and 48.5% were black. High-risk conditions were present in 53.5%. Severe complications developed in 35.3% (95% confidence interval [CI] 29.3–41.3), most frequently pneumonia (26.1%). The risk for severe complications was increased in subjects with neurologic or neuromuscular conditions (relative risk 4.0; 95% CI 1.9–8.2). No specific respiratory virus was associated with development of severe complications. Among patients with influenza, severe complications were greater with subtype H1N1 infection (relative risk 1.45, 95% CI 0.99–2.13, P = .048), and were at highest risk for pneumonia (relative risk 4.2, 95% CI 1.2–15.9). CONCLUSION: In children presenting to the ED for moderate to severe ILI, those with neurologic and neuromuscular disease are at increased risk for severe complications. Development of severe complications did not differ by infecting virus; however, risk of severe complications was greater with subtype H1N1 compared with other influenza.

A prospective study of chemotherapy immunologic effects and predictors of humoral influenza vaccine responses in a pediatric oncology cohort

Please cite this paper as: Kersun et al. (2013) A prospective study of chemotherapy immunologic effects and predictors of humoral influenza vaccine responses in a pediatric oncology cohort. Influenza and Other Respiratory Viruses 7(6), 1158–1167.

Beyond the bundle: a survey of central line-associated bloodstream infection prevention practices used in US and Canadian pediatric hospitals.

We surveyed US and Canadian pediatric hospitals about their use of central line-associated bloodstream infection (CLABSI) prevention strategies beyond typical insertion and maintenance bundles. We found wide variation in supplemental strategies across hospitals and in their penetration within hospitals. Future studies should assess specific adjunctive prevention strategies and CLABSI rates.

Improving the central line-associated bloodstream infection surveillance definition: a work in progress.

Surveillance of healthcare-associated infections (HAIs) historically has been performed at hospitals to define endemic rates, track longitudinal trends, and help detect outbreaks. These hospital-specific infection data are also essential for measuring the impact of improvement efforts aimed at preventing HAIs. Having a standardized surveillance definition for HAIs is necessary to allow benchmarking of an individual hospital’s performance against others. For years, these reference data were provided by a defined group of hospitals that voluntarily submitted surveillance data to the Centers for Disease Control and Prevention’s (CDC’s) National Nosocomial Infection Surveillance (NNIS) system. The transition of NNIS system to the National Healthcare Safety Network (NHSN) and new state and federal requirements to report data to the NHSN have transformed the landscape of national HAI reporting. In an era of increasing public scrutiny, the NHSN has become a means to supply HAI data for public reporting.

Parent willingness to remind health care workers to perform hand hygiene

BACKGROUND Health care worker (HCW) hand hygiene (HH) is the core strategy to prevent health care-associated infections (HAI). Suboptimal HCW HH rates continue despite hospital efforts to increase compliance. OBJECTIVES To determine whether parents of hospitalized children perceive they have a role in preventing HAI and whether they are willing to remind HCW to perform HH, with and without an invitation. METHODS We conducted structured interviews of parents of children admitted to a pediatric hospital. Questions assessed knowledge, attitudes, and behaviors about HAI and HH. The primary outcome was willingness to remind a HCW to do HH (5-point Likert scale). RESULTS We interviewed 115 parents, of whom 84% were aware of HAI. Most parents (78%) perceived HH as the most important practice to prevent HAI. However, only 67% would definitely remind a HCW to perform HH. Importantly, 92% said that an invitation from a HCW would make them more likely to remind a HCW to do HH in the future. CONCLUSION Our results suggest that parents of hospitalized children are willing to help prevent HAI; however one-third are still reluctant to remind HCW to perform HH. An invitation by HCW to parents to remind HCW to perform HH might effectively engage parents as partners in HAI prevention.