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Research Article
Chandrashekar GS1, Sanchita Shettigar2, Ronald Roche2, Dr Narendra Nayak2, Anitha KB2, Santhosh Soans1
1 2
Dept. of Paediatrics and Dept. of Microbiology, A.J. Institute of Medical Sciences, Mangalore.
ABSTRACT
Background: Nosocomial infections (NI) are major public health concern because of the substantial morbidity and
the mortality which are associated with them.
Objectives: To know the incidence of NI, site of infection, pathogens involved and their antibiogram.
Methods: One year prospective study involving children who were admitted to PICU for more than 48 hours were
included. Isolates were identified from the clinical samples including blood, urine, sputum, wound/pus swab,
intravenous catheter tips, endotracheal secretions/tip, urinary catheter, central venous line, inter costal drainage
catheter tip.
Result: Out of 288 patients, 34 patients had NI. The overall NI rate was 9.26 % and the incidence density was 16.8
per 1000 patient-days. Primary bloodstream infections (38.2%), pneumonia (29.4%), and urinary tract infections
(26.5%) were most frequent. Nosocomial-related mortality was 23.5% and most commonly due to pneumonia
(62.5%). Staphylococcus aureus (46%) were the most common bloodstream isolates. Pseudomonas aeruginosa
(40%) followed by Acinetobacter baumanii (30%) were the most common species reported from pneumonia and
Escherichia coli (44%) from urinary tract infections. Nearly, 78% of pneumonia, 82% of urinary tract infection and
94% of blood stream infection were associated with ventilator use, urinary catheter and central venous catheter
respectively. All bacterial isolates showed high frequency of resistance to multiple antibiotics.
Conclusion: The presence of NI was associated with a long period of hospitalization and use of invasive devices.
Adherence to infection control protocols and short term use of invasive devices and judicious use of antibiotics are
important in preventing such infections.
Nosocomial infection (NI) in the paediatric intensive overburdening the already strained health economy. In
care unit (PICU) is associated with increased studies conducted by various authors, the incidence of
mortality, morbidity and length of stay. In addition nosocomial infections ranged from 5.3% to 27.3%.1-5
It is defined as infection that begins 48 hours after Those having fever prior to admission to the PICU, or
admission to hospital.6 The commonest types are any other clinical features of infection secondarily
ventilator-associated pneumonia (VAP), central line- acquired in the wards prior to transfer to the PICU
rapid and accurate diagnosis, which improves Specific site related investigations included the
outcomes and reduces drug resistance. This study following:
aimed to determine the incidence of NI, site of
infection, pathogens involved and their antibiogram. • Blood culture at the time of admission to
leukocytosis >12,000 WBC/mm3; (ii) new infiltrates • Urine and tips of indwelling catheters were
secretions; (iii) turbid urine, suprapubic tenderness, suspected urinary tract infections.
each catheter was cut using a sterile blade and the tip
identified and antibiotic susceptibility was determined Primary bloodstream infections and pneumonia were
by Kirby Bauer’s disc diffusion method according to reported more frequently in infants aged 12 months or
Clinical and Laboratory Standards Institute (CLSI) less as compared with older children. Urinary tract
OBSERVATION AND RESULTS Staphylococcus aureus (46%) were the most common
A total of 367 patient admissions and 2019 patient- bloodstream isolates, and aerobic Gram-negative
days were evaluated. Among the 288 patients, 34 bacilli were reported in 38% of primary bloodstream
patients had NI (28 patients with single site and 6 infections. Pseudomonas aeruginosa (40%) followed
patients with dual site). The overall NI rate was 9.26 by Acinetobacter baumanii (30%) were the most
% and the incidence density was 16.8 per 1000 common species reported from pneumonia and
patient-days. Primary bloodstream infections (38.2%), Escherichia coli (44%) from urinary tract infections
pneumonia (29.4%), and urinary tract infections (Table 1& Figure 2). Nearly, 78% of pneumonia, 82%
(26.5%) were most frequent and were almost always of urinary tract infection and 94% of blood stream
associated with use of an invasive device (Figure 1). infection were associated with ventilator use, urinary
the primary bloodstream infection-associated mortality Patients in ICU are always at higher risk of developing
rate was 37.5%. Mortality was higher in patients with nosocomial infections with antibiotic resistant strains.
NI, compared to patients without NI. Prevention of NIs is the key procedure in quality of
All bacterial isolates showed high frequency of et al had found highest NI in urinary tract followed by
resistance to multiple antibiotics. In case of gram wound infections and pneumonia.5 In their study,
negative bacilli, susceptibility to imipenem (89%), blood stream infection was less common condition
was better than ampicillin, gentamicin, co- pneumonia was the most common nosocomial
trimoxazole, cefotoxime. ceftriaxone, ceftazidime, infection, followed by urinary tract infections and
gram positive cocci, vancomycin , teicoplanin and In the present study, an increased duration of stay in
linezolid showed 100% sensitivity and amikacin PICU and the number of days of intervention were
Pseudomonas aeruginosa 02 04 01 00 07
Acinetobacter baumanii 01 03 00 00 04
Escherichia coli 01 00 04 00 05
Klebsiella pneumoniae 01 02 01 00 04
Staphylococcus aureus 06 01 01 01 09
Streptococcus spp. 00 00 00 01 01
Enterococcus spp. 01 00 00 00 01
Candida spp. 01 00 02 00 03
Total 13 10 09 02 34
study done by Porto JP et al.8 However, Richards MJ adequate use of initial empirical antibiotic therapy.
and colleagues9 had refuted this observation. Further Nosocomial-related mortality in our study was 23.5%,
they have reported primary bloodstream infections and the pneumonia-associated mortality rate was 62.5%
surgical site infections were more frequently seen in and the primary bloodstream infection-associated
infants aged 2 months or less as compared with older mortality rate was 37.5%. Abramczyk ML et al had
children. Urinary tract infections were reported more reported nosocomial-related mortality was 21.3%, the
frequently in children >5 years old compared with pneumonia-associated mortality rate was 11.4% and
younger children which was similar to present study. the primary bloodstream infection-associated mortality
They have also found that NI was almost always rate was 33.3%.3 They concluded that mortality was
associated with use of an invasive device. significantly higher in patients with NI, compared to
Nosocomial infection associated mortality is patients without NI. Bowen-Jones et al. analyzed
multifactorial, and depends on the patients’ mortality rates in children admitted to the ICU and
Penicillin -- -- R -- -- R 89
Ampicillin 86 100 R 80 75 R 89
Amoxyclav 71 75 R 60 75 S 78
Erythromycin -- -- R -- -- S 67
Clindamycin -- -- S -- -- S 44
trimoxazole
Gentamicin 57 75 S 40 75 S 67
Amikacin 43 50 S 40 50 S 56
Cefotaxime 57 50 S 20 25 S 67
Ceftriaxone 43 50 S 20 25 S 56
Ceftazidime 29 50 -- 40 25 S 67
Ciprofloxacin 71 75 R 60 75 R 67
Levofloxacin 71 75 R 60 50 R 67
Imipenem 14 25 S 20 00 -- --
Meropenem 14 25 S 20 00 -- --
Cefoperazone- 43 25 S 20 25 -- --
sulbatam
Pipercillin- 29 25 S 40 25 -- --
tazobatam
Vancomycin -- -- S -- -- S 00
Teicoplanin -- -- -- -- -- -- 00
Linezolid -- -- -- -- -- -- 00
R- Resistant, S- Sensitive
mortality rate of 18% in children without NI.12 1. Jordan García I, Arriourtúa AB, Torre JA, Antón
In the present study, most common bacterial pathogens JG, Vicente JC, González CT. A national multicentre
were Staphylococcus aureus and Pseudomonas study on nosocomial infections in PICU. An Pediatr
baumannii, and Klebsiella pneumoniae. Richards MJ 2010.09.010. Epub 2011 Jan 12.
most common species reported from pneumonia and 3. Abramczyk ML, Carvalho WB, Carvalho ES,
Escherichia coli (19%), from urinary tract infections.9 Medeiros EAS. Nosocomial infection in a pediatric
All bacterial isolates showed high frequency of intensive care unit in a developing country. Braz J
resistance to multiple antibiotics but maximum Infect Dis. 2003 Dec;(6):375-380.
7. Clinical and Laboratory Standards Institute. Nosocomial colonization and infection in a pediatric
Performance standards for antimicrobial susceptibility respiratory intensive care unit. S Afr Med J
Dr Chandrashekar GS
8. Porto JP, Mantese OC, Arantes A, Freitas C, Associate Professor, Dept. of Paediatrics,
A.J. Institute of Medical Sciences, Kuntikana,
Gontijo Filho PP, Ribas RM. Nosocomial infections in Mangalore-575004, India.
E-mail address: drchandru2003@rediffmail.com
a pediatric intensive care unit of a developing country:
ISSN-2321-9351
9. Richards MJ, Edwards JR, Culver DH, Gaynes RP. www.ijocsa.in
Nosocomial infections in pediatric intensive care units
187.