Articles
Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European Centre for Disease Prevention and Control point-prevalence survey

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Summary

Background

In 2011–12, the European Centre for Disease Prevention and Control (ECDC) held the first Europe-wide point-prevalence survey of health-care-associated infections in acute care hospitals. We analysed paediatric data from this survey, aiming to calculate the prevalence and type of health-care-associated infections in children and adolescents in Europe and to determine risk factors for infection in this population.

Methods

Point-prevalence surveys took place from May, 2011, to November, 2012, in 1149 hospitals in EU Member States, Iceland, Norway, and Croatia. Patients present on the ward at 0800 h on the day of the survey and who were not discharged at the time of the survey were included. Data were collected by locally trained health-care workers according to patient-based or unit-based protocols. We extracted data from the ECDC database for all paediatric patients (age 0–18 years). We report adjusted prevalence for health-care-associated infections by clustering at the hospital and country level. We also calculated risk factors for development of health-care-associated infections with use of a generalised linear mixed-effects model.

Findings

We analysed data for 17 273 children and adolescents from 29 countries. 770 health-care-associated infections were reported in 726 children and adolescents, corresponding to a prevalence of 4·2% (95% CI 3·7–4·8). Bloodstream infections were the most common type of infection (343 [45%] infections), followed by lower respiratory tract infections (171 [22%]), gastrointestinal infections (64 [8%]), eye, ear, nose, and throat infections (55 [7%]), urinary tract infections (37 [5%]), and surgical-site infections (34 [4%]). The prevalence of infections was highest in paediatric intensive care units (15·5%, 95% CI 11·6–20·3) and neonatal intensive care units (10·7%, 9·0–12·7). Independent risk factors for infection were age younger than 12 months, fatal disease (via ultimately and rapidly fatal McCabe scores), prolonged length of stay, and the use of invasive medical devices. 392 microorganisms were reported for 342 health-care-associated infections, with Enterobacteriaceae being the most frequently found (113 [15%]).

Interpretation

Infection prevention and control strategies in children should focus on prevention of bloodstream infections, particularly among neonates and infants.

Funding

None.

Introduction

For many years, point-prevalence surveys have been used for surveillance of health-care-associated infections.1 The pioneering project Study on the Efficacy of Nosocomial Infection Control (SENIC), initiated in the 1970s by the US Centers for Disease Control and Prevention (CDC), used repeated point-prevalence surveys to study the benefit of establishing infection prevention and control teams in US hospitals.2 In the following years, the US National Nosocomial Infection Surveillance (NNIS) system established prospective surveillance for health-care-associated infections in intensive care units, which was adopted for use by national surveillance networks in other countries. Incidence surveillance has become the gold standard for surveillance of health-care-associated infections in high-risk specialties such as intensive care, oncology, or neonatal care, and for selected infections such as ventilator-associated pneumonia and catheter-associated urinary tract and bloodstream infections. However, incidence surveillance is almost never done for all infection types because it is cumbersome and resource-demanding. Point-prevalence surveys offer an alternative method to incidence surveillance to estimate the hospital-wide burden of health-care-associated infections within a reasonable budget.1 Thus, they can be used a wider range of settings including institutes with limited resources and allow broader comparison of rates across a wider range of sociocultural contexts.

In July, 2008, the coordination of the European Union (EU)-funded network Improving Patient Safety in Europe (IPSE) and its surveillance component (previously Hospitals in Europe Link for Infection Control through Surveillance [HELICS]) were transferred to the European Centre for Disease Prevention and Control (ECDC) to form a new surveillance network (HAI-Net), which, in 2009, started planning the first EU-wide point-prevalence survey of health-care-associated infections and antimicrobial use in acute care hospitals.3

Research in context

Evidence before this study

We searched PubMed with the search terms “cross infection” [MeSH], “healthcare-associated infection$”, “nosocomial infection$”, and “hospital-acquired infection$”) in combination with “prevalence”, with age restriction (0–18 years) but without language or time restriction (up to June 30, 2016). Of 928 titles and abstracts, 15 reports were multicentre national or multinational prevalence surveys in high-income countries. One report was the pilot testing of the European Centre for Disease Prevention and Control (ECDC) point-prevalence survey in 2010. Two national surveys (Scotland and Poland) were part of the ECDC point-prevalence survey 2011–12 reported in this study. Most surveys were done in acute care adult or mixed adult and paediatric health-care settings. Only one multinational point-prevalence survey reported paediatric data. Between 1983 and 1987, WHO conducted a multinational prevalence survey in 47 hospitals of 14 high-income and upper-middle-income countries. Nine surveys were conducted in a general population in which children were included, two addressed neonatal intensive care only, and one was done in general paediatric wards. Finally, one study in the UK and Ireland focused exclusively on respiratory tract infections in children.

Added value of this study

This analysis of paediatric data from the ECDC point-prevalence survey 2011–12 represents the largest multinational study on prevalence of health-care-associated infections in children. The adjusted prevalence of health-care-associated infections was 4·2% (95% CI 3·7–4·8). The survey confirms that the burden of infections is highest in infants younger than 12 months and in neonatal and paediatric intensive care units. Bloodstream infection was the most common type of health-care-associated infection, not only in neonates and infants in their first 11 months of life but throughout most of childhood. With older age, infections such as lower respiratory tract infections or surgical-site infections were more common. The variation of prevalence among countries could not be explained by the distribution of paediatric settings, nor did it follow a geographical or socioeconomic pattern.

Implications of all the available evidence

Infection prevention and control should focus on the prevention of bloodstream infections in the youngest age groups, particularly in neonatal and paediatric intensive care units.

In 2011–12, the EU Member States, Iceland, Norway, and Croatia participated in this ECDC point-prevalence survey. Data for 273 753 patients from 1149 hospitals were submitted to ECDC and, to obtain similar precision in health-care-associated infections prevalence estimates for all participating countries, a representative subsample of hospitals was drawn from the data for countries that were over-represented such as Belgium, Portugal, and Spain. 231 459 patients from 947 hospitals remained in the final ECDC database.3 The prevalence of patients with one or more health-care-associated infections was 6·0% (country range 2·3–10·8%).3 When extrapolated to the average daily number of occupied beds per country, the adjusted overall prevalence of health-care-associated infections was estimated to be 5·7% (95% CI 4·5–7·4). The most frequent types of infections were lower respiratory tract infections (pneumonia and other lower respiratory tract infections), followed by surgical-site infections, urinary tract infections, bloodstream infections, and gastrointestinal infections.3

In this Article, we present results of an analysis of data from paediatric patients who were enrolled in the ECDC point-prevalence survey. We aimed to calculate the prevalence of health-care-associated infections among hospitalised children and adolescents in Europe; to describe the distribution of types of health-care-associated infections in different paediatric settings and age groups; and to determine risk factors for health-care-associated infections among hospitalised children and adolescents in Europe.

Section snippets

The ECDC point-prevalence survey

National contact-points in EU Member States, Iceland, Norway, and Croatia agreed to organise a point-prevalence survey of health-care-associated infections and antimicrobial use in acute care hospitals in their country based on a standardised study protocol developed by ECDC.4 These surveys took place on one day during one of the following periods: May to June, 2011, September to October, 2011, May to June, 2012, and September to November, 2012. These periods were chosen to fall outside winter

Results

Of the 231 459 patients included in the final ECDC point-prevalence survey database, 17 273 were children in 29 countries. Children were hospitalised in 1356 wards in 618 hospitals, of which 148 (24%) were primary hospitals, 260 (42%) secondary hospitals, 146 (24%) tertiary hospitals, 39 (6%) specialised hospitals, and 25 (4%) of unknown status. Most children were hospitalised in general paediatric wards (n=8298; 48%), followed by neonatal units (n=4467; 26%), NICUs (2283; 13%), paediatric

Discussion

Our results show that the burden of health-care-associated infections in childhood is highest in the first year of life and demonstrate the importance of bloodstream infections as the most common type of infections in children. Lower respiratory tract infections and surgical-site infections were more frequent in older age groups and the distribution of infections in children aged 5 years or older was close to the distribution of health-care-associated infections in adults.1, 3, 9, 10 These

References (28)

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