Catheter-associated bloodstream infection in the pediatric intensive care unit: a multidisciplinary approach.

BACKGROUND: Catheter-associated bloodstream infections have been reported to occur in 3% to 8% of all central venous catheters inserted and are the predominant cause of hospital-acquired infection in intensive care units. OBJECTIVE: Decreasing the pediatric intensive care unit rate of catheter-associated bloodstream infections became a high priority in 2008 for all members of the intensive care unit team affiliated with central venous catheter insertion and maintenance. INTERVENTIONS: Through a series of multidisciplinary initiatives, the annual average catheter-associated bloodstream infection rate in the pediatric intensive care unit fell from 7.9 infections per 1000 central catheter days in 2007 to 1.3 infections per 1000 central catheter days in 2009, a decrease of 83%. We attribute this success to the implementation of several key interventions, adherence to published insertion and maintenance bundles, and collaboration among pediatric intensive care unit physicians and nurses in all aspects of central catheter care. MEASUREMENTS AND MAIN RESULTS: Statistically significant interventions included improvements to central venous catheter insertion practices, the development of a dedicated central catheter team, and regular collaborative discussion of central venous catheter necessity. In this 24-month period, this equates to 50 catheter-associated infections avoided, six potential deaths prevented, and an estimated cost savings of $1.45 million (based on $29,000 per infection). CONCLUSION: While implementation of these and other interventions has shown a positive impact, this project will continue into the future to assure sustainable successes and continued best practice improvements.

Spirometry centile charts for young Caucasian children: the Asthma UK Collaborative Initiative.

RATIONALE: Advances in spirometry measurement techniques have made it possible to obtain measurements in children as young as 3 years of age; however, in practice, application remains limited by the lack of appropriate reference data for young children, which are often based on limited population-specific samples. OBJECTIVES: We aimed to build on previous models by collating existing reference data in young children (aged 3-7 yr), to produce updated prediction equations that span the preschool years and that are also linked to established reference equations for older children and adults. METHODS: The Asthma UK Collaborative Initiative was established to collate lung function data from healthy young children aged 3 to 7 years. Collaborators included researchers with access to pulmonary function test data in healthy preschool children. Spirometry centiles were created using the LMS (lambda, micro, sigma) method and extend previously published equations down to 3 years of age. MEASUREMENTS AND MAIN RESULTS: The Asthma UK centile charts for spirometry are based on the largest sample of healthy young Caucasian children aged 3-7 years (n = 3,777) from 15 centers across 11 countries and provide a continuous reference with a smooth transition into adolescence and adulthood. These equations improve existing pediatric equations by considering the between-subject variability to define a more appropriate age-dependent lower limit of normal. The collated data set reflects a variety of equipment, measurement protocols, and population characteristics and may be generalizable across different populations. CONCLUSIONS: We present prediction equations for spirometry for preschool children and provide a foundation that will facilitate continued updating.

Pulmonary diffusing capacity in healthy African-American and Caucasian children.

Previous studies of pulmonary diffusing capacity in healthy children primarily focused upon Caucasian (C) subjects. Since lung volumes in African-Americans (AA) are smaller than lung volumes in C subjects of the same height, diffusing capacity values in AA children might be interpreted as low or abnormal using currently available equations without adjusting for race. Healthy AA (N = 151) and C (N = 301) children between 5 and 18 years of age performed acceptable measurements of single breath pulmonary diffusing capacity for carbon monoxide (DLCO ) and alveolar volume (VA ) according to current ATS/ERS guidelines. The natural log of DLCO and VA were associated with height, gender, age, and race; AA children had lower DLCO and VA compared to C children. Adjustment of DLCO for Hemoglobin (Hgb) resulted in no significant difference in DLCO among these healthy subjects with normal Hgb. In summary, we report prediction equations for DLCO and VA that include adjustment for race (C; AA) demonstrating that AA have lower DLCO and VA compared to C children for the same height, gender, and age.

Safety features of budesonide inhalation suspension in the long-term treatment of asthma in young children.

Early inhaled corticosteroid treatment improves symptom control and pulmonary function in children with asthma; however, long-term safety data are limited in infants and young children. This study assessed the long-term safety of budesonide inhalation suspension (BIS) in young children with persistent asthma. To continue to provide BIS to children who needed it-prior to US Food and Drug Administration approval-children 8 years of age or younger with mild, moderate, or severe persistent asthma who previously completed a 52-week open-label study of BIS were enrolled in an additional multicenter, open-label study that was to be concluded upon BIS approval. Patients already receiving BIS continued their current regimens. Patients younger than 4 years and those 4 years of age or older not receiving BIS at baseline started with total daily doses of 0.5 and 1.0 mg, respectively. BIS doses were adjusted throughout the study based on individual response. Adverse events and changes in laboratory parameters, vital signs, and physical examination findings were assessed. Of 198 enrolled patients, 152 (76.8%), 68 (34.3%), and 31 (15.7%) completed 1, 2, and 3 years of BIS treatment (mean daily dose 0.62+/-0.32 mg), respectively. One hundred sixty-six (83.8%) patients experienced an adverse event, of which 8.6% were considered by the investigator to be drug related. Adverse events were those typically occurring in a pediatric asthma population, with respiratory infection (49.0%) and sinusitis (25.3%) occurring at the greatest incidence. Only 2 patients withdrew due to adverse events. Mean changes in laboratory test results and physical examination findings were not clinically important throughout the study. Long-term BIS treatment is well tolerated in young children with persistent asthma, with a safety profile similar to that of short-term administration.

Efficacy of budesonide in inhaled corticosteroid-naive patients and patients with mild persistent asthma.

BACKGROUND: Patients with mild intermittent or mild persistent asthma represent 70% of asthma sufferers. Inhaled corticosteroids (ICSs) are the mainstay of treatment for persistent asthma, although many of the early clinical studies of these drugs included only patients with moderate to severe asthma. OBJECTIVE: This article reviews the literature on the efficacy of budesonide in the treatment of mild persistent asthma, including newly diagnosed ICS-naive patients. METHODS: Published data were identified by a MEDLINE search of the English-language literature from 1992 to 2002 using the terms budesonide plus efficacy or safety, both with and without the termsfluticasone or beclomethasone. An AstraZeneca reference database was also used to identify publications from the same period. Controlled, randomized studies that included patients with mild persistent asthma and early-treatment intervention were selected for inclusion. RESULTS: Inhaled budesonide has been used for almost 20 years in the treatment and control of moderate to severe asthma. Studies involving patients with mild persistent asthma have demonstrated significant improvements in peak expiratory flow (PEF) rates (P < 0.01) and forced expiratory volume in I second (P < 0.016) values for adult, adolescent, and pediatric patients treated with budesonide compared with placebo. Budesonide therapy is effective when given once or twice daily via dry powder inhaler or nebulizer, even at a low starting dose (200 microg/d). No significant adverse events have been reported with budesonide within the dose range used to treat mild persistent asthma (200 to 400 microg/d). Significant improvements in PEF rates (P < 0.01) and significant reductions in the risk of exacerbations and the number of days with poorly controlled asthma have been reported for ICS-naive patients treated with budesonide compared with placebo (both P < 0.001). In the primary care setting, mild persistent asthma may be undertreated. Patients with mild persistent asthma benefit significantly from early treatment with budesonide (P < 0.05). CONCLUSIONS: Budesonide is effective and well tolerated in the treatment of mild persistent asthma in adults and children, including many patients whose primary care physicians do not think they require daily ICS treatment.

Pulmonary diffusing capacity in healthy Caucasian children.

Previous studies of pulmonary diffusing capacity in children differed greatly in methodologies; numbers of subjects evaluated, and were performed prior to the latest ATS/ERS guidelines. The purpose of our study was to establish reference ranges for the diffusing capacity to carbon monoxide (DL(CO) ) and alveolar volume (V(A) ) in healthy Caucasian children using current international guidelines and contemporary equipment. Healthy children from the United States (N = 303) and from Australia (N = 176) performed acceptable measurements of single breath pulmonary diffusing capacity and alveolar volume according to current ATS/ERS guidelines. The natural log of DL(CO) and V(A) were associated with height, age and an age-sex interaction term, while DL(CO) /V(A) was related to height and the age-sex interaction term only. Adjustment of DL(CO) for hemoglobin (n = 303; USA data only) resulted is a small but significant decrease in DL(CO) of ∼1% but did not significantly alter the regression equations. In this dataset there was no influence of center for DL(CO) or DL(CO) /V(A) , while Australian children had a statistically smaller V(A) (mean difference 0.14 L after accounting for height, age and age-sex; P = 0.012). We report that diffusing capacity outcomes can be collated from multiple centers using similar equipment and collection protocols. Using collated data we have derived regression equations for pulmonary diffusing capacity outcomes in healthy Caucasian children aged 5-19 years.

Budesonide inhalation suspension: a nebulized corticosteroid for persistent asthma.

Guidelines for managing asthma in pediatric patients published by the American Academy of Allergy, Asthma, and Immunology and the American Academy of Pediatrics recommend the use of inhaled corticosteroids for the management of persistent asthma in infants and young children. When these guidelines were published, pressurized metered-dose inhalers and dry-powder inhalers were the only delivery devices available for inhaled corticosteroids in the United States. These devices can be difficult for young children to use correctly. Furthermore, no inhaled corticosteroid was approved in the United States for the treatment of children younger than 4 years. Budesonide inhalation suspension (Pulmicort Respules; AstraZeneca LP, Wilmington, Del) was developed to meet the medication delivery needs of infants and young children with persistent asthma. Pulmicort Respules is the first inhaled corticosteroid approved for administration by means of a nebulizer and the only inhaled corticosteroid approved in the United States for infants as young as 12 months. Budesonide has been studied extensively worldwide. In the United States the tolerability and efficacy of budesonide inhalation suspension were confirmed in 3 placebo-controlled multicenter trials. These studies demonstrated that both once- and twice-daily dosing of budesonide inhalation suspension (0.25-1 mg) improved pulmonary function and ameliorated asthma symptoms in infants and young children with persistent asthma. Budesonide inhalation suspension was well tolerated, and the incidences of reported adverse events were similar among patients in the budesonide, placebo, and conventional asthma therapy groups. This article reviews the results of these studies, as well as the pharmacokinetics, pharmacodynamics, and clinical use of budesonide inhalation suspension.

Spirometry in 3- to 6-year-old children with cystic fibrosis.

Spirometry is routinely used to assess pulmonary function of older children and adults with cystic fibrosis (CF); however, few data exist concerning the preschool age group. We have reported normative spirometric data for 3- to 6-year-old children. The current study was designed to assess a similarly aged group of clinically stable patients with CF. Thirty-three of 38 children with CF were able to perform 2 or 3 technically acceptable maneuvers. These patients had significantly decreased FVC, FEV(1), FEV(1)/FVC, and FEF(25-75) when expressed as z scores (number of SD from predicted): -0.75 +/- 1.63, -1.23 +/- 1.97, -0.87 +/- 1.33, and -0.74 +/- 1.63, respectively. There were significant positive correlations of the Brasfield radiological score with FVC and FEV(1) z scores (r(2) = 0.26, p < 0.01 and r(2) = 0.24, p < 0.01). In addition, homozygous patients for the DeltaF508 mutation had lower z scores for FVC (-1.21 versus 0.47, p < 0.01) and FEV(1) (-1.38 versus 0.21, p < 0.05) than heterozygous patients. Of the 14 patients who had full flow-volume spirometric measurements during infancy, 10 had FEF(25-75) z scores greater than -2 at both evaluations. Our findings suggest that spirometry can successfully be used to assess lung function in preschool children with CF and has the potential for longitudinal assessment from infancy through adulthood.