Multinational prospective study of incidence and risk factors for central-line-associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years.

OBJECTIVE: To identify central-line (CL)-associated bloodstream infection (CLABSI) incidence and risk factors in low- and middle-income countries (LMICs). DESIGN: From July 1, 1998, to February 12, 2022, we conducted a multinational multicenter prospective cohort study using online standardized surveillance system and unified forms. SETTING: The study included 728 ICUs of 286 hospitals in 147 cities in 41 African, Asian, Eastern European, Latin American, and Middle Eastern countries. PATIENTS: In total, 278,241 patients followed during 1,815,043 patient days acquired 3,537 CLABSIs. METHODS: For the CLABSI rate, we used CL days as the denominator and the number of CLABSIs as the numerator. Using multiple logistic regression, outcomes are shown as adjusted odds ratios (aORs). RESULTS: The pooled CLABSI rate was 4.82 CLABSIs per 1,000 CL days, which is significantly higher than that reported by the Centers for Disease Control and Prevention National Healthcare Safety Network (CDC NHSN). We analyzed 11 variables, and the following variables were independently and significantly associated with CLABSI: length of stay (LOS), risk increasing 3% daily (aOR, 1.03; 95% CI, 1.03-1.04; P < .0001), number of CL days, risk increasing 4% per CL day (aOR, 1.04; 95% CI, 1.03-1.04; P < .0001), surgical hospitalization (aOR, 1.12; 95% CI, 1.03-1.21; P < .0001), tracheostomy use (aOR, 1.52; 95% CI, 1.23-1.88; P < .0001), hospitalization at a publicly owned facility (aOR, 3.04; 95% CI, 2.31-4.01; P <.0001) or at a teaching hospital (aOR, 2.91; 95% CI, 2.22-3.83; P < .0001), hospitalization in a middle-income country (aOR, 2.41; 95% CI, 2.09-2.77; P < .0001). The ICU type with highest risk was adult oncology (aOR, 4.35; 95% CI, 3.11-6.09; P < .0001), followed by pediatric oncology (aOR, 2.51;95% CI, 1.57-3.99; P < .0001), and pediatric (aOR, 2.34; 95% CI, 1.81-3.01; P < .0001). The CL type with the highest risk was internal-jugular (aOR, 3.01; 95% CI, 2.71-3.33; P < .0001), followed by femoral (aOR, 2.29; 95% CI, 1.96-2.68; P < .0001). Peripherally inserted central catheter (PICC) was the CL with the lowest CLABSI risk (aOR, 1.48; 95% CI, 1.02-2.18; P = .04). CONCLUSIONS: The following CLABSI risk factors are unlikely to change: country income level, facility ownership, hospitalization type, and ICU type. These findings suggest a focus on reducing LOS, CL days, and tracheostomy; using PICC instead of internal-jugular or femoral CL; and implementing evidence-based CLABSI prevention recommendations.

Critically ill infants with SARS-COV-2 delta variant infection.

BACKGROUND: SARS-CoV-2 is described to cause mild to moderate symptoms in children. To date, clinical data and symptoms of the Delta variant in pediatric patients are lacking. AIM: To describe clinical characteristics and outcomes of infants admitted in the pediatric intensive care unit (PICU) during the period of Delta variant predominance. METHODS: We performed a retrospective study, between June 23, 2021 and August 16, 2021. We included children aged under 15 years, admitted to PICU with severe and critical form of SARS-CoV-2 infection as confirmed by RT-PCR. We reviewed medical records for all patients. RESULTS: During the study period, 20 infants were included. The median age was 47 days (IQR: 26.5-77). The sex ratio was 0.8 (9 males). No underlying medical conditions were noted. Parents were not vaccinated. Respiratory involvement was the main feature to be observed in our cohort. Eleven patients had pediatric acute respiratory distress (PARDS) with a median oxygen saturation index (OSI) of 9 (IQR: 7-11). PARDS was mild in 4 cases, moderate in 5 cases and severe in 2 cases. Hemodynamic instability was observed in 4 cases. The main radiological finding was ground glass opacities in 11 cases. Seventeen patients were mechanically ventilated and 3 of them were escalated to high-frequency oscillatory ventilation. The median duration of mechanical ventilation was 6 days (IQR 2.5-12.5). The remaining patients were managed with high flow nasal cannula. Four patients died. CONCLUSION: We report herein a case series of very young infants, with no comorbidities, and with a life-threatening illness due to SARS-CoV-2 Delta variant.

Severe and critical SARS-COV-2 delta variant infection in infants without underlying medical conditions.

We report herein a case series of infants, with no comorbidities, who developed a life-threatening illness due to the SARS-CoV-2 Delta variant. We retrospectively reviewed the medical records of children, aged under 15 years, admitted to PICU, during the peak of Delta infection, between June 23 and August 16 2021, with severe and critical forms of SARS-CoV-2 infection, confirmed by RT-PCR. Twenty infants were included, the median age was 47 days (IQR: 26.5-77) and sex ratio was 0.8. No underlying medical conditions were noted. Parents were not vaccinated. Respiratory involvement was the main feature observed. Eleven patients had paediatric acute respiratory distress (PARDS) with a median oxygen saturation index (OSI) of 9 (IQR: 7-11). PARDS was mild in four, moderate in five, and severe in two cases. Hemodynamic instability was observed in 4 cases. The main radiological finding was ground glass opacities in 11 cases. Seventeen patients were mechanically ventilated, and three of them were escalated to high-frequency oscillatory ventilation. The median duration of mechanical ventilation was 6 days (IQR 2.5-12.5). The remaining patients were managed with high-flow nasal cannula. Four patients died.

High flow nasal cannula therapy versus continuous positive airway pressure and nasal positive pressure ventilation in infants with severe bronchiolitis: a randomized controlled trial.

INTRODUCTION: non-invasive ventilation is widely used in the respiratory management of severe bronchiolitis. METHODS: a randomized controlled trial was carried out in a tertiary pediatric university hospital´s PICU over 3 years to compare between continuous positive airway pressure/nasal positive pressure ventilation (CPAP/NPPV) and high flow nasal cannula (HFNC) devices for severe bronchiolitis. The trial was recorded in the national library of medicine registry (NCT04650230). Patients aged from 7 days to 6 months, admitted for severe bronchiolitis were enrolled. Eligible patients were randomly chosen to receive either HFNC or CPAP/NPPV. If HFNC failed, the switch to CPAP/NPPV was allowed. Mechanical ventilation was the last resort in case of CPAP/NPPV device failure. The primary outcome was the success of the treatment defined by no need of care escalation. The secondary outcomes were failure predictors, intubation rate, stay length, serious adverse events, and mortality. RESULTS: a total of 268 patients were enrolled. The data of 255 participants were analyzed. The mean age was 51.13 ± 34.43 days. Participants were randomized into two groups; HFNC group (n=130) and CPAP/NPPV group (n=125). The success of the treatment was significantly higher in the CPAP/NPPV group (70.4% [61.6%- 78.2%) comparing to HFNC group (50.7% [41.9%- 59.6%])- (p=0.001). For secondary outcomes, lower baseline pH was the only significant failure predictor in the CPAP/NPPV group (p=0.035). There were no differences in intubation rate or serious adverse events between the groups. CONCLUSION: high flow nasal cannula was safe and efficient, but CPAP/ NPPV was better in preventing treatment failure. The switch to CPAP/NPPV if HFNC failed, avoided intubation in 54% of the cases.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module.

BACKGROUND: We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific. METHODS: Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied. RESULTS: We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases. CONCLUSIONS: DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

First Tunisian Cluster Admissions of Critically Ill Patients with Multisystem Inflammatory Syndrome in Children (MIS-C).

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C) is a new emerging severe disease that is temporally related to previous exposure to coronavirus infection disease (COVID-19). AIM: To describe the clinical features, laboratory findings, therapies, and outcomes for the first Tunisian cluster admissions of critically ill children with severe MIS-C. METHODS: Retrospective study conducted from November 01 to November 30, 2020According to the WHO definition case, we included eight children aged less than 15 years who were admitted to our pediatric intensive care and met MIS-C criteria. We reviewed all patients' medical records to collect demographic and clinical data, severity scores, laboratory test results, echocardiographic findings, treatment, and outcomes. RESULTS: The median age was 8 years (IQR: 4-10years). All children were previously fit and well. Seven patients were boys. Known exposure to COVID-19 was reported in 4 cases. Fever and gastrointestinal symptoms were reported in all cases. Five patients had marked abdominal pain and were examined by the surgeon for possible appendicitis. Seven patients had diarrhea. On examination, we found rash (n=7), conjunctivitis (n=7), cheilitis (n=5), and meningism (n=3). We reported cardiac dysfunction in 7 cases and shock with hypotension in 3 cases. All patients received immunoglobulins, methylprednisolone, and a low dose of aspirin. No deaths occurred. CONCLUSION: We reported here the first Tunisian cluster admissions of 8 critically ill children with MIS-C to highlight the increase of a new severe emerging disease with evidence of prior COVID-19 infection in older children.

Povidone Iodine Pleurodesis for Refractory Congenital Chylothorax: A Review of Literature.

BACKGROUND: Povidone iodine (PVI) pleurodesis is commonly used in adult. However, this procedure is still nonconsensual in newborns. AIMS: This article aimed to report a new case of refractory congenital chylothorax (CCT) managed with PVI pleurodesis with a review of previousreported cases. METHODS: a systematic review of similar cases published in PubMed. Clinical patterns, therapeutic modalities and outcome variables werereported. RESULT: In a full term neonate presenting refractory CCT, PVI pleurodesis was performed at day 16 of life by one intrapleural instillation of PVI4% with rapid success and no side effects. Renal function and thyroid tests stilled normal before and after instillation. The analysis of 18 casesreported in Medeline and our observation provided the following data: this procedure was successful without side effects in 11/19 cases. Severeside effects were reported in four patients with high risks before procedure. CONCLUSION: PVI pleurodesis seems to be effective and inoffensive in the management of refractory CCT. It may be a good alternative tosurgery. Nevertheless, randomized studies on large neonatal population are required to precise: the risks and benefits of this procedure, thetiming and the modalities of its realization (duration of intervention, dilution and dosage of PVI) according to the patient`s field (gestational age,weight and associated morbidity).

Predictors of Mortality in Mechanically Ventilated Critical Pertussis in a low Income Country.

BACKGROUND: Critical pertussis is characterized by severe respiratory failure, important leukocytosis, pulmonary hypertension, septic shock and encephalopathy. AIM: To describe the clinical course of critical pertussis, and identify predictors of death at the time of presentation for medical care. METHODOLOGY: Retrospective study conducted in children's hospital Tunisian PICU between 01 January and 31 October 2013. Patients with critical pertussis confirmed by RT-PCR and requiring mechanical ventilation were included. Predictors of death were studied. RESULTS: A total of 17 patients was studied. Median age was 50 days. Mortality was 23%. Predictors risk of mortality were : high PRISM score (Pediatric Risk of Mortality Score) (p=0,007), shock (p=0,002), tachycardia (p=0,005), seizures (p=0,006), altered mental status (p=0,006), elevated WBC count (p=0,003) and hemodynamic support (p=0022). However, the difference did not reach statistical significance in comorbidity, pneumoniae, high pulmonary hypertension or exchange transfusion. Concomitant viral or bacterial co-infection was not related to poor outcome. CONCLUSION: Young infants are at high risk to have critical pertussis. Despite advances in life support and the treatment of organ failure in childhood critical illness, critical pertussis remains difficult to treat.

Perforated Meckel's diverticulum in a very preterm baby revealed at birth.

Perforated Meckel's diverticulum (MD) in a preterm baby is very rare. We report a case of a very preterm baby, born at 29-week gestation, with a birth weight of 1400 g, admitted in the third hour of life to our intensive care unit (ICU) for respiratory distress syndrome with abdominal distention. An abdominal radiograph showed a pneumoperitoneum. Laparotomy revealed Meckel's perforation. The baby was discharged healthy at the age of 16 days. MD should be kept in mind as one cause of an acute abdomen in preterm neonates mimicking necrotizing enterocolitis. To our knowledge, our patient is the third reported case described in the literature and the first one revealed at birth.

Neurological variant of Lemierre's Syndrome with purulent meningitis: a case report and literature review.

We report an unusual variant of Lemierre's Syndrome (LS) in a 10-year-old-girl admitted to the intensive care unit for septic shock with meningitis. The primary infection was otitis media. A gram negative bacillus was identified in the direct exam of the purulent ear discharge and the cerebrospinal fluid but cultures were negative. Computerized tomography of the neck revealed a thrombus in the internal jugular vein. Septic shock improved rapidly under supportive treatment. The patient recovered without sequellae after a prolonged duration of parenteral antibiotherapy and hospital stay. Neurologic variants of LS with meningitis, previously reported in the literature, are reviewed.

Lidocaine toxicity secondary to local anesthesia administered in the community for elective circumcision.

We report three previously healthy infants aged, respectively, 23 days, 6 weeks, and 3 months with systemic lidocaine toxicity following administration of subcutaneous lidocaine for regional anesthesia during an elective circumcision. The patients developed a generalized seizure requiring endotracheal intubation but recovered fully with supportive care. We report the clinical details of these cases as well as a review of lidocaine toxicity.

Community-acquired methicillin-resistant Staphylococcus aureus infections requiring admission to a Tunisian pediatric intensive care unit.

BACKGROUND: There is limited literature describing severe community acquired methicillin-resistant S aureus (CA-MRSA) in children admitted to an intensive care unit. AIM: To review clinical features and outcome of children admitted in a Tunisian pediatric intensive care with CA-MRSA. METHODS: Retrospective chart review of patients coded for CAMRSA over 10 years. RESULTS: There were 14 (0.32% of all admissions) patients identified with severe CA-MRSA. The median age was 3 months (range,0.5-156 months). All patients had pulmonary involvement. Six children (42.8%) developed septic shock. Two (14.3%) patients had multifocal infection with deep venous thrombosis. Two (14.3%) patients died. CONCLUSION: Severe CA-MRSA pneumonia dominated presentation. The mortality of CA-MRSA infection in our series is lower than reported in the literature.

[Outcome at 2 years of very premature infants. A Tunisian series]. / Devenir neurologique à l'âge de 2 ans des grands prématurés. Série Tunisienne.

BACKGROUND: Neurodevelopmental outcome of very premature infant can be associated with a high rate of cerebral palsy. AIM: To assess the impact of very preterm birth on neurological outcome at the age of two years. METHODS: Retrospective study of all cases of very premature infants born at less than 33 weeks of gestational age, during the years 2005 to 2007. Neurodevelopmental outcome is reported. RESULTS: During the study period, the very premature infant rate was 1.5 %. A complete information about neurological outcome at the age of two years, was obtained in 60 cases.Eight infants (13.4%) showed major handicap (cerebral palsy) and four others infants developed neurosensoriel difficulties. CONCLUSION: The incidence of neurosensoriel handicap in our population seems relatively high. A strong effort must be made for identification of risk factors of neurodevelopmental disability.

Community-associated methicillin-resistant Staphylococcus aureus infections in a pediatric intensive care unit.

INTRODUCTION: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection is an increasing problem worldwide. In developing countries, there is little data on CA-MRSA infection in children. This study reviewed the clinical features and outcomes of children admitted in a Tunisian pediatric intensive care unit with severe CA-MRSA infections. METHODOLOGY: Retrospective chart review of patients coded for CA-MRSA over 10 years. RESULTS: There were 14 (0.32% of all admissions) patients identified with severe CA-MRSA infections. The median age was three months (range, 0.5-156 months). All patients had pulmonary involvement. Six children (42.8%) developed septic shock. Two (14.3%) patients had multifocal infection with deep venous thrombosis. Two (14.3%) patients died. CONCLUSIONS: Severe CA-MRSA pneumonia dominated presentation. The mortality of CA-MRSA infection in our series is lower than that previously reported.

Management of meconium aspiration syndrome with highfrequency oscillatory ventilation.

BACKGROUND: High-frequency oscillatory ventilation (HFOV) has been advocated for use to improve lung inflation while potentially decreasing lung injury. There were few data on the early use of HFOV in hypoxemic term neonates. AIM: To evaluate the effectiveness of HFOV, used as the initial mode of ventilation, in neonates with severe meconium aspiration syndrome (MAS). METHODS: In a tertiary care paediatric intensive care unit, 17 term neonates with severe MAS were managed with HFOV, used as the initial mode of ventilation, and prospectively evaluated. Ventilator settings, blood gases, oxygenation index (OI) and alveolar-arterial oxygen difference (P(A-a)O2) were prospectively recorded during HFOV treatment and compared at the multiple time intervals. RESULTS: Target ventilation was easily achieved with HFOV. Initiation of HFOV caused a significant decrease in FIO2, achieved as early as 1 hour (from 0.93 ± 0.11 to 0.78 ± 0.25; p=0.031) and the improvement was sustained during the 1-32 hours period. There were a significant decreases in P (A-a) O2 and OI, respectively, at 4 hours (from 562.5 ± 71.7 to 355.4 ± 206 mm Hg; p=0.03) and 8 hours (from 23.3±17 to 14.6±16.3; p=0.04), that were sustained up to 16 and 40 hours . Three neonates (17.6%) developed pneumothorax on HFOV. One patient required oxygen support at 28 days. No significant others complications associated with HFOV were detected. Sixteen infants (94 %) were successfully weaned from HFOV and 15 (88%) survived to hospital discharge. CONCLUSION: Use of HFOV as the initial mode of ventilation in neonates with severe MAS is an effective strategy.

Datura stramonium L. poisoning in a geophagous child: a case report.

Datura stramonium L. (DS) is a wild-growing plant widely distributed and easily accessible. It contains a variety of toxic anticholinergic alkaloids such as atropine, hyoscamine, and scopolamine. Voluntary or accidental ingestion can produce severe anticholinergic poisoning. We report an unusual case of DS intoxication occurring in a geophagous young child after accidental ingestion of the plant. Our case is original because of the young age of the victim and the underlying geophagia facilitating the occurrence of poisoning.

Community acquired methicillin-resistant Staphylococcus aureus preseptal cellulitis complicated by zygomatic osteomylitis, cavernous sinus thrombosis and meningitis in a healthy child.

We report a case of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA) preseptal cellulitis complicated by zygomatic osteomyelitis, cavernous sinus thrombosis, meningitis, and necroziting pneumonia in a previously healthy two and half month old girl. This case exemplifies an aggressive and disseminated CA-MRSA infection with deep venous thrombosis in an infant without predisposing risk factors. The literature is reviewed and recommendations for management are provided.

Fatal subdural empyema caused by Streptococcus constellatus and Actinomyces viscosus in a child--case report.

Group milleri streptococci that colonize the mouth and the upper airways are generally considered to be commensal. In combination with anaerobics, they are rarely responsible for brain abscesses in patients with certain predisposing factors. Mortality in such cases is high and complications are frequent. We present a case of fatal subdural empyema caused by Streptococcus constellatus and Actinomyces viscosus in a previously healthy 7-year-old girl.