Preventing bloodstream infection in patients receiving home parenteral nutrition.

Patients receiving home parenteral nutrition (HPN) are at particularly high risk of meticillin-sensitive Staphylococcus aureus (MSSA) catheter-related bloodstream infections (CRBSI). We developed a multidisciplinary enhanced care pathway encompassing a number of minimal cost interventions involving line/exit site care, training for staff and parents, multidisciplinary discharge planning, and monitoring compliance. Implementation reduced the mean rates of MSSA CRBSI (from 0.93, 95% CI 0.25-1.61, to 0.23, 95% CI -0.06 to 0.52, per 1000 parenteral nutrition [PN] days) and all-cause CRBSI (from 1.98, 95% CI 0.77-3.19, to 0.45, 95% CI 0.10-0.80, per 1000 PN days). A similar approach could be applied to preventing health care-associated infections in other complex, vulnerable patient groups.

Antimicrobial treatment of serious gram-negative infections in newborns.

The choice of antibiotics for serious Gram-negative bacterial infections in the newborn must balance delivery of effective antibiotics to the site(s) of infection with the need to minimize selection of antibiotic resistance. To reduce the risk of selective pressure from large-scale cephalosporin usage, a penicillin-aminoglycoside combination is recommended as empiric therapy for neonatal sepsis. Where Gram-negative sepsis is strongly suspected or proven, a third-generation cephalosporin should ordinarily replace penicillin. Piperacillin-tazobactam can provide better Gram-negative cover than penicillin-aminoglycoside combinations, without the risk of selecting antibiotic resistance seen with cephalosporins, but further clinical studies are required before this approach to empiric therapy can be recommended. For antibiotic-resistant infections, a carbapenem remains the mainstay of treatment. However, rapid emergence and spread of resistance to these antibiotics means that in the future, neonatologists may have to rely on antibiotics such as colistin, whose pharmacokinetics, safety, and clinical efficacy in neonates are not well-defined.

Surveillance of infection in neonatal intensive care units.

Monitoring infection rates is increasingly regarded as an important contributor to safe and high quality health care, especially in intensive care settings. Early-onset neonatal sepsis rates are an important indicator of ante- and intra-partum care, especially as medicalisation of obstetric practice increases. However, surveillance of late-onset neonatal sepsis is required to monitor the quality of Neonatal Intensive Care Unit (NICU)-related care. Infection surveillance on NICUs presents a number of unique challenges, including defining infections, the preponderance of coagulase-negative staphylococci as both pathogens and commensals, and allowing for the influence of important risk factors. Ideally an infection surveillance programme should permit benchmarking of infection rates, and multi-centre programmes have been reported to decrease the incidence of healthcare-associated infections on NICUs. However, further research is required to identify the most clinically- and cost-effective means of surveying NICU-acquired infections before a national programme can be implemented. Until then, considerable value can be obtained from local infection surveillance.

A 7-year study of bloodstream infections in an English children's hospital.

UNLABELLED: Knowledge of the pattern of bloodstream infection (BSI) can help determine antibiotic prescribing policy and infection control procedures. Data on 2364 consecutive episodes of BSI at Birmingham Children's Hospital over 7 years were collected prospectively. A total of 1224 (51.8%) episodes were community-acquired, but only 281 (11.9%) were in previously healthy children. Intravascular devices (IVDs) were the most common source of infection, accounting for 48.9% of episodes. Gram-positive, gram-negative and anaerobic bacteria accounted for 66.2%, 31.3% and 0.4% of isolates, and 2.2% were yeasts. Coagulase-negative staphylococci, Staphylococcus aureus and enterococci accounted for over 50% of all isolates. Of these, only enterococci were predominantly hospital-acquired. Neisseria meningitidis was the most common cause of community-acquired BSI in previously healthy children. Of cases of meningococcaemia, 55.6% were diagnosed by PCR alone. Antibiotic resistance, especially in Enterobacteriaceae, S. aureus and enterococci, was more common than in earlier studies of BSI in children, and varied between specialties. The overall mortality rate directly attributable to infection was 2.4%, but was higher in neonates (6.2%) and in previously healthy children with community-acquired infections (5.3%). CONCLUSION: Intravascular devices have emerged as the commonest source of bloodstream infection in children, leading to marked similarities in the species distribution of blood culture isolates across specialties other than General Paediatrics, and explaining the low overall mortality rate. Antibiotic resistance was found frequently in most commonly isolated pathogens, but differences between specialties suggest the existence of local risk factors, some of which might be amenable to infection control interventions.

Childhood tuberculosis and its early diagnosis.

Traditional methods for laboratory diagnosis of tuberculosis are unsatisfactory, especially for children, in whose specimens mycobacteria are usually sparse. Recent changes in tuberculosis epidemiology in developed countries, including a large increase in incidence in children from certain ethnic minorities, have prompted interest in newer diagnostic methods. Liquid-based culture detection systems offer improved sensitivity and speed of diagnosis, although the time taken for detection of growth is still upwards of 1 week. Nucleic acid amplification techniques offer more rapid results, but perform best on smear-positive samples; sensitivities may be as low as 50% in smear-negative specimens. Although these newer techniques are widely used in some developed countries, in others, they are not perceived as offering sufficient benefit to justify their routine use. The diagnostic accuracy of mycobacteriophage and serologic methods is insufficient to justify their wide use even in developing countries. Despite recent developments, there is still no panacea for diagnosis of childhood tuberculosis.