Epidemiologic study of 4684 hospital-acquired infections in pediatric patients.

During a 4-year period 4684 nosocomial infections occurred in a university pediatric hospital which admitted 78,120 patients (nosocomial infection rate (NIR) = 6.0). NIR varied from 0.17 to 14.0 on different wards or services; the highest rates (greater than or equal to 5.6) were found in the Neonatal Intensive Care Unit, infant neurosurgery, hematology/oncology, neonatal surgery, cardiology/cardiovascular surgery, Pediatric Intensive Care Unit and infant/toddler medicine areas. Infections were most common in patients less than or equal to 23 months (NIR = 11.5), were less common in the 2- to 4-year age group (NIR = 3.6) and occurred least frequently in patients greater than or equal to 5 years (NIR = 2.6). The median day of onset of infections was 15.3 days. The proportional frequencies of infections were: 35% gastrointestinal; 21% bacteremia; 16% respiratory (10% upper, 6% lower); 7% postoperative wound; 6% urinary tract; 5% skin (32% of these skin infections were related to intravascular lines); 5% eye; 3% cerebrospinal fluid; and 2% other. A similar proportional frequency of 379 infections in patients hospitalized for more than 100 days was observed. The etiologic agents were Gram-positive bacteria (50%), viruses (23%), Gram-negative bacteria (18%), fungi (4%) and mixed/other (5%).

Nosocomial Pseudomonas aeruginosa conjunctivitis in a pediatric hospital.

Conjunctivitis accounted for 5% of nosocomial infections occurring in a university-affiliated pediatric hospital between January 1984 and April 1986. Pseudomonas aeruginosa was recovered from the conjunctiva of 30 patients. The primary diseases of these patients were chronic and debilitating. Eighty percent of patients were under 18 months of age although only 30% of admissions are represented in this age group. Seventy percent of cases occurred in pediatric intensive care unit/neonatal intensive care unit patients. Seventy percent of patients who had antecedent nasopharyngeal/endotracheal cultures obtained were colonized with P aeruginosa. All patients except one had one or more of the following interventions prior to the onset of conjunctivitis: tracheostomy, endotracheal tube, oxygen by hood, or suctioning. Two children (7.4%) have residual corneal scars. Improvements in eye care including protection of the eye during suctioning, other respiratory care, and nasogastric tube procedures are warranted.

Evaluation of a new method of detection of nosocomial infection in the pediatric intensive care unit: the Infection Control Sentinel Sheet System.

To improve the efficiency of nosocomial infection detection, a highly structured system combining initial reporting by the bedside night nurse of symptoms possibly related to infection with follow-up by the infection control nurse (ICN) was developed: The Infection Control Sentinel Sheet System (ICSSS). Between July 1, 1987 and February 28, 1988, a prospective comparison of results obtained through ICSSS and daily bedside observation/chart review by a full-time trained intensivist was undertaken in the pediatric intensive care unit (PICU). Ratios of nosocomial infections and nosocomially-infected patients were 15.8 and 7.0 respectively among 685 admissions; included are seven infections identified only through the ICSSS so that the "gold standard" became an amalgamation of the two systems. The sensitivity for detection of nosocomially-infected patients by bedside observation/chart review and ICSSS was 100% and 87% respectively. The sensitivity for detection of standard infections (blood, wound and urine) was 88% and 85% respectively. The sensitivity for detection of nosocomial infections at all sites was 94% and 72% respectively. Missed infections were minor (e.g., drain, skin, eye), required physician diagnosis (e.g., pneumonia), were not requested on the sentinel sheet (SS) (e.g., otitis media), related to follow-up of deceased patients or were minor misclassifications or failures to associate with device (e.g., central-line related). Daily PICU surveillance by the ICN required only 20 minutes a day. The ICSSS appears highly promising and has many unmeasured benefits.

Normal values of maximal inspiratory and expiratory pressures with a portable apparatus in children, adolescents, and young adults.

Maximal inspiratory and expiratory mouth pressures (Plmax and PEmax) were measured over a wide age range using a cylindrical mouthpiece and a multiple trial procedure. Two hundred forty-three students and 30 adults were studied. In addition, a comparison of a cylindrical and a scuba-type mouthpiece was made in 16 subjects. Fifty percent of the subjects required five or more trials to achieve their maximal mouth pressures. Higher PEmax values were obtained using a cylindrical mouthpiece than with a scuba-type mouthpiece in 15 of the 16 subjects tested. Plmax was not affected by mouthpiece type. Males had higher Plmax and PEmax values than females except in the 8-10 years age group. Maximal mouth pressures correlated with age in boys only. Technical considerations, such as the number of trials and the type of mouthpiece used, are important determinants of maximal mouth pressure values.

Creutzfeldt-Jakob disease guidelines: a regional approach.

Creutzfeldt-Jakob Disease (CJD) is an infectious, progressive, degenerative neurological disorder. Unique CJD Precautions must be adhered to as the infectious agent is difficult to destroy. A regional group in Hamilton-Burlington Ontario developed CJD guidelines based on critical review of the current evidence of transmission in a Canadian healthcare environment, current published standards of practice in North America, the United Kingdom and Australia; and principles of laboratory and patient care safety as well as expert opinion.

The validity of the transcutaneous oxygen tension method in children with cardiorespiratory problems.

Transcutaneous oxygen tension (tcPO2) was continuously monitored and compared with simultaneous arterial oxygen tension (PaO2) in 68 patients 1.5 to 23 yr of age (mean age, 7.7 yr) with cardiopulmonary disease. Two groups of patients were studied: (1) Patients during cardiac catheterization (56) in whom the PaO2 ranged from 34 to 98 mmHg (mean, 72.4 +/- 17 mmHg) and (2) patients in the Intensive Care Unit (12) in whom the PaO2 ranged from 54 to 158 mmHg (mean, 106 +/- 37 mmHg). Studies lasted for 30 to 210 min (mean, 80 +/- 33.4 min). The overall relation between tcPO2 and PaO2 in the 68 patients studied was r = 0.96 (p less than 0.001). These results indicated that tcPO2 measurement is a reliable method for assessing low as well as high PaO2 values in children and young adults without gross circulatory impairment.

Increased incidence of bronchial reactivity in children with a history of bronchiolitis.

To assess bronchial reactivity in children who have had bronchiolitis, we studied 48 children by challenging them with methacholine nine or ten years after admission to hospital with bronchiolitis. Pulmonary function was also evaluated. Fifty-seven percent of children studied had bronchial hyperreactivity. Thirty-three percent of first-degree relatives of those with a positive MCH challenge had a positive response. There was a significant correlation between the occurrence of a positive MCH challenge and a history of recurrent bronchiolitis. Pulmonary function tests demonstrated lower flow rates in the positive responders. Fourteen children had a history of asthma or wheezing, but this did not appear to be severe or frequent, and few required long-term therapy. There appears to be a strong genetic component in the prevalence of bronchial reactivity in these children. Bronchial hyperreactivity may be a risk factor in the development of COPD.

The immediate effect of sodium cromoglycate on the airway.

The authors compared the bronchodilator effect of nebulized solutions of sodium cromoglycate (SCG), salbutamol, and saline (placebo) in 10 asthmatic children, measuring peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and forced expiratory flow from 25% to 75% of the forced vital capacity (FEF25%-75%) before and every five minutes to a maximum of 20 minutes after each aerosol. SCG produced significant bronchodilation compared with saline as measured by PEF. This effect was not seen with FEV1 or FEF25%-75%. Salbutamol had a more immediate effect and produced a greater degree of bronchodilation than SCG. When an immediate bronchodilator effect is required SCG is not recommended.

Cost-effectiveness of intensive care for respiratory failure patients.

Fifty-eight consecutive patients admitted to the ICU requiring ventilatory support for respiratory failure were studied. The Therapeutic Intervention Scoring System (TISS) was used daily as an objective measure of the severity of critical illness in each patient. Patients who survived (27 of 58) 8-10 months after admission to the ICU were interviewed in their homes to assess the outcome of their illness. Most survivors were functioning at or above their premorbid level with respect to their activities of self care and community living. Survivors had minimal recall of the pain and anguish of their ICU experience. The financial cost of care was estimated. Of the total ICU cost, 40% was expended on the 27 survivors. The TISS alone could not distinguish survivors from nonsurvivors in this patient population. The major factor determining the outcome of the illness was the age of the patient. More information on the outcome of critical illness in elderly patients is needed.

Long-term evaluation of fenoterol by two different modes of administration (oral versus metered aerosol).

Thirteen asthmatic children were treated double-blind for 6 weeks each with either inhaled or oral fenoterol (a beta-2-selective adrenergic bronchodilator) three times a day. The oral dose regimen resulted in superior bronchodilation on the basis of peak expiratory flow rates, although clinical symptom scores did not differ with the route of administration. We conclude that oral fenoterol can be used on a chronic basis for the treatment of moderate asthmatics. Doses of inhaled fenoterol higher than 0.4 mg three times per day used in this study may be required to produce a similar effect to 0.8 mg/kg of oral fenoterol in three divided doses.

Comparison of the long-term effect of fenoterol hydrobromide and theophylline syrups in pre-school asthmatic children.

Eleven asthmatic children less than six years were treated double-blind for eight weeks with fenoterol, theophylline or placebo syrups. Both active drugs significantly decreased the incidence of cough compared to placebo. Nocturnal symptoms and wheezes were also reduced but were not improved to a statistically significant degree.

Comparison of three different preparations of disodium cromoglycate in the prevention of exercise-induced bronchospasm: a double-blind study.

In its usual form, disodium cromoglycate (DSG) contains lactose as a carrier (DSGL +). It has been suggested that lactose may effect irritant receptor sites, thus causing a degree of bronchoconstriction or less blocking of exercise-induced bronchospasm (EIB). This study was designed to assess and compare the ability of three different forms of DSG to block EIB. Eighteen asthmatic children and adolescents were given either DSGL+ by Spinhaler, DSG without lactose (DSGL-) by Spinhaler, nebulized (and also lactose-free) DSG solution (DSGN), or placebo in a randomized double-blind fashion on four occasions within a 10-day period. Pulmonary function tests were performed before and after medication and again after a standardized treadmill exercise test. After the exercise that followed treatment with each form of DSG the decreases in peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1) were significantly less than that seen after treatment with placebo. There was no significant difference between any of the three preparations of DSG. A complete block of EIB (decreases in PEFR and FEV1 of less than 12.5% and 10%, respectively) was seen in ony 11% of studies using all forms of DSG however, DSG was considered to be 'clinically effective' in 59% of studies.

Maximal inspiratory and expiratory pressures are reduced in hyperinflated, malnourished, young adult male patients with cystic fibrosis.

We measured maximal inspiratory and expiratory pressures (MIP and MEP, respectively) in 23 male patients with cystic fibrosis (CF), 16 to 35 yr of age (22.1 +/- 3.7), and in a control group of 33 male volunteers, 17 to 39 yr of age (22.5 +/- 6.8), to evaluate the effects of chronic hyperinflation and malnutrition on MIP and MEP in the patients with CF. Routine pulmonary function tests and skeletal muscle indexes, such as the force generated by the adductor pollicis muscle with supramaximal ulnar nerve stimulation at a frequency of 10 Hz as percentage of force at 100 Hz (F10/100) and midarm muscle circumference as a percentage of predicted (MAMC), were also measured in the patients with CF. Severe hyperinflation in this study was defined as a ratio of residual volume to total lung capacity above 50% and malnutrition as a ratio of actual weight to the ideal weight for the patient's age and height of 90% or less. The severely hyperinflated subgroup of patients with CF had significantly reduced MIP values in comparison with those in the other patients with CF. The malnourished subgroup, which was also severely hyperinflated, differed from the well-nourished one in both skeletal muscle indexes; MAMC was reduced, whereas F10/100 was elevated, and respiratory muscle pressure generation, MIP, and MEP were reduced. We conclude that patients with CF who are malnourished and/or severely hyperinflated have reduced maximal respiratory pressures.

The incidence of viral-associated diarrhea after admission to a pediatric hospital.

For determination of the incidence of viral-associated diarrhea after admission to a pediatric hospital, all patients admitted to general pediatrics, cardiology, and neurosurgery wards without diarrhea between January 1 and July 31, 1985 were followed 5 days per week for presence of diarrhea, etiologic agent, and possible risk factors. A total of 1,530 patients were followed for 3,642 days. Of these patients, 69 developed 80 nosocomial diarrhea episodes after 72 hours in hospital for a nosocomial diarrhea rate of 4.5 infected children per 100 admissions. Of 358 patients with an infected roommate, 37 (10.3%) developed nosocomial diarrhea. Etiologic agents recognized included rotavirus (43%), calicivirus (16%), astrovirus (14%), minreovirus (12%), adenovirus (8%), Salmonella sp. (4%), and parvo/picornavirus (3%). The nosocomial diarrhea rate by age was: 0-11 months, 8.8%; 12-35 months, 3.6%; and 36 months or more, 0.6%. The rate by length of stay was: 3-7 days, 8.4%; 8-14 days, 10.4%; 15-21 days, 7.9%; and 22 days or more, 8.8%, and by number of roommates/1,000 patient-days it was: 0-1, 15.7; 2 to 3, 27.7; and 4 or more, 45.2. Patients who acquired diarrhea were more likely to be diapered (9.6% vs. 1.8%, p less than 0.001). Playroom use was not significantly different in the two groups. A total of 64 patients developed diarrhea within 72 hours of admission (community diarrhea rate = 4.2). Nosocomial viral-associated diarrhea is almost exclusively a disease of diapered children less than age 36 months and occurs at any time during hospital stay. It is more common in multibed rooms, but does occur in single-bed rooms.

Isolation usage in a pediatric hospital.

In a prospective 12-month study at a university-affiliated pediatric hospital, isolation usage was quantitated by ward/service, season, isolation category and type of infection (community-acquired vs nosocomial). Such information may be helpful in designing hospitals, recognizing time utilization of the pediatric infection control nurse, and defining educational and isolation needs. Hospitals with multiple bed rooms and inadequate numbers of single rooms may be unable to meet current federal isolation guidelines. The mean number of isolation days was 153 per 1000 patient days or 15.3% of bed days used. This ranged from 18.5% on the infant/toddler/preschool medical ward to 2.8% on child/teenage orthopedic surgery. Isolation requirements vary seasonally and rose to 32% in winter on one ward. Proportional frequencies of isolation category included enteric--29%, protective--28%, strict--16%, barrier (contact)--10%, multiply resistant organism (MRO)--8%, wound--5%, pregnant women (careful handwashing)--3%, blood and body fluid precautions--1%. Isolation of patients with and contacts of nosocomial infections account for 32% of isolation usage. During one third of the 365-day year, the hospital is unable to provide adequate numbers of single rooms for one to 20 patients.

Assessment of a new device (aerochamber) for use with aerosol drugs in asthmatic children.

We compared the pulmonary response to fenoterol delivered by a conventional MDI with the response after MDI plus the aerochamber (AC). Twelve children with moderate to severe asthma (mean age 10.8 years) participated in this double-blind crossover study. On two consecutive days, in random order, subjects received one puff of fenoterol hydrobromide (200 mcg) either by MDI or MDI plus AC. Pulmonary function, cardiovascular response and tremor were assessed over a period of four hours. In a similar fashion, the children received one puff of fenoterol three times a day for six weeks by either method in a randomized open study. Daily symptoms and peak flows before and after drug were recorded in daily diaries. The patients returned to the pulmonary function laboratory at 6 and 12 weeks for four hour pulmonary function tests. In the short-term study, the magnitude and time course of pulmonary response was similar for both treatment regimens (p greater than 0.4). No significant effects on blood pressure or pulse or differences in tremor assessment were seen. Similarly, in the long term study the baseline pulmonary function and pulmonary response were markedly consistent between the two treatment regimens (p greater than 0.05). Peak flows were significantly higher in the evening than in the morning (p less than 0.001) and the magnitude of the response to drug was higher in the morning than the evening (p less than 0.001). There were no differences between MDI and MDI plus AC in daily symptom scores or use of concomitant medication. We conclude that acute or chronic administration of fenoterol aerosol to asthmatic children by MDI with or without the AC produces similar benefits in pulmonary function, symptomatology and concomitant medication. The AC device would be a useful adjunct for a child who has difficulty in coordinating the metered dose inhaler.

Dose-response characteristics of nebulized fenoterol in asthmatic children.

Fenoterol hydrobromide, a beta 2-selective bronchodilator, was administered by aqueous nebulization to 31 children with stable asthma. An initial comparison of 0, 100, 300, and 1000 micrograms drug in 20 of these patients showed a significant change in forced expiratory volume in 1 second for all three doses compared with change after placebo (P less than 0.0001). However, the differences in peak pulmonary response from 100 to 1000 micrograms were not large (P greater than 0.2). Assessment of spirometric responses of 11 children to 3, 10, 30, or 100 micrograms nebulized fenoterol clearly revealed the dose-response effect (P less than 0.01). When all the FEV1 data were plotted over the entire range of 3 to 1000 micrograms, the resultant log dose vs response curve could be characterized by the ED50, the amount of drug producing half-maximal response. At 15, 30, or 60 minutes, the ED50 was in the range 8 to 10 micrograms. With increasing time there was a parallel shift of the entire dose response curve to the right, manifested by ED50 of 47 and 150 micrograms at two and three hours, respectively, after administration. This decreasing potency of a sympathomimetic drug with time shows that duration of effect and dosage are interdependent variables and must be evaluated simultaneously. Such considerations cannot be derived from cumulative dose-response studies. In our patients, 100 to 300 micrograms fenoterol delivered by aqueous nebulization achieved optimal bronchodilation with no detectable cardiovascular side effects.

Nosocomial infections in a pediatric intensive care unit.

In a prospective 30-month study of nosocomial infections in a pediatric ICU (PICU), the incidence, sites, and causes of infection were determined. Factors associated with increased risk of infection were investigated. In 1,388 patients who remained in the PICU for a minimum of 72 h, 116 infections occurred (6.1 infections/100 admissions). Primary bacteremias comprised 38% of PICU infections and lower respiratory infections comprised 15%. The remaining infections were divided equally among GI, skin, eye, upper respiratory, postoperative wounds, and other sites. Coagulase-negative staphylococci, Pseudomonas aeruginosa, and Staphylococcus aureus were the most prevalent pathogens. Surgical patients had similar rates of infection to medical patients. Patients in the first 2 yr of life, particularly those between 7 and 30 days of age, had the highest rate of infection. Onset of infection was more common after the first week in the PICU with 11% of patients staying 14 to 20 days, 27% of patients staying 21 to 27 days, 48% of patients staying 28 to 34 days, and 52% of patients staying more than 35 days before the onset of infection. The risk of nosocomial infection increases with arterial and central line use, prolonged intubation, ventilation, intracranial pressure monitoring, and paralysis.

Pathophysiology of the ciliary motility syndromes.

The ciliary motility syndromes are characterised by specific and genetically determined defects of cilia with resulting impairment of mucociliary defense mechanisms in the respiratory tract. The ciliary pathobiology, clinical observations, serial pulmonary function and chest radiographs are reviewed and correlated for a series of 33 patients with the ciliary motility syndromes, aged from 0.5 to 75 years. The clinical course and progressive nature of this disease emphasizes the importance of early and accurate diagnosis to prevent irreversible pulmonary damage.