1289CHAPTER 109 Healthcare Associated Infections complicated, determining whether the BSI is a CRBSI may be a valuable diagnostic step 47–50 Empiric antimicrobial therapy should be initiated based on[.]
CHAPTER 109 Healthcare-Associated Infections complicated, determining whether the BSI is a CRBSI may be a valuable diagnostic step.47–50 Empiric antimicrobial therapy should be initiated based on local antibiograms and patient considerations, with particular attention to high-risk characteristics such as neutropenia, bone marrow transplantation, dependence on total parenteral nutrition, or prolonged antibiotic use.50 The decision to remove a CVC is guided by multiple factors, including the infecting organism and CVC type given that the relapse risk differs and given the ongoing necessity of the CVC, prior difficulties obtaining vascular access, and potential risks of line replacement If the CVC is no longer needed or can be removed without compromising the patient’s care, it should be removed promptly for source control Reinsertion of a new CVC should be delayed until blood cultures are negative, a minimum of 48 hours When the CVC needs to be salvaged, antibiotic locks should be used in addition to systemic therapy.50 Hospital-Acquired Lower Respiratory Tract Infections (LRTIs) Viral Lower Respiratory Tract Infections Viral respiratory infections are one of the most common reasons that children require admission to the hospital.59 Every winter, pediatric wards in acute care hospitals, as well as freestanding children’s hospitals, are inundated with children suffering from lower respiratory tract infections (LRTIs), primarily due to viruses such as respiratory syncytial virus (RSV), influenza virus, and rhinovirus (see Chapter 108) Fortunately, a targeted approach to infection prevention using the methods described earlier—including handwashing, PPE, and visitor restrictions—are effective in reducing the incidence of healthcare-associated LRTIs.60–63 For example, one study estimated that every dollar invested in a targeted infection control program saved approximately six dollars due to the reduction in healthcare-associated RSV infections.61 Surprisingly, however, the data on healthcare-associated LRTIs due to these common viruses in the PICU setting is limited Most studies suggest that children who develop respiratory viral LRTIs after admission to the PICU (i.e., healthcare-associated) have a higher risk of morbidity (increased duration of mechanical ventilation and LOS) and mortality compared with children with community-acquired respiratory viral LRTIs, even after adjusting for the presence of chronic diseases.64–66 Given these results, it is likely that targeted infection control efforts in the PICU will have an even greater impact on improving outcomes and reducing the costs of care A hospital’s overall VAP rate was previously used as a quality metric for interhospital benchmarking However, the VAP definition used at the time was problematic for several reasons It lacked acceptable sensitivity and specificity70–74 and was difficult to apply in critically ill children admitted to the PICU.69 Critically ill patients who failed to meet specific criteria for diagnosing VAP were often diagnosed with ventilator-associated tracheobronchitis (VAT) instead This was usually owing to the lack of infiltrate on chest radiography or the inability to distinguish chest radiograph findings of pneumonia in patients with acute respiratory distress syndrome Several investigators have suggested that VAT is associated with longer durations of mechanical ventilation and ICU LOS in both critically ill children75–78 and adults.79–82 Importantly, the pathogens causing VAP and VAT were strikingly similar Studies performed in adults suggested that nearly one-third of patients with VAT eventually developed criteria consistent with VAP.81,83 Collectively, these findings suggest that VAT was likely a precursor for VAP and both infections may occur along a continuum, adding further confusion Finally, several studies showed that the clinical VAP definition failed to correlate with histopathologic findings of pneumonia.84,85 There have been multiple attempts to develop consensus-based definitions for ventilator-associated respiratory infections with the appropriate specificity, sensitivity, and validity All of these definitions have flaws Over time, healthcare-associated LRTIs in critically ill patients on invasive mechanical ventilation have been known as VAP, VARI,86 and, most recently, ventilator-associated conditions (VACs) and infection-related VACs (iVACs),87 and the more global conditions known as ventilator-associated events (VAEs; Table 109.5).88,89 Relatively few studies have used the newly proposed VAE definitions in critically ill children, and the initial experience suggests these newer definitions remain difficult to apply and are far from clear.89–92 For now, the data are sufficiently ambiguous regarding the diagnosis of VAP-like conditions Accordingly, bedside clinicians must use their best clinical judgment, in collaboration with infection control practitioners as TABLE Changing Definitions for Ventilator-Associated 109.5 Pneumonia and Related Conditions Condition Definition Ventilator-associated condition (VAC) 2 calendar days of stable or decreasing daily minimum PEEP or Fio2, followed by rise in PEEP 3 cm H2O or rise in Fio2 20 points sustained for 2 days Infection-related VAC VAC plus temperature 38°C or ,36°C or leukocytosis or leukopenia and one or more new antibiotics continued for 4 days within days before or after VAC onset excluding the first days of mechanical ventilation Possible pneumonia IVAC plus sputum/BAL with 25 neutrophils/ field or positive culture for pathogenic organism Probable pneumonia IVAC plus sputum/BAL with 25 neutrophils/ field and positive quantitative/semiquantitative culture for pathogenic organism Ventilator-Associated Pneumonia As discussed previously, critically ill children who are tracheally intubated and mechanically ventilated are at significant risk of developing healthcare-associated LRTIs These HAIs are generally known as ventilator-associated respiratory infections (VARIs) or VAPs and are the second most common pediatric HAI after bloodstream infections.9,11,17 VAPs account for up to 20% of HAIs in certain pediatric series.67 More importantly, the empiric treatment of presumed VAP cases with broad-spectrum antibiotics accounts for nearly 50% of PICU antibiotic utilization.68 Unfortunately, there is no diagnostic gold standard for VAP, especially in critically ill children.69 The pathogenesis of VAP is not entirely clear, though these infections most likely arise as a result of microaspiration of bacteria from the mouth and nasopharynx Environmental contamination, facilitated by periodic disconnections from the ventilator circuit, via the endotracheal tube as the subsequent portal of entry, is another potential cause of VAP.67 1289 BAL, Bronchoalveolar lavage; Fio2, fraction of inspired oxygen; H2O, ***; PEEP, positive endexpiratory pressure 1290 S E C T I O N X I Pediatric Critical Care: Immunity and Infection needed, when deciding on the need to treat critically ill children with presumed VAP.93 Given all of these issues, it seems that the adage “an ounce of prevention is worth a pound of cure” certainly applies to VAP VAP prevention would obviate the need to decide whether to initiate broad-spectrum antibiotic treatment Several early studies in adults suggested that implementation of a “VAP bundle” significantly reduced VAP and led to improved outcomes and lower hospital costs Importantly, the earliest VAP bundles incorporated four main elements: peptic ulcer disease prophylaxis, deep venous thrombosis (DVT) prophylaxis, head of the bed (HOB) elevation to 30 degrees, and use of so-called “sedation holidays.”94 Arguably, at least two of these elements (peptic ulcer disease prophylaxis and DVT prophylaxis) addressed other healthcare-acquired conditions different from VAP Regardless, widespread implementation of the adult VAP bundle did, in fact, reduce VAP.94–96 Based on this initial experience, a pediatric-focused VAP bundle was developed focusing on the major elements shown in Table 109.4 (mouth care, draining condensation from the ventilator circuit, changing circuits only when visibly soiled, and elevating the HOB to 30 degrees) Use of this pediatric-specific VAP bundle decreased VAP rates at a major tertiary children’s hospital from 7.8 cases per 1000 ventilator days to 0.5 cases per 1000 ventilator days, reducing hospital days by 400 days and total hospital costs by $2.3 million.97,98 Even though the definitions of VARIs have changed over time, the key bundle elements that have been recommended to reduce the incidence and consequence of these infections have remained remarkably similar (see Table 109.4).99 Urinary Tract Infections UTIs are one of the most common nosocomial infections in children, including among those in critical care units.9,100,101 The vast majority of hospital-acquired UTIs, 70% to 80%, are CAUTIs, occurring in the presence of an indwelling bladder catheter.102 Once an indwelling urethral catheter is inserted, the incidence of bacteriuria is approximately 3% to 7% per day.102,103 Bacteriuria alone is not sufficient to diagnose a CAUTI Per NHSN criteria, each of the following three elements must be present46: An indwelling urinary catheter in place for more than consecutive calendar days at the time of infection and in place on the event date or day before; At least one of the following symptoms: fever 38°C or higher, suprapubic tenderness, costovertebral angle pain/tenderness, or if catheter has been removed, urinary urgency or frequency, or dysuria Urine culture growing no more than two organisms, at least one being a bacterium with 105 or more CFU/mL For CAUTI surveillance and reporting purposes, it is important to note that an indwelling catheter is defined as one that drains the bladder via the urethra, remains in place for some period of time—for example, overnight—and connects to a drainage system.46 In the 1990s, before reporting requirements and widespread prevention efforts, the incidence of CAUTI was quite high, with a PICU rate from 65 hospitals reporting data at the time of 5.2 CAUTIs per 1000 catheter days CAUTI rates ranged from 3.3 in adult cardiac patients to 10.1 in burn units.100 The Centers for Medicare and Medicaid Services’ Quality Reporting Programs have required the reporting of CAUTI data from US PICUs since January 2012 By 2013, the PICU rate was significantly improved, with a pooled rated of 2.5 CAUTIs per 1000 catheter days based on data from 297 institutions reporting to the NHSN.104 Data is sparse regarding pediatric-specific morbidity and mortality directly attributable to CAUTI In a single-center, retrospective, case-matched study on the impact of CAUTI in critically ill children, Samraj and colleagues found a statistically significant mortality difference between the CAUTI and control groups Seven of 41 (17%) patients died in the CAUTI group compared with of 73 (5%) in the control group (P 04).101 Hospital and PICU duration of stay, duration of mechanical ventilation, and total hospital charges were each significantly greater in the CAUTI group as well.101 Obviously, the greatest risk for developing a CAUTI is an indwelling bladder catheter, followed closely by the duration of catheterization.100–103 Other risk factors include female sex, breaks in the closed collecting system, and lapses in catheter and hygiene care.100,102,103 An indwelling catheter provides direct access to the bladder for pathogens; if aseptic insertion practices are not adhered to, bacteria from the patient’s own microbiome may potentially inoculate the bladder.103 The common CAUTI pathogens include E coli, Pseudomonas, Klebsiella, Enterococcus, Proteus, Serratia, and Candida,101,103 although Candida is no longer included in the list of organisms that meet the UTI or CAUTI definition per 2015 NHSH criteria.105 Successful CAUTI prevention programs use multimodal strategies consisting of care bundles for insertion and maintenance; outcome and process surveillance; feedback to staff about events; unit-level data, including infection control practices; and cultivating a climate of safety, that is, culture change.106 Key insertion and maintenance bundle elements for indwelling catheters are included in Table 109.4 Prevention is driven primarily by avoiding use of unnecessary indwelling catheters and minimizing the duration of those placed.100,102,103 This may be achieved by restrictive indications for insertion at the institutional or unit level,100,102 daily review of necessity,102,103 and protocol or nurse-driven removal at 48 to 72 hours.100,102 Intermittent catheterization should be considered as an alternative to indwelling catheterization.103 Guidelines not recommend systemic prophylactic antimicrobials, routine catheter changes, antimicrobial-impregnated catheters or catheters made from special materials, bladder irrigation, or screening catheterized patients for asymptomatic bacteriuria as part of a routine CAUTI prevention strategy.102 When a CAUTI is diagnosed, the indwelling catheter should be removed immediately if possible Once inserted, catheters develop a biofilm, usually migrating to the bladder within to days,103 to which microorganisms can adhere and are unlikely to clear with antimicrobial therapy.107 If a clinical indication for the catheter remains, it should be removed and a new one inserted.103 Alternatively, intermittent catheterization should be considered Empiric antimicrobial treatment should cover common pathogens and then be tailored to the identified organism(s) and sensitivities The usual duration of therapy is days, but this may be adjusted based on the patient’s clinical condition, response, and the organism/sensitivities.103 Asymptomatic bacteriuria should be treated only in catheterized patients undergoing invasive urologic procedures.102 Surgical Site Infections While SSIs account for nearly one-third of all HAIs in hospitalized adults,1 they account for significantly fewer HAIs in hospitalized children9,12,13,108 and are the least common HAI in the PICU Neurosurgical (see especially the section on ventriculostomy CHAPTER 109 Healthcare-Associated Infections infections to follow), cardiothoracic, and spinal fusion surgeries appear to have the highest SSI rates in children.109,110 Staphylococci are by far the most common pathogens causing SSIs in these procedures.110 Like the more common HAIs discussed previously, SSIs account for significant morbidity and mortality, with one hospital estimating that each individual SSI increased hospital LOS by almost 11 days and costs by nearly $30,000.111 Here again, up to 50% of these infections are likely preventable6 when evidence-based prevention bundles are implemented, to include preoperative bathing, intraoperative skin antisepsis, and timely administration of prophylactic antibiotics (see Table 109.4).109,111–113 Ventriculostomy-Related Infections External ventricular drains (EVDs) are common devices found in the PICU They are clinically indicated in the management of obstructive hydrocephalus, intracranial hemorrhage, and intracranial hypertension, often associated with traumatic brain injury.114,115 The most frequent complications of EVDs are infection and hemorrhage.116 It is difficult to quantify the incidence of EVD-associated infections given that the infection definition for meningitis or ventriculitis varied significantly between studies cited in the literature.115 However, the most commonly cited studies report rates ranging from 0% to 22%, and a meta-analysis of 35 studies, the majority of which enrolled adult patients, had a pooled incidence rate of 11.4 infections per 1000 catheter days.115,117 Risk factors associated with EVD-associated infection include the duration that the EVD remains in place, frequent sampling of cerebrospinal fluid (CSF), intraventricular or subarachnoid hemorrhage, and CSF leak.118,119 The literature is sparse regarding the prevention of EVDassociated infections, especially so in pediatric patients Based on the earlier discussion, removing an EVD as soon as the clinical indication for insertion is resolved and avoiding CSF sampling in absence of a clinical indication should decrease infection risk The Neurocritical Care Society recently published a consensus statement for adults, which may offer additional guidance for pediatric patients (Table 109.6).120 Selected Recommendations Specific to External TABLE 109.6 Ventricular Drain–Associated Infection Risk and Prevention Recommendations Notes • Remove the EVD early, when no longer clinically indicated • A single dose of antibiotic should be administered prior to EVD insertion • Antimicrobials for the duration of an EVD is not recommended • Use antimicrobial-impregnated catheters • Avoid routine changes of EVD sites • Maintain a closed drainage system; keep manipulations to a minimum • Risk of infection is associated with duration of catheter placement • Due to the risk for resistant organisms and/or hospital- acquired diarrhea • Avoid routine/surveillance CSF sampling CSF, Cerebral spinal fluid; EVD, external ventricular drain 1291 Healthcare-Associated Diarrhea Clostridioides (formerly Clostridium) difficile infection (CDI) causes a spectrum of disease in hospitalized children, from diarrhea to fulminant colitis.121–123 This gram-positive bacillus is commonly implicated in antibiotic-associated and nosocomial diarrhea and can be life-threatening in severe cases The incidence of CDI has increased, particularly in children younger than years.123–125 Children younger than years are often asymptomatic carriers and may be reservoirs for transmission of infection to others.121 The greatest risk factor for CDI among hospitalized pediatric patients is a comorbid disease, specifically inflammatory bowel disease, solid-organ or hematopoietic stem cell transplant, human immunodeficiency virus, or malignancy.123–125 Additionally, environmental exposure or cross-transmission, frequent antibiotic exposures, and the use of proton pump inhibitors (PPIs) have been associated with CDI.87,123–127 Because of the high prevalence of colonization, CDI testing is not recommended for infants 12 months or younger, and recommended for children to years of age only when other causes have been excluded.121,125,128 In older children, testing is recommended for patients with prolonged or worsening diarrhea and the comorbid conditions listed earlier.128 As with other HAIs, CDI is associated with increased LOS and hospital charges.124 Viral etiologies of hospital-acquired diarrhea—notably, rotavirus, norovirus, and adenovirus—have been implicated in ICU outbreaks Immunocompromised children are particularly susceptible and may also have prolonged viral shedding, a risk factor for crosscontamination if gaps in isolation practices are present.129–132 Meticulous hand hygiene and adherence to isolation practices remain the most important interventions to prevent hospital-acquired diarrhea These were addressed earlier in this chapter but worth reiterating Uniquely for patients with CDI, hand hygiene with soap and water is imperative as alcohol-based disinfection will not neutralize spore-forming pathogens such as C difficile.133 Limiting exposure to and minimizing antimicrobials may reduce CDI risk; when feasible, an antibiotic stewardship program may be beneficial in operationalizing this practice Additionally, using PPIs only when indicated may help reduce CDI risk.87,123,126,128,134 Vaccination against rotavirus has been protective against hospitalacquired infection in addition to dramatically decreasing communityacquired disease.129,135 Treatment of diarrheal illness in a critical care setting is mostly supportive and tailored to the severity of illness, volume of stool losses, impact on hemodynamics and electrolytes, and so on Specific antimicrobial treatment is indicated for CDI and is guided by severity of disease The most up-to-date recommendations should be reviewed when initiating therapy However, initial nonsevere episodes may be treated with 10 days of either enteral metronidazole or vancomycin Severe disease is treated with oral vancomycin; fulminant disease characterized by hypotension, shock, toxic megacolon or ileus is treated with maximal doses of oral vancomycin plus intravenous metronidazole and, if the oral route is not tolerated, rectal vancomycin by retention enema.128 Key References Adams SM, Ngo L, Morphew T, Babbitt CJ Does an antimicrobial timeout impact the duration of therapy of antimicrobials in the PICU? Pediatr Crit Care Med 2019;20(6):560-567 Centers for Disease Control and Prevention Core infection prevention and control practices for safe healthcare delivery in all settings 1292 S E C T I O N X I Pediatric Critical Care: Immunity and Infection Recommendations of the Healthcare Infection Control Practices Advisory Committee 2017 Available at: https://www.cdc.gov/ hicpac/pdf/core-practices.pdf Hooton TM, Bradley SF, Cardenas DD, et al Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Clin Infect Dis 2010;50(5):625-663 Ista E, van der Hoven B, Kornelisse RF, et al Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis Lancet Infect Dis 2016;16(6):724-734 Lo E, Nicolle LE, Coffin SE, et al Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update Infect Control Hosp Epidemiol 2014;35(5):464-479 National Healthcare Safety Network (NHSN) Patient Safety Component Manual Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/ pcsmanual_current.pdf Patrick SW, Kawai AT, Kleinman K, et al Health care-associated infections among critically ill children in the US, 2007-2012 Pediatrics 2014;134(4):705-712 Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings Am J Infect Control 2007;35(10 suppl 2):S65-S164 Zingg W, Hopkins S, Gayet-Ageron A, et al 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 Lancet Infect Dis 2017; 17(4):381-389 The full reference list for this chapter is available at ExpertConsult.com e1 References Klevens RM, Edwards JR, Richards CLJ, et al Estimating health care-associated infections and deaths in U.S hospitals, 2002 Public Health Rep 2007;122:160-166 Kung HC, Hoyert DL, Xu J, Murphy SL Deaths: Final data for 2005 Natl Vital Stat Rep 2008;56:1-120 Anton Y, Peleg MB, Hooper DC Hospital-acquired infections due to gram-negative bacteria N Engl J Med 2010;362:1804-1813 Stone PW, Hedblom EC, Murphy DM, Miller SB The economic impact of infection control: Making the business case for increased infection control resources Am J Infect Control 2005;33:542-547 Yokoe DS, Mermel LA, Anderson DJ, et al A compendium of strategies to prevent healthcare-associated infections in acute care hospitals Infect Control Hosp Epidemiol 2008;(29 suppl 1):S12-S21 Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs Infect Control Hosp Epidemiol 2011;32:101-114 Asanathong NW, Rongrungreung Y, Assanasen S, et al Epidemiology and trends of important pediatric healthcare-associated infections at Siriraj Hospital, Thailand Southeast Asian J Trop Med Public Health 2017;48:641-654 Esteban E, Ferrer R, Urrea M, et al The impact of a quality improvement intervention to reduce nosocomial infections in a PICU Pediatr Crit Care Med 2013;14(5):525-532 Patrick SW, Kawai AT, Kleinman K, et al Health care-associated infections among critically ill children in the US, 2007-2012 Pediatrics 2014;134(4):705-712 10 Rutledge-Taylor K, Matlow A, Gravel D, et al A point prevalence survey of health care-associated infections in Canadian pediatric inpatients Am J Infect Control 2012;40(6):491-496 11 Zingg W, Hopkins S, Gayet-Ageron A, et al 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 Lancet Infect Dis 2017;17(4):381-389 12 Stover BH, Shulman ST, Bratcher DF, et al Nosocomial infection rates in US children’s hospitals’ neonatal and pediatric intensive care units Am J Infect Control 2001;29(3):152-157 13 Stockwell JA Nosocomial infections in the pediatric intensive care unit: affecting the impact on safety and outcome Pediatr Crit Care Med 2007;8(2 suppl):S21-S37 14 Rosenthal VD, Al-Abdely HM, El-Kholy AA, et al International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module Am J Infect Control 2016;44(12):1495-1504 15 Richards MJ, Edwards JR, Culver DH, Gaynes RP Nosocomial infections in pediatric intensive care units in the United States National Nosocomial Infections Surveillance System Pediatrics 1999;103(4):e39 16 Grohskopf LA, Sinkowitz-Cochran RL, Garrett DO, et al A national point-prevalence survey of pediatric intensive care unitacquired infections in the United States J Pediatr 2002;140(4): 432-438 17 Gravel D, Matlow A, Ofner-Agostini M, et al A point prevalence survey of health care-associated infections in pediatric populations in major Canadian acute care hospitals Am J Infect Control 2007; 35(3):157-162 18 Weiner LM, Webb AK, Limbago B, et al Antimicrobial-Resistant Pathogens Associated With Healthcare-Associated Infections: Summary of Data Reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2011-2014 Infect Control Hosp Epidemiol 2016;37(11):1288-1301 19 Allegranzi B, Nejad SB, Castillejos GG, et al Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care Geneva, Switzerland: World Health Organization; 2011 20 Rosenthal VD, Jarvis WR, Jamulitrat S, et al Socioeconomic impact on device-associated infections in pediatric intensive care units of 16 limited-resource countries: International Nosocomial Infection Control Consortium findings Pediatr Crit Care Med 2012;13(4):399-406 21 Dramowski A, Whitelaw A, Cotton MF Burden, spectrum, and impact of healthcare-associated infection at a South African children’s hospital J Hosp Infect 2016;94(4):364-372 22 Gupta A, Kapil A, Lodha R, et al Burden of healthcare-associated infections in a paediatric intensive care unit of a developing country: a single centre experience using active surveillance J Hosp Infect 2011;78(4):323-326 23 de Mello MJ, de Albuquerque Mde F, Lacerda HR, Barbosa MT, de Alencar Ximenes RA Risk factors for healthcare-associated infection in a pediatric intensive care unit Pediatr Crit Care Med 2010;11(2): 246-252 24 Gilio AE, Stape A, Pereira CR, Cardoso MF, Silva CV, Troster EJ Risk factors for nosocomial infections in a critically ill pediatric population: a 25-month prospective cohort study Infect Control Hosp Epidemiol 2000;21(5):340-342 25 Singh-Naz N, Sprague BM, Patel KM, Pollack MM Risk factors for nosocomial infection in critically ill children: a prospective cohort study Crit Care Med 1996;24(5):875-878 26 Carcillo JA, Dean JM, Holubkov R, et al Inherent risk factors for nosocomial infection in the long stay critically ill child without known baseline immunocompromise: A post hoc analysis of the CRISIS trial Pediatr Infect Dis J 2016;35(11):1182-1186 27 Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory C 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings Am J Infect Control 2007;35(10 suppl 2):S65-S164 28 Centers for Disease Control and Prevention Core infection prevention and control practices for safe healthcare delivery in all settings Recommendations of the Healthcare Infection Control Practices Advisory Committee 2017 Available at: https://www.cdc.gov/ hicpac/pdf/core-practices.pdf 29 Smulders CA, van Gestel JP, Bos AP Are central line bundles and ventilator bundles effective in critically ill neonates and children? Intensive Care Med 2013;39(8):1352-1358 30 Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann D, Stone PW Central line bundle implementation in US intensive care units and impact on bloodstream infections PLoS One 2011;6(1): e15452 31 Cheema AA, Scott AM, Shambaugh KJ, et al Rebound in ventilatorassociated pneumonia rates during a prevention checklist washout period BMJ Qual Saf 2011;20:811-817 32 Miller MR, Niedner MF, Huskins WC, et al Reducing PICU central line-associated bloodstream infections: 3-year results Pediatrics 2011;128(5):e1077-e1083 33 Allegranzi B, Conway L, Larson E, Pittet D Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities Am J Infect Control 2014;42(3):224-230 34 Munjal I, Litman N Isolation precautions Pediatr Rev 2010;31(12): 525-527 35 Folgori L, Bernaschi P, Piga S, et al Healthcare-associated infections in pediatric and neonatal intensive care units: impact of underlying risk factors and antimicrobial resistance on 30-day Case-Fatality in Italy and Brazil Infect Control Hosp Epidemiol 2016;37(11): 1302-1309 36 Lake JG, Weiner LM, Milstone AM, Saiman L, Magill SS, See I Pathogen distribution and antimicrobial resistance among pediatric healthcare-associated infections reported to the national healthcare safety network, 2011-2014 Infect Control Hosp Epidemiol 2018; 39(1):1-11 37 Fontela PS, Quach C, Karim ME, et al Determinants of antibiotic tailoring in pediatric intensive care: a national survey Pediatr Crit Care Med 2017;18(9):e395-e405 38 Araujo da Silva AR, Albernaz de Almeida Dias DC, Marques AF, et al Role of antimicrobial stewardship programmes in children: a systematic review J Hosp Infect 2018;99(2):117-123 ... Regardless, widespread implementation of the adult VAP bundle did, in fact, reduce VAP.94–96 Based on this initial experience, a pediatric-focused VAP bundle was developed focusing on the major elements... circuit, changing circuits only when visibly soiled, and elevating the HOB to 30 degrees) Use of this pediatric-specific VAP bundle decreased VAP rates at a major tertiary children’s hospital from... use of unnecessary indwelling catheters and minimizing the duration of those placed.100,102,103 This may be achieved by restrictive indications for insertion at the institutional or unit level,100,102