Where did all the pediatric HAIs go?

In keeping with the pediatric theme this week, there is a nice study just published in Pediatrics outlining the general trends in Pediatric HAIs between 2007 and 2012. Stephen Patrick and colleagues from Vanderbilt and Boston Children's Hospital used CDC NHSN data from 173 NICUs and 64 PICUs to track CLABSI, VAP and CAUTI rates.

The good news is that CLABSIs declined from 4.9 to 1.5 per 1000 central-line days in the NICU and from 4.7 to 1.0 per 1000 CL-days in the PICU. There were also significant reductions seen in VAP in both NICUs and PICUs. CAUTIs were not adequately reported in NICUs; however, in PICUs the authors found that CAUTI rates did not change significantly over the 6-year study period. I've included the NICU and PICU figures below. Importantly,  CLABSI rates were twice as high and VAP rates were over three times as high in very low birth weight ( < 1500g) infants.

Apart from highlighting recent successes in reducing HAI, I think the main messages (as I've already stated elsewhere) are that HAI are still very common in VLBW infants and that rates remain above zero in all pediatric populations. Thus, despite cultural changes, implementation of insertion bundles and technological innovations, such as antimicrobial-coated catheters, we still need additional evidence-based methods to prevent HAI in children. While we might take this occasion to rest on our laurels and celebrate past successes, we should instead increase funding for development of HAI prevention interventions, particularly in VLBW populations.

And while policymakers might think we can mandate further HAI reductions through such things pay-for-performance, it is clear from these data that those tools have already done their job yet there's much more hard work to do. Notice the almost flat rates in both figures over the past 3-4 years. We need more than quality-improvement goals. Without scientifically proven methods to further reduce HAI, I suspect rates will remain stagnant. That would be unfortunate.

Love The Glove

It's pretty easy to hate on gloves. They're certainly annoying to put on and wear. Yet, much of what we do in medicine is difficult yet worth it, if what we do is effective. Now if we really could get hand hygiene compliance beyond 90%, I think a narrow focus on hand rub utilization would be OK. But, irrespective of what facilities are reporting, when you really look, their compliance is closer to 50% (if they're lucky). That's why I continue to (a) encourage investment in hand hygiene research and (b) recommend glove use in our infection control bundles.

In a recent JAMA Pediatrics, David Kauffman and colleagues reported the results of a single-center RCT comparing mandatory glove use before all patient and IV catheter contacts vs hand hygiene alone. The study took place in the NICU during 2008-2011 and was funded by University of Virginia and Cardinal Health Foundation. The 120 enrolled infants (60 in each arm) needed to weigh less than 1000 g and/or have a gestational age less than 29 weeks and age less than 8 days old. The primary outcomes were infection in the bloodstream, urinary tract, or cerebrospinal fluid or necrotizing enterocolitis.  Randomization was fairly effective; however, the glove use arm neonates were more likely to have a central line, require mechanical ventilation and receive TPN.

Their were several significant difference between the outcomes in the two groups. Neonates in the glove-use arm had lower rates of late-onset invasive infection or necrotizing enterocolitis (32% vs 45%, p=0.13), fewer Gram-positive BSIs (15% vs 32%, p=0.03) and fewer CLABSI (3.4 vs 9.4/1000 catheter days, p=0.01).  Frankly, with such a small study, I'm surprised they found any significant differences. What would I recommend after reading this study? I would recommend (a) NIH/AHRQ/PCORI fund a follow-up multicenter study to validate these findings and (b) in the meantime, wear gloves when caring for pediatric patients based on this study and our earlier study in Pediatrics.

Give Gloves a Chance: Benefits of Mandatory Gloving Policy in Pediatrics

We spend a lot of time discussing the importance of clean hands in preventing hospital-acquired infections (HAIs). Most of the time we equate clean hands with hand-hygiene compliance and complicated and fleeting surveillance and educational programs. It would be one thing if these efforts led to compliance levels above 90%, but even the Joint Commission could barely get compliance above 80% after massive efforts.

Which leads me to one question - are we asking the wrong question?

Instead of focusing solely on driving hand hygiene compliance above 90%, perhaps we should focus on clean hands. If we ask a new question: "What do we need to do at our hospital to get healthcare worker hands to be 90% clean?", we get very different answers than if we focus solely on increasing hand rub use. For example, we could begin studying long-acting hand disinfection products that work all day or environmental cleaning products that keep hands clean in the first place. And another thing we could consider looking at is the benefits of the humble examination glove. We just published a study in Pediatrics, led by Jun Yin a PhD student in statistics, that aimed to do just that.

At the University of Iowa, we have a policy that mandates that healthcare workers wear gloves for all patient contacts during RSV season. We wanted to see if we could take advantage of this natural experiment to see what happened to HAI infection rates during the mandatory gloving periods compared to non-gloving periods.  To do that we completed a quasi-experimental study using time series analysis (Poisson regression models) on data from 2002-2010. We studied the effect in 5 units including a 20-bed PICU, a 62-bed NICU, a 5-bed Pediatric Bone Marrow Transplant Unit, a 26-bed Pediatric Hematology-Oncology Special Care Unit, and a 35-bed Pediatric Medical/Surgical Mixed Acuity Unit.

What did we find? Universal gloving periods were associated with a 25% reduction in HAI rates after adjusting for long term trends and seasonal effects. There was a 37% reduction in bloodstream infections (BSIs), a 39% reductions in central line-association BSIs and an 80% reduction in hospital-acquired pneumonias. The reductions were statistically significant in the PICU, NICU and Bone-Marrow Transplant Unit.

Yes, this unfunded study has limitations. It's a non-randomized, single center study. There could have been other factors that started just when RSV season started every year along with the gloving policy (although we couldn't think of any). Since this intervention was turned on and off every year for 9 years (with an exemption in 2009 for the novel H1N1 pandemic), it's unlikely there were other interventions that biased these results every year at the exact same time. 

Perhaps we need further study and cluster-randomized trails. We won't have to wait long. There is an important AHRQ-funded study that Anthony Harris's group is just completing at the University of Maryland that looks at the benefits of mandatory glove+gown policies in ICUs. However, this study won't tell us if it's the gowns or gloves or if they work in Pediatrics. So what do we do in the interim while waiting for future trials and magical interventions that get hand hygiene compliance above 90%?  All we are saying is "Give Gloves a Chance."

Reference: Yin J et al. Pediatrics April 22, 2013

Image: wikipedia

Media coverage: Reuters Health and Wired (Superbug)