Background: Infections caused by antibiotic-resistant organisms are a significant healthcare burden for hospitalized children, especially for those who are critically ill. Previous studies on antibiotic-resistant organisms in pediatrics have been largely limited to either a description of specific pathogens or focused on colonization. Children in pediatric long-term care (LTC) have multiple comorbidities, high acuity, and frequent antibiotic treatment, which may increase their risk for infection with antibiotic-resistant organisms - particularly when they are transferred to acute care. Previous research has characterized the high incidence of infections and the ubiquitous prescribing of antibiotic agents in pediatric LTC residents. However, few, if any, studies have characterized antibiotic resistance in this unique pediatric population. Therefore, we sought to determine the relationship between admission from a pediatric LTC facility and subsequent infection with an antibiotic-resistant organism.
Methods: We conducted a retrospective cohort study of all patients ≤18 years admitted to four New York metropolitan area hospitals from 1/1/2006 through 12/31/16. Data were collected from the electronic medical record pertaining to demographic (e.g., age, sex, and admission source), clinical (e.g., infection type, invasive device use, antibiotic use, and length of stay), and microbial (e.g., pathogen and susceptibilities) factors. Bloodstream, urinary tract, surgical site, and/or pneumonia Infections were identified using a validated algorithm based on clinical data and ICD-9/10 codes. During the study period, commonly implicated organisms in both healthcare associated and community acquired infections were evaluated for antibiotic resistance including Staphylococcus, Enterococci, Klebsiella, Acinetobacter, Pseudomonas, or Streptococcus. Antibiotic resistance was based on common resistance patterns, e.g., methicillin-resistant staphylococcus and vancomycin-resistant enterococci. Data analysis was based on admission, e.g., if an admitted patient had at least one antibiotic resistant infection during their hospital stay, the admission was analyzed as resistant. The association between admission from pediatric LTC and subsequent infection with either antibiotic-resistant or antibiotic-sensitive pathogens was assessed using multinomial regression. The potential confounders of age, sex, invasive device use, antibiotic use, and length of stay were included in the analysis. Significance was determined a priori at 0.05.
Results: From 2006 through 2016, there were 252,255 pediatric admissions, of which 1,088 were from a pediatric LTC facility. There were 2,989 infections in 1% (2,818) of admissions which included 1,247 (42%) bloodstream, 805 (27%) urinary tract, 559 (19%) pneumonia, and 378 (13%) surgical site infections. Of the 2,818 admissions with an infection, 79% (2,236) were sensitive and 21% (582) were resistant. The most common organism was Staphylococcus (995, 31%) followed by Klebsiella (24%), Enterococci (22%), Pseudomonas (16%), Acinetobacter (4%), and Streptococcus (3%). Children admitted from pediatric LTC were 2.7 times (CI95 1.5-4.8) more likely to have a resistant infection and 1.6 times (CI95 1.1-2.4) more likely to have a sensitive infection, controlling for age, sex, invasive device use, antibiotic use, and length of stay.
Conclusions: Children admitted from pediatric LTC facilities are at increased risk for antibiotic-resistant infections and may harbor resistant bacteria upon admission. While this study only represented a subset of infection causing pathogens, due to the nature of the care needed for children residing in pediatric LTC facilities, it is likely that the pattern of increased antibiotic-resistant infections is consistent across organisms. Therefore, it is important for hospital infection control programs to consider including a focus on pediatric LTC patients in their antibiotic stewardship and infection surveillance measures. Further research is needed to identify effective infection control measures to limit the incidence of antibiotic-resistant infections in this vulnerable and growing population.
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