Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts.
Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
JAMA Pediatr. 2020 Dec 1;174(12):1176-1183. doi: 10.1001/jamapediatrics.2020.3223.
Central catheter-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) increase morbidity, mortality, and health care costs in pediatric patients.
To examine changes over time in CLABSI and CAUTI rates between 2013 and 2018 in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) using prospective surveillance data from community hospitals, children's hospitals, and pediatric units within general hospitals.
DESIGN, SETTING, AND PARTICIPANTS: This time series study included 176 US hospitals reporting pediatric health care-associated infection surveillance data to the National Healthcare Safety Network from January 1, 2013, to June 30, 2018. Patients aged 18 years or younger admitted to PICUs or level III NICUs were included in the analysis.
The primary outcomes were device-associated rates of CLABSI in NICUs and PICUs and CAUTI in PICUs (infections per 1000 device-days). Secondary outcomes included population-based rates (infections per 10 000 patient-days) and device utilization (device-days per patient-days). Regression models were fit using generalized estimating equations to assess yearly changes in CLABSI and CAUTI rates, adjusted for birth weight (≤1500 vs >1500 g) in neonatal models.
Of the 176 hospitals, 132 hospitals with NICUs and 114 hospitals with PICUs contributed data. Of these, NICUs reported 6 064 172 patient-days and 1 363 700 central line-days and PICUs reported 1 999 979 patient-days, 925 956 central catheter-days, and 327 599 indwelling urinary catheter-days. In NICUs, there were no significant changes in yearly trends in device-associated (incidence rate ratio [IRR] per year, 0.99; 95% CI, 0.95-1.03) and population-based (IRR, 0.96; 95% CI, 0.92-1.00) CLABSI rates or central catheter utilization (odds ratio [OR], 0.97; 95% CI, 0.95-1.00). Results were similar in PICUs, with device-associated (IRR, 1.03; 95% CI, 0.99-1.07) and population-based (IRR, 1.03; 95% CI, 0.99-1.07) CLABSI rates and central catheter utilization (OR, 0.99; 95% CI, 0.97-1.01) remaining stable. While device-associated CAUTI rates in PICUs also remained unchanged over time (IRR, 0.97; 95% CI, 0.91-1.03), population-based CAUTI rates significantly decreased by 8% per year (IRR, 0.92; 95% CI, 0.86-0.98) and indwelling urinary catheter utilization significantly decreased by 6% per year (OR, 0.94; 95% CI, 0.91-0.96).
Recent trends in CLABSI rates noted in this study among critically ill neonates and children in a large cohort of US hospitals indicate that past gains have held, without evidence of further improvements, suggesting novel approaches for CLABSI prevention are needed. Modest improvements in population-based CAUTI rates likely reflect more judicious use of urinary catheters.
重要性：中心导管相关血流感染（CLABSI）和导管相关尿路感染（CAUTI）会增加儿科患者的发病率、死亡率和医疗保健成本。
目的：使用来自社区医院、儿童医院和综合医院儿科病房的前瞻性监测数据，研究 2013 年至 2018 年新生儿重症监护病房（NICU）和儿科重症监护病房（PICU）中 CLABSI 和 CAUTI 发生率的时间变化趋势。
设计、地点和参与者：本时间序列研究包括 176 家向国家医疗保健安全网络报告儿科医疗保健相关感染监测数据的美国医院，时间从 2013 年 1 月 1 日至 2018 年 6 月 30 日。分析纳入了年龄在 18 岁或以下、入住 PICU 或 3 级 NICU 的患者。
主要结果和测量：主要结果是 NICU 和 PICU 中与设备相关的 CLABSI 发生率以及 PICU 中 CAUTI 的发生率（每 1000 个设备日的感染数）。次要结果包括基于人群的发生率（每 10000 个患者日的感染数）和设备利用率（每个患者日的设备天数）。使用广义估计方程拟合回归模型，调整新生儿模型中的出生体重（≤1500 g 与>1500 g），以评估 CLABSI 和 CAUTI 发生率的逐年变化。
结果：在 176 家医院中，有 132 家医院有 NICU，114 家医院有 PICU 提供了数据。其中，NICU 报告了 6064172 个患者日和 1363700 个中心静脉置管日，PICU 报告了 1999979 个患者日、925956 个中心导管日和 327599 个留置导尿日。在 NICU 中，与设备相关的（发病率比每年每 1000 个患者的发病率，0.99；95%CI，0.95-1.03）和基于人群的（发病率比每年每 10000 个患者的发病率，0.96；95%CI，0.92-1.00）CLABSI 率或中心导管使用率（比值比每年每 1000 个患者的发病率，0.97；95%CI，0.95-1.00）没有显著变化趋势。在 PICU 中也得到了类似的结果，与设备相关的（发病率比每年每 1000 个患者的发病率，1.03；95%CI，0.99-1.07）和基于人群的（发病率比每年每 10000 个患者的发病率，1.03；95%CI，0.99-1.07）CLABSI 率和中心导管使用率（比值比每年每 1000 个患者的发病率，0.99；95%CI，0.97-1.01）保持稳定。尽管 PICU 中与设备相关的 CAUTI 率也随着时间的推移保持不变（发病率比每年每 1000 个患者的发病率，0.97；95%CI，0.91-1.03），但基于人群的 CAUTI 率每年显著下降 8%（发病率比每年每 10000 个患者的发病率，0.92；95%CI，0.86-0.98），留置导尿使用率每年显著下降 6%（比值比每年每 1000 个患者的发病率，0.94；95%CI，0.91-0.96）。
结论和相关性：本研究在大量美国医院的危重新生儿和儿童中观察到的 CLABSI 率的近期趋势表明，过去的成果得到了保持，没有进一步改善的迹象，这表明需要采取新的方法来预防 CLABSI。基于人群的 CAUTI 率的适度改善可能反映了导尿管使用更加谨慎。
