Frequency of Nosocomial Infections in Pediatric Intensive Care Unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background: Nosocomial infections in PICU vary from 6–26%. Causative pathogens isolated depend upon patient disease, exposure to invasive and non-invasive procedures, and body-system affected. Objectives: To determine frequency of nosocomial infections, organisms involved, sites affected and clinical outcome in pediatric patients. Methods: It is a retrospective cross-sectional study on pediatric patients who acquired infections after 48 hours of admission in PICU at King Abdulaziz Medical City during 2012. Data was collected from medical, laboratory records. Results: 22 (3%) patients acquired nosocomial infections in 684 admissions during year 2012, out of which 12 were female and 10 were male patients. The common incidence was found in first year of age (10 patients). There were a total of 57 events in these patients; respiratory infections were the commonest (24) followed by urinary infections (19). Most common organism involved was Klebsiella (16) followed by Candida (13). Most common pathogens isolated from respiratory infections were Klebsiella pneumoniae (6) and Pseudomonas aeruginosa (5), while Klebsiella (6) and Candida (5) were found in urinary tract infections. The common organisms causing septicemia included Candida (4) and Klebsiella pneumoniae (4). In initial 10 days of admission at PICU, 10 patients acquired the infection (median 14 days). Acquisition of nosocomial infections prolonged hospitalization (median 49.5 days). Conclusion: Nosocomial infections were caused by Klebsiella and Candida. These pathogens mainly caused respiratory, urinary and hematogenous infections, respectively. They have prolonged hospitalization. There is an extensive need for further studies to identify risk factors and review empiric management. *Corresponding author: Mohammed G Alotaibi, College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, P.O. Box 3660, Riyadh-11481, Kingdom of Saudi Arabia, Tel: +966507417451, E-mail: ommmmo@hotmail.com Received July 10, 2015; Accepted September 14, 2015; Published September 21, 2015 Citation: Alotaibi MG, Rahman S, Al-Shalaan MA, Omair A (2015) Frequency of Nosocomial Infections in Pediatric Intensive Care Unit at King Abdulaziz Medical City, Riyadh, Saudi Arabia. J Infect Dis Ther 3: 234. doi:10.4172/23320877.1000234 Copyright: © 2015 Alotaibi MG. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Infections are one of the main causes of morbidity and mortality globally [1]. Some patients acquire infections during hospitalization. The infections contracted from hospital by a patient, admitted for a reason other than that specific infection, or acquired during a visit to hospital are called nosocomial infections or hospital-acquired infections [2]. These include also infections acquired from hospital but appearing after discharge and the occupational infections among staff of the health facility [2]. These infections lead to localize or systemic effects. To label a nosocomial infection, patient should not be in an incubation period for that infection before the admission to the health facility [3].
Incidence of nosocomial infections in pediatric intensive care unit is different among different countries and hospitals which vary between 6.1% and 26%. While in Middle East, the incidence of nosocomial infections in PICU is 14.7% [4][5][6]. Among these differences, it varies between ages. Pediatric patients are more susceptible for infection than adult particularly in the first two years of life [4,7]. These infections commonly include hematological infections, lower respiratory tract and urinary tract infections respectively [7,8]. The nosocomial pathogens affecting pediatric patients vary depending upon the site of infection. Blood stream infections related to central lines are polymicrobial (48%) [7]. The common organisms isolated from blood stream infection are Klebsiella pneumoniae, Coagulase-negative Staphylococci, and Pseudomonas aeruginosa respectively. Common nosocomial pathogens identified from lower respiratory tract infections are Pseudomonas aeruginosa followed by Staphylococcus aureus [8,9]. The common nosocomial pathogens from urinary tract infections are E. coli followed by Candida albicans [8]. Device-related infections were mostly described [8,10]. Those infected patients have five times risk of mortality [6].
Incidence and prevalence of many infectious diseases in developed countries have reduced due to better public health measures and effective medications. Moreover the extensive use of primary care preventive measures and new diagnostic investigation might have changed the pattern and mortality of infectious diseases [11,12]. Pediatric nosocomial infections can be reduced by 50% by adopting appropriate preventive measures [10]. The risk of nosocomial infection increases with prolonged hospitalization and it becomes common after first week and increases to reach 52% after a month of admission [4]. The risk of nosocomial infections depend on various factors, for example: host factors, duration of stay in PICU, number of interventions, invasive procedure, aseptic techniques employed, and inappropriate use of antimicrobial agents [10]. Nosocomial infections in pediatric patients are different from adult infections [8]. The frequencies of these hospital acquired infections among pediatric patients are variable in different countries and there is limited data available for KSA [7,9]. Our study aimed to determine frequency of nosocomial infections at a tertiary care hospital in Riyadh.

Methods
Study was a retrospective cross-sectional study on pediatric patients from neonate to 14 years who acquired nosocomial infections in PICU at King Abdulaziz Medical City, in Riyadh during 2012. Patients were included via non-probability convenience sampling technique. Patients who had an infection before admission or who got infection within 48 hours of admission were excluded.
As protocol of King Abdulaziz Medical City, any patient who is suspected to have an infection should be cultured properly. Investigations include culture with appropriate specimen depending on site of infection. Data was collected from lab Database for positive culture of specimens (blood, urine and sputum) for admitted patients. Then, medical records of patients were reviewed to obtain information; including demographic data (age and sex), purpose of admission, date of admission, date of discharge, date of acquisition of infection, site of infection, culture result and isolated organism. If the information were not mentioned in lab or medical record or electronic database it was marked as unmentioned.
Data was coded prior to entry in SPS. These data were collected, reviewed, coded, entered, filtered, cleaned and then analyzed by first author and co-authors by using version 19 of IBM SPSS software. It was a descriptive analysis by using frequencies to summarize categorical variables that collected during period of one month. Also, continuous variables were expressed as mean or median and standard deviation. A p-value of <0.05 was considered as significant. Consent was not needed as it was retrospective study but proper permission was sought from King Abdullah International Medical Research Center. Patient's information was not collected to maintain confidentiality and coding of patients was used.

Results
Among 684 patients admitted to pediatric ICU during 2012, there were 22 patients who had nosocomial infections that show incidence of 3 % (9 patients were excluded). During admission of these patients, 13 patients had two or more infections to be a total of 57 episodes of infections. Frequency of respiratory, urinary tract and blood infections were 24, 19 and 14, respectively (Table 1). Different age groups and genders were affected by nosocomial infections. Ten patients had nosocomial infections during first year of age. There were 12 female and 10 male (Table 2).
Among infected patients, 10 of them affected by the first infection during first ten days after admission while four patients got it during the rest of first month. (Median 14 days) hospitalization Length was prolonged. Thus, six patients stayed more than month up to two months and nine patients stayed more than two months (Median 49.5 days) ( Table 3). The most common organisms in PICU (out of 65 organisms) were Klebsiella species (16 episodes), followed by Candida species (13 episodes) ( Table 4). The most common organisms in respiratory infections were Klebsiella pneumoniae (six episodes) and Pseudomonas aeruginosa (five episodes), respectively (Table 4). While in urinary tract infections (UTI), the most common organisms are Klebsiella species (six episodes) and Candida (five episodes), respectively ( Table 4). The most common organism in blood stream infections are Candida (four episodes) and Klebsiella pneumoniae (four episodes) ( Table 4). Among these patients, 17 patients (out of 22 patients) have died during that admission ( Table 3).

Frequency of nosocomial infection (n=684)
Category Frequency

Two infection 6 -
Three or more 7 -

Discussion
Nosocomial infection in PICU varies between hospitals and countries in according to incidence, common systems involved and organisms. We found less incidence of nosocomial infection compared to other researches that varies between 6.1% to 26% [4,5]. According to systems involved in nosocomial infection our study results showed the most common systems affected were respiratory, UTI and blood. In most of other studies outside of KSA, blood stream infections are the commonest followed by respiratory infection then UTI. [8,[13][14][15]. Another study reported the most common system was respiratory followed by UTI then blood [6]. Organisms that affect PICU in general, were variable among hospitals. Our study showed Klebsiella species the commonest, followed by Candida then Pseudomonas aeruginosa. In another researches, Coagulase-negative Staphylococcus species is the most common. It was followed by Klebsiella, Pseudomonas aeruginosa and Staphylococcus aureus. [4,6,14].
Among variability in common organisms in each system, our result showed Klebsiella pneumoniae the most common organism in respiratory infection, followed by Pseudomonas. While in other researches, there was variability regarding the common organisms (Staphylococcus aureus and Pseudomonas) in respiratory infection. [8,13,15]. Klebsiella pneumoniae and Candida were the most common organism in blood stream infections. Among other researches, there was wide variability for common organism causing blood infection. A study from Brazil, reported E. fecalis and E. coli the commonest cause of blood infection followed by Staphylococcus epidermis. [13]. Another study from Brazil reported Candida species were the commonest cause of blood stream infections followed by Coaugulase negative Staphylococcus [15]. In US and Estonia, Coagulase-negative Staphylococcus was the most common organism in blood infection [8,16]. Klebsiella pneumoniae is most common organism in UTI followed by Candida then E. coli. Studies reported the Yeast and E. coli were the commonest organism in UTI [8,13,15]. Thus, our study and others showed difference in common organisms and sites affected. Length of stay and mortality rate were found to be higher in our study that reaches 77% while it not exceeds 40% other studies. Mortality rate is insignificant because it was observed in one year and associated comorbidites in these children. [6,[14][15]17]. Also, hospitalization length prior to get first infection was found to be equal to other study [15]. The nosocomial infections risk decreases after first year of age. The most risk for nosocomial infection is in first two weeks after admission then it slightly decreases.

Conclusion
Our study showed lower frequency of nosocomial infection and higher mortality compared to other studies. Respiratory infections is the most common system infected followed by blood and UTI. Klebsiella species were the commonest organism isolated from respiratory infection and UTI while Klebsiella species and Candida were the most common organisms that affect the blood stream. Further studies are recommended in Saudi Arabia that include large sample size and in different hospitals about nosocomial infections in PICU and specific consideration for prevention and management of nosocomial infection.