Epidemiology of Nosocomial Pneumonia in Infants After Cardiac Surgery

doi:10.1378/chest.125.2.410

Chest

Volume 125, Issue 2, February 2004, Pages 410-417

https://doi.org/10.1378/chest.125.2.410 Get rights and content

Background

The pattern of nosocomial pneumonia (NP) in infants in a pediatric surgical ICU after cardiac surgery may differ from that seen in adult ICUs.

Study objectives

The primary aim of this study was to describe the epidemiology of NP in infants after cardiac surgery and, secondarily, to describe the changes of the distribution and antibiotic resistance of the pathogen during the last 3 years.

Methods

Data were collected between June 1999 and June 2002 from 311 consecutive infants who underwent open-heart surgery in our hospital. We retrospectively analyzed the distribution and antibiotic resistance pattern of all the pathogenic microbial isolates cultured from lower respiratory tract aspirations.

Results

Of 311 infants, 67 patients (21.5%) acquired NP after cardiac surgery. The incidence of NP was more frequently associated with complex congenital heart defect (CHD) compared to simple CHD (43% vs 15.9%, χ² = 22.47, p < 0.0001). The proportion of late-onset NP was higher in patients with complex CHD (χ² = 6.02, p = 0.014). A total of 79 pathogenic microbial strains were isolated. Gram-negative bacilli (GNB) were the most frequent isolates (68 isolates, 86.1%), followed by fungi (6 isolates, 7.6%) and Gram-positive cocci (5 isolates, 6.3%). The main GNB were Acinetobacter baumanii (11 isolates, 13.9%), Pseudomonas aeruginosa (10 isolates, 12.7%); other commonly seen GNB were Flavobacterium meningosepticum (7 isolates, 8.9%), Klebsiella pneumoniae (7 isolates, 8.9%), Escherichia coli (6 isolates, 7.6%), and Xanthomonas maltophilia (5 isolates, 6.2%). The most commonly seen Gram-positive cocci were Staphylococcus aureus (2 isolates, 2.5%) and Staphylococcus epidermidis (2 isolates, 2.5%). The frequent fungi were Candida albicans (5 isolates, 6.3%). Most GNB were sensitive to cefoperazone-sulbactum, piperacillin-tazobactam, imipenem, ciprofloxacin, amikacin. The bacteria producing extended spectrum β-lactamases were mainly from K pneumoniae and E coli; the susceptibility of ESBL-producing strains to imipenem was 100%. There were one case of methicillin-resistant S aureus (MRSA) and 1 case of methicillin-resistant S epidermidis; their susceptibility to vancomycin, gentamycin, and ciprofloxacin were 100%. From 1999 to 2002 in infants with NP after open-heart surgery, there was a trend of increasing frequency of multiresistant GNB such as A baumanii, P aeruginosa, and K pneumoniae. However, no remarkable changes of distribution were found in Gram-positive cocci and fungi in the 3-year period. Early onset episodes of NP were frequently caused by Haemophilus influenzae, methicillin-sensitive S aureus, and other susceptible Enterobacteriaceae. Conversely, in patients who acquired late-onset NP, P aeruginosa, A baumannii, other multiresistant GNB, MRSA, and fungi were the predominant organisms.

Conclusions

The pattern of pathogens and their antibiotic-resistance patterns in NP in infants after cardiac surgery had not shown an increasing prevalence of Gram-positive pathogens as reported by several adult ICUs. GNB still remained the most common pathogens during the last 3 years in our hospital. There was a trend of increasing antibiotic resistance in these isolates.

Section snippets

Setting

This was a retrospective study using prospectively collected data performed at the pediatric cardiovascular surgical ICU in a 580-bed teaching children's hospital.

Patients

Data were collected on 311 consecutive infants (age, 8 days to 12 months) with congenital heart defect (CHD) who underwent open-heart surgery in our hospital between June 1999 and June 2002.

Surveillance Samples

All patients were monitored for NP after cardiac surgery by clinical standards and also by quantitative cultures of endotracheal aspirate. The

Demographic Variables

A total of 311 consecutive infants with CHD who underwent open-heart surgery were enrolled in the study. Sixty-seven patients (including 28 patients with complex CHD and 39 patients with simple CHD; Table 1) acquired NP. The incidence rate of NP was 21.5%. NP more frequently occurred in patients with complex CHD compared to simple CHD (43% vs 15.9%, χ² = 22.47, p < 0.0001) [Table 2]. The proportion of late-onset NP was higher in patients with complex CHD (χ² = 6.02, p = 0.014) [Fig 1].

Distribution of Pathogens

Discussion

Many studies have noted the development of pneumonia was closely associated with severity of the underlying disease.¹⁰¹¹¹²¹³ In our study, NP in infants after cardiac surgery was more frequently found in patients with underlying complex CHD. This may due to recurrent pneumonia before operation, longer surgical procedure, and prolonged mechanical ventilation after surgery in these patients. Early- onset episodes of NP were caused frequently by H influenzae, MSSA, and other susceptible

Conclusion

The pattern of microbial pathogens in NP in infants after cardiac surgery has not seen an increasing prevalence of Gram-positive pathogens as reported by several adult ICUs. GNB still remains the most common pathogens during the past 3 years in our study. There was a trend of increasing antibiotic resistance of these isolates. Understanding of the epidemiology, changes of pathogen distribution, and antibiotic resistance profile promotes rational use of antibiotics. This is crucial to reduce

ACKNOWLEDGMENT

The authors thank Dr. David McFadden from Loma Linda University Medical Center for helpful comments on the article. The authors also thank Xiaojun He, Caiyun Zhang, Shanshan Shi, for help with data collection, and all of the contributing intensivists and nurses.

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The epidemiology of infective complications following pediatric cardiac surgery previously has been described in the literature. Gram-negative bacilli are the most frequently reported pathogens in nosocomial infections in children after cardiac surgery.16 The incidence of symptomatic viral respiratory infections in children following cardiac surgery was reported to be between 1.7% and 4.2%.17,18
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Using the National Surgical Quality Improvement- Pediatric (NSQIP-P) database, we first selected children (N = 17,776; age under 18 years) who underwent inpatient pediatric otolaryngology procedures between 2012 and 2017. Using a random subset of 80% of the study population (derivation cohort), we next developed a multivariable logistic regression model to identify independent risk factors for postoperative pneumonia. We then divided children into risk groups and evaluated whether the Pareto principle applied to distribution of postoperative pneumonia across the risk groups.
Among the 12,443 children in the derivation cohort, 177 (1.4%) developed postoperative pneumonia. A multivariable risk model identified patients who developed postoperative pneumonia with good accuracy in both the derivation and validation cohorts. Stratification of patients into five mutually exclusive risk groups showed that 71% of postoperative pneumonia occurred in the highest risk group representing 20% the study cohort. Children who developed postoperative pneumonia were 18 times more likely to require an extended hospital length of stay (OR: 18.6; 95%CI: 12.3–28.2), and 7 times more likely to die compared to children without pneumonia (OR: 7.40, 95%CI: 3.53–15.48).
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Congenital heart diseases are among the most common congenital malformations. Approximately 50% of the patients with congenital heart disease undergo cardiac surgery. Nosocomial infections (NIs) are the main complications and an important cause of increased morbidity and mortality associated with congenital heart diseases. This study's objective was to identify the risk factors associated with the development of NIs after cardiac surgery in newborns with congenital heart disease.
This was a nested case–control study that included 112 newborns, including 56 cases (with NI) and 56 controls (without NI). Variables analyzed included perinatal history, associated congenital malformations, Risk-Adjusted Congenital Heart Surgery (RACHS-1) score, perioperative and postoperative factors, transfusions, length of central venous catheter, nutritional support, and mechanical ventilation. Statistical analysis: Differences were calculated with the Mann–Whitney-U test, Pearson X², or Fisher's exact test. A multivariate logistic regression was used to determine the independent risk factors.
Sepsis was the most common NI (37.5%), and the main causative microorganisms were gram-positive cocci. The independent risk factors associated with NI were non-cardiac congenital malformations (OR 6.1, CI 95% 1.3–29.4), central venous catheter indwelling time > 14 days (OR 3.7, CI 95% 1.3–11.0), duration of mechanical ventilation > 7 days (OR 6.6, CI 95% 2.1–20.1), and ≥5 transfusions of blood products (OR 3.1, CI 95% 1.3–8.5). Mortality attributed to NI was 17.8%.
Newborns with non-cardiac congenital malformations and with >7 days of mechanical ventilation were at higher risk for a postoperative NI. Efforts must focus on preventable infections, especially in bloodstream catheter-related infections, which account for 20.5% of all NIs.
Extended-spectrum beta-lactamase-producing Enterobacteriaceae infections after cardiac surgery: their impact on mortality
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Las enterobacterias productoras de betalactamasas de espectro extendido (EP BLEE) causan infecciones nosocomiales de modo creciente. Es controvertido si se asocian a peor pronóstico. El objetivo de este trabajo fue analizar si las infecciones por EP BLEE tras cirugía cardiaca presentan peor pronóstico que las causadas por enterobacterias no multirresistentes.
Estudio retrospectivo de las infecciones postquirúrgicas por enterobacterias, diagnosticadas en el Servicio de Cirugía Cardiaca de un Hospital Universitario (1/12/2007-1/12/2012). Se analizó la presencia de BLEE, la idoneidad del tratamiento empírico y la mortalidad global y relacionada.
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Citation Excerpt :
VAP following cardiac surgery has been studied extensively in the adult population, but there have been few studies of VAP among pediatric patients following cardiac surgery specifically [2]. The rate of VAP post-cardiac surgery in the pediatric population varies between 8.8% and 21.5%, and the majority of these cases have been reported in infants [3]. Necrotizing pneumonia typically occurs as a complication of community-acquired pneumonia [6,7].

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: Financial support provided by Science and Technology Committee Fund of Zhejiang Province, China (No. 2003C33022).

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Chest

Clinical InvestigationsSURGERYEpidemiology of Nosocomial Pneumonia in Infants After Cardiac Surgery

Background

Study objectives

Methods

Results

Conclusions

Section snippets

Setting

Patients

Surveillance Samples

Demographic Variables

Distribution of Pathogens

Discussion

Conclusion

ACKNOWLEDGMENT

Diagn Microbiol Infect Dis

Chest

Chest

Chest

Diagn Microbiol Infect Dis

Diagn Microbiol Infect Dis

Chest

Chest

Chest

J Hosp Infect

Diagn Microbiol Infect Dis

Chest

Chest

Pediatric and neonatal intensive care

Can J Anaesth

Infections in a pediatric intensive care unit

Am J Dis Child

Nosocomial infections in a pediatric intensive care unit

Crit Care Med

Ventilator-associated pneumonia: state of the art

Am J Respir Crit Care Med

Nosocomial infection update

Emerg Infect Dis

Enterobacter bacteremia: clinical features and emergence of antibiotic resistance during therapy

Ann Intern Med

Performance standards for antimicrobial susceptibility testing.Ninth Informational Supplement: NCCLS Document M100-S9

Ventilator-associated pneumonia: a multivariate analysis

JAMA

Clinical Investigations
SURGERY
Epidemiology of Nosocomial Pneumonia in Infants After Cardiac Surgery