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Non-ventilator health care-associated pneumonia (NV-HAP): Pediatrics

      There is a paucity of data on the prevalence, risk factors or prevention of nonventilator health care-associated pneumonia (NV-HAP) in children. As with adults, viral, fungal and bacterial infections can lead to NV-HAP, but surveillance definitions and case ascertainment remain a challenge. This section will review the known epidemiology of NV-HAP in the pediatric population, risk factors, surveillance, and prevention practices. Prevention strategies specific to pediatrics, aimed at reducing risk of viral transmission to hospitalized children will be discussed.

      Key Words

      Epidemiology

      There are few published studies on the prevalence, risk factors, or prevention of nonventilator health care-associated pneumonia (NV-HAP) in children. A Canadian study published in 2012 suggests that pneumonia is the second most common health care-associated infection in children, with a prevalence of 1.5% of the pneumonia cases in the study sample, 45% were not ventilator associated.
      • Rutledge-Taylor K
      • Matlow E
      • Gravel D
      • et al.
      A point prevalence survey of health care-associated infections in Canadian pediatric inpatients.
      Another study published using Pennsylvania data from 2011 to 2012 found that of the pediatric pneumonia events reported to the National Healthcare Safety Network (NHSN), 28% were not ventilator associated.
      • See I
      • Chang J
      • Gualandi N
      • et al.
      Clinical correlates of surveillance events detected by National Healthcare Safety Network pneumonia and lower respiratory infection definition—Pennsylvania, 2011–2012.
      These findings indicate that NV-HAP is less common event in hospitalized children than in hospitalized adults.
      As in adults, the etiology of pneumonia in children may be bacterial, fungal, or viral. A common bacterium isolated from children with pneumonia is Staphylococcus aureus.
      • Jantausch BA
      • Deville J
      • Adler S
      • et al.
      Linezolid for the treatment of children with bacteremia or nosocomial pneumonia caused by resistant gram-positive bacterial pathogens.
      Gram-negative organisms, such as Pseudomonas sp. and Klebsiella pneumoniae, have also been reported as predominant causes of pneumonia.
      • Rutledge-Taylor K
      • Matlow E
      • Gravel D
      • et al.
      A point prevalence survey of health care-associated infections in Canadian pediatric inpatients.
      ,
      • Casado RJA
      • de Mello MJ
      • de Aragão RC
      • et al.
      Incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit.
      ,
      • Zar HJ
      • Cotton MF
      Nosocomial pneumonia in pediatric patients.
      Respiratory syncytial virus is widely recognized as a viral cause of NV-HAP; additionally, many other viruses, including parainfluenza viruses, metapneumovirus, and rhinovirus, can result in significant morbidity and mortality for medically complex children.
      • Zar HJ
      • Cotton MF
      Nosocomial pneumonia in pediatric patients.
      ,
      • Hei H
      • Bezpalko O
      • Smathers SA
      • et al.
      Development of a novel prevention bundle for pediatric healthcare-associated viral infections.
      Hospitalized children who develop a viral infection have poor outcomes, including escalation of care, transfer to the intensive care unit, delayed discharge, and readmission, and 2.5% of these patients develop pneumonia.
      • Hei H
      • Bezpalko O
      • Smathers SA
      • et al.
      Development of a novel prevention bundle for pediatric healthcare-associated viral infections.
      Fungal infection in immunocompromised pediatric and adult patients is also well described. Notably, in pediatrics there are limited options for antifungal treatments, making prevention practices especially important for this patient population.
      Risk factors for pneumonia in children vary by age categories, and some pediatric risk factors are distinctive from those for adults. For example, there are specific comorbid conditions of concern in children, and certain hospital circumstances such as visitation practices (eg, sick siblings at the bedside) may pose distinctive risks for pediatric patients.
      The 2012 Canadian study did not report any cases in neonates (age ≤30 days). Of the children with pneumonia, infants (age >30 days but <2 years) were most likely to acquire pneumonia in the hospital.
      • Rutledge-Taylor K
      • Matlow E
      • Gravel D
      • et al.
      A point prevalence survey of health care-associated infections in Canadian pediatric inpatients.
      In the study using Pennsylvania data from 2011 to 2012, children under the age of 1 year accounted for most pediatric cases.
      • See I
      • Chang J
      • Gualandi N
      • et al.
      Clinical correlates of surveillance events detected by National Healthcare Safety Network pneumonia and lower respiratory infection definition—Pennsylvania, 2011–2012.
      Other children who are at increased risk for pneumonia include patients of low mobility, such as neurologically impaired children who experience frequent aspirations and patients in the intensive care unit.
      • Casado RJA
      • de Mello MJ
      • de Aragão RC
      • et al.
      Incidence and risk factors for health care-associated pneumonia in a pediatric intensive care unit.
      ,
      • Thomson J
      • Hall M
      • Ambroggio L
      • et al.
      Aspiration and non-aspiration pneumonia in hospitalized children with neurologic impairment.

      Surveillance

      Case ascertainment for NV-HAP in children and neonates can be especially challenging. If IPs rely on the use of tracheal aspirate cultures as a trigger to investigate a possible VAP or ventilator-associated event, patients without endotracheal tubes are unlikely to have sputum cultures, which may lead to underreporting and lack of recognition by the infection prevention department.
      The use of radiographic evidence is required by NHSN to meet the definition of pneumonia (PNEU),
      Centers for Disease Control and Prevention
      Pneumonia (ventilator-associated [VAP] and non-ventilator-associated pneumonia [PNEU]) event.
      but radiographic assessment is complicated by the complexity of pediatric patients who have underlying comorbidities, such as chronic lung disease of prematurity or cardiac conditions. For surveillance of these patient populations, some investigators have tried building electronic data pulls with select chest imaging key phrases to identify potential patients with lung changes suggestive of a developing pneumonia. These reports have low sensitivity and specificity and are a resource challenge, as IPs must look through many nonspecific findings for limited or no yield.
      Applying the NHSN PNEU definition in the pediatric population is also challenging because of a discrepancy between terminology used within the PNEU definition and actual practice by radiologists. The NHSN definition requires imaging evidence of “new and persistent or progressive and persistent: infiltrate, consolidation, cavitation, or pneumatoceles (in infants ≤1 year old).”
      Centers for Disease Control and Prevention
      Pneumonia (ventilator-associated [VAP] and non-ventilator-associated pneumonia [PNEU]) event.
      However, in pediatric patients with premature chronic lung disease or cardiac disorders, chest imaging is abnormal, and it can be difficult to interpret radiography to determine when a change occurs. Imaging reports may indicate atelectasis and opacities in complex care patients, which could represent infiltrates and/or consolidation, requiring the IP to obtain additional interpretation by the radiologist or clinical teams to determine whether imaging surveillance criteria are met. The use of a third-party radiologist as an independent reviewer can help provide consistency and validity to application of the surveillance criteria for radiographic evidence, thereby assisting with terminology and addressing differences in interpretation from clinical teams.
      Improved electronic surveillance systems that incorporate chest imaging, clinical symptoms, and antibiotic use are needed for improved case ascertainment. As discussed in The Infection Preventionist's Role in Indentifying NV-HAP of this supplement, Ji et al investigated the use of electronic medical record data for clinical symptoms, white blood cell count, chest imaging, and antibiotic days to objectively track NV-HAP in the adult population and found their system produced results similar to manual surveillance.
      • Ji W
      • McKenna C
      • Ochoa A
      • et al.
      Development and assessment of objective surveillance definitions for nonventilator hospital-acquired pneumonia.
      Validating this model or creating one specific to the pediatric setting would help infection prevention programs accurately identify and track NV-HAP in children.
      To support case ascertainment in pediatric patient populations, it is crucial to build relationships and communication structures between the facility's antimicrobial stewardship program, infectious diseases consulting team, and unit-based clinicians to identify potential pneumonia in high-risk patients. Creating a communication system to report possible NV-HAP to the infection prevention program that is based on clinical diagnosis helps identify patients who would not otherwise be known to the IP.
      PNEU reporting is mandated in Pennsylvania.

      Pennsylvania Patient Safety Authority. Act 52—Medical Care Availability and Reduction of Error (MCARE) Act: reduction and prevention of health care-associated infection and long-term care nursing facilities. Available at:http://patientsafety.pa.gov/PatientSafetyAuthority/Governance/Pages/Act52.aspx. Accessed November 2, 2019.

      Given the challenges with case ascertainment and application of the NHSN definition to neonatal and pediatric populations, few pediatric institutions outside of Pennsylvania are tracking PNEU.

      Prevention practices

      Many of the prevention practices for NV-HAP in children are similar to those in adults. It is important for providers to ensure that hospitalized children remain up to date with vaccination schedules for bacterial and viral causes of vaccine-preventable pneumonia such as influenza, pneumococcal, Haemophilus influenzae type b, varicella, and measles.
      Viral transmission is a particular area of focus in pediatrics. Hospitalized children often have visitors from their families, schools, sport teams, and communities, and the potential for viral transmission increases due to the volume and frequency of visitors. Keeping sick people from visiting at the bedside is crucial to prevent viral infections in hospitalized children. To reduce patient exposures, strategies include screening visitors, especially siblings and other family members; limiting visitors when appropriate, such as during peak viral season; and partnering with families to avoid sick visitors, including the caregivers, at the bedside. Caregivers who are ill may refuse to leave their child; therefore, it is very important to (1) educate them on the risks, (2) provide opportunities to stay connected with their child if they choose to leave, and (3) share information on prevention strategies such as education on hand hygiene, respiratory etiquette, and mask use (if appropriate).
      The health care-associated viral infection prevention bundle by Hei et al showcases strategies that can be taken to prevent health care-associated viral infection; it includes basic infection prevention practices combined with visitor screening, managing staff illness, and environmental cleanliness (Fig 1).
      • Hei H
      • Bezpalko O
      • Smathers SA
      • et al.
      Development of a novel prevention bundle for pediatric healthcare-associated viral infections.
      Fig 1
      Fig 1Health care-associated viral infection (HAVI) prevention bundle. Source: Reprinted with permission.
      • Hei H
      • Bezpalko O
      • Smathers SA
      • et al.
      Development of a novel prevention bundle for pediatric healthcare-associated viral infections.
      Key points
      • Pneumonia is one of the most common health care-associated infections in children; however, data on the risk factors, prevention, and epidemiology of NV-HAP are lacking.
      • Enhanced surveillance tools that use clinical criteria as well as chest imaging are needed to identify potential NV-HAP cases from the electronic medical record. Such tools would not only ease the burden on IPs but also create systematic and validated methodology to apply a pneumonia surveillance definition.
      • The use of infection prevention practices such as hand hygiene, isolation, personal protective equipment, and environmental cleaning combined with novel systems to prevent sick visitors from reaching the bedside should be part of a pediatric NV-HAP prevention bundle.
      • Further work is needed to identify novel practices to prevent all causes of NV-HAP in children and adults.

      References

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      1. Pennsylvania Patient Safety Authority. Act 52—Medical Care Availability and Reduction of Error (MCARE) Act: reduction and prevention of health care-associated infection and long-term care nursing facilities. Available at:http://patientsafety.pa.gov/PatientSafetyAuthority/Governance/Pages/Act52.aspx. Accessed November 2, 2019.