Tackling infection on the paediatric ward

Dr Andrew Riordan, consultant in paediatric diseases, Alder Hey Children’s NHS Foundation Trust, examined the issue of infection prevention and control in paediatrics – raising important issues concerning the relevance of mandatory surveillance and infection prevention guidance in relation to children. “We have to do things differently with children when it comes to infection prevention and control,” he commented. “The first rule of infection prevention, when it comes to paediatrics, is that you cannot make children behave like adults.” Comparing infection rates for a number of adult and paediatric hospitals, he illustrated how mandatory surveillance has shown major reductions in MRSA bacteraemia at adult hospitals, but very little change in rates for paediatric hospitals. This is not a poor reflection on paediatric infection control, he explained, but is due to the fact that rates of MRSA bacteraemia in these patients were already very low. The very low rates of MRSA bacteraemia make it difficult to show a significant change over a given surveillance period, he pointed out, adding that this is also the case for mandatory reporting of C. difficile. Dr Riordan explained that mandatory reporting of MRSA and C. difficile rates (which indicate very low rates of infection on paediatric units) can lead to board members concluding that they do not have a problem. In fact, MRSA and C. difficile rates are not good markers of infection prevention and control for children’s hospitals. Dr Riordan warned that national targets focusing on MRSA bacteraemia and C. difficile miss the majority of hospital-acquired infections in children and may take attention away from preventing the more important paediatric healthcare-associated infections. He added: “Children actually have very high rates of hospital-acquired infection (HAI) and these infections are quite hard to prevent.” Presenting data on prevalence in Europe, he revealed that the biggest cause of HAI on the general paediatric ward is gastroenteritis. On the children’s oncology unit, bloodstream infection tends to be the main cause, while on ITU, hospital-acquired respiratory infections are more prevalent.

Hospital-associated diarrhoea

He highlighted a two year study, examining all of the cases of gastroenteritis at Alder Hey children’s hospital. Around two-thirds were found to be community associated, while a third of cases were hospital acquired. The biggest cause was rotavirus, although norovirus and other viruses were also implicated. Rotavirus is the most common cause of hospital-associated diarrhoea, in children, and causes around half a million deaths per year, around the world, due to dehydration, he pointed out. “For every two or three children you admit with rotavirus, you will get another one who will obtain the virus as a hospital-acquired infection,” he warned. “There are very few studies that have shown decreases in the rates of hospital-acquired rotavirus.” The Alder Hey study revealed that community-acquired cases of rotavirus tended to be found on the general paediatric wards, while the hospital-acquired cases tended to be found on units where children’s hospital stays were longer, such as the critical care areas, neurology, cardiology and long-stay ventilation wards. Dr Riordan added that while C. difficile is the infection most often associated with diarrhoea in adult patients, it is difficult to gain an accurate picture of rates in children. “C. difficile is part of the natural bowel flora in babies. It is normal to find C. difficile in young children’s stools, but what does this mean?” he commented. He revealed that the number of hospitalised children with C. difficile has increased, according to figures from the US. However, this may be due to the fact that they are simply testing more children. Severity in children does not appear to have increased as it has in adults, although children with cancer seem to have higher rates of C. difficile. He cautioned the audience on drawing conclusions from these statistics, adding that 1 in 5 may have C. difficile in their stool but may also be asymptomatic – while there may be other causes of the diarrhoea in these patients, such as the medication they are taking, for example. “Having to report C. difficile when we don’t really know what it means, has become a source of frustration for us at children’s hospitals,” Dr Riordan commented.