Rate, Risk Factors, and Outcomes of Nosocomial Primary Bloodstream Infection

in Pediatric Intensive Care Unit Patients

Jeya S. Yogaraj, Alexis M. Elward and Victoria J. Fraser
Pediatrics 2002;110;481
DOI: 10.1542/peds.110.3.481

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/110/3/481.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2002 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
 Rate, Risk Factors, and Outcomes of Nosocomial Primary Bloodstream
Infection in Pediatric Intensive Care Unit Patients
Jeya S. Yogaraj, MPH*; Alexis M. Elward, MD‡; and Victoria J. Fraser, MD*
ABSTRACT. Objective. The objective of this study
was to determine the rate, risk factors, and outcomes of
nosocomial primary bloodstream infection in pediatric
intensive care unit (PICU) patients.
Design. Prospective cohort study.
Settings. This study was performed at St Louis Chil-
dren’s Hospital, a 235-bed academic tertiary care center
with a combined 22-bed medical and surgical PICU.
Patients. Subjects for this study were patients admit-
ted to the PICU between September 1, 1999, and May 31,
2000.
Interventions. None.
Outcome Measures. Patients were monitored for the
development of nosocomial bloodstream infections from
the day of PICU admission until 48 hours after PICU
discharge.
Results. Of 911 patients, 526 (58%) were male and 674
(74%) were white. Congenital heart disease (29%), lung
disease (25%), and genetic syndrome (18%) were com-
mon. There were 65 episodes of primary bloodstream
infection in 57 patients; 5 were polymicrobial and 7 pa-
tients had multiple bloodstream infections. Coagulase-
negative Staphylococcus was the leading cause of blood-
stream infection (n ⴝ 28), followed by Enterobacter
cloacae (n ⴝ 8). The rate of bloodstream infection was
13.8 per 1000 central venous catheter days. In multiple
logistic regression analysis, patients with bloodstream
infection were more likely to have multiple central ve-
nous catheters (adjusted odds ratio [aOR]: 5.7; 95% con-
fidence interval [CI]: 2.9 –10.9), arterial catheters (aOR:
5.5; 95% CI: 1.8 –16.3), invasive procedures performed in
the PICU (aOR: 4.0; 95%CI: 2.0 –7.8), and be transported
out of the PICU (aOR: 3.4; 95% CI: 1.8 – 6.7) to the radiol-
ogy or operating room suites. Severity of illness as mea-
sured by admission Pediatric Risk of Mortality score,
underlying illnesses, and medications were not associ-
ated with increased risk of nosocomial bloodstream in-
fection.
Conclusions This study identified a high rate of
bloodstream infection among St Louis Children’s Hospi-
tal PICU patients. Risk factors for bloodstream infection
were related more to process of care than to severity of
illness. Additional research is needed to develop inter-
ventions to reduce nosocomial bloodstream infections in
children. Pediatrics 2002;110:481– 485; pediatric intensive
care unit, nosocomial, bloodstream infection.
From the Division of Infectious Diseases, Departments of *Internal Medi-
cine and ‡Pediatrics, Washington University School of Medicine, St Louis,
Missouri.
Received for publication Dec 17, 2001; accepted Apr 3, 2002.
Reprint requests to (V.J.F.) Infectious Diseases Division, Washington Uni-
versity School of Medicine, Campus Box 8051, 660 S Euclid Ave, St Louis,
MO 63110. E-mail: vfraser@im.wustl.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 110 No. 3 September 2002
Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
ABBREVIATIONS. PICU, pediatric intensive care unit; NNIS, Na-
tional Nosocomial Infections Surveillance; SLCH, St Louis Chil-
dren’s Hospital; PRISM III, Pediatric Risk of Mortality; aOR, ad-
justed odds ratio; CI, confidence interval.
B
loodstream infections represent a major cause
of hospital-acquired infections in pediatric in-
tensive care unit (PICU) patients.1,2 According
to the 1999 National Nosocomial Infections Surveil-
lance (NNIS) report,2 bloodstream infections (28%)
are the most frequent nosocomial infection reported
in PICUs, followed by ventilator-associated pneumo-
nias (21%). PICUs have one of the highest central
venous catheter-associated bloodstream infection
rates—7.7 infections per 1000 central venous catheter
days—with only burn units and neonatal intensive
care units surpassing these rates of bloodstream in-
fection.5 Coagulase-negative staphylococci (38%) are
the most common pathogen, although Gram-nega-
tive rods are isolated in 25% of PICU patients with
bloodstream infections.2
The majority of literature concerning bloodstream
infection is generated from studies of critically ill
adult patients. In adults, independent risk factors for
developing bloodstream infections include pro-
longed hospitalization, severity of illness at admis-
sion, comorbidities, exposure to invasive procedures,
inappropriate antimicrobial therapy, immunosup-
pressive therapy, use of steroids, parenteral nutri-
tion, and histamine type-2 receptor blockers.1,7–11
Critically ill adult patients with bloodstream infec-
tions have a longer hospital length-of-stay, higher
treatment costs, and greater risks for mortality.3 In a
cohort of critically ill adult surgical patients, the ex-
cess hospital length-of-stay resulting from blood-
stream infection is 24 days.3 The mean attributable
cost of bloodstream infection is $40 000 per survivor,
and the attributable mortality rate is 35%.3 Unfortu-
nately, the substantial amount of literature on the
epidemiology of nosocomial infections in adults can-
not be directly extrapolated to children because of
the significant differences between adults and chil-
dren which include age, underlying medical condi-
tions, process of care, and type and distribution of
pathogens.2,4,5
Most PICUs care for a heterogeneous population
of children of varying age, diagnosis, and underlying
illness, ranging from infants with congenital anom-
alies to adolescents with multiple traumas. Conse-
quently, even patients admitted to the same PICU
may differ substantially in their risk for nosocomial
481
infections. Additional epidemiologic studies in PICU
patients in nonoutbreak settings are necessary to bet-
ter understand the scope of the problem to develop
interventions. We performed a prospective cohort
study to determine the rate, risk factors, and out-
comes of bloodstream infection in PICU patients.
METHODS
Setting
This study was performed at St Louis Children’s Hospital
(SLCH), a 235-bed teaching hospital affiliated with Washington
University School of Medicine. SLCH is located in the metropol-
itan St Louis area and has a 300-mile radius referral base in
southeastern Missouri and southwestern Illinois. SLCH has a com-
bined medical and surgical PICU with 22 beds. There are ⬃1400
admissions per year. In April 2000, a new facility for the PICU
opened with an increase to a 28-bed capacity. In the new facility,
patient rooms are separated by walls rather than curtains, and
each room has a sliding glass door and a sink placed next to the
door. In the old facility there were 12 sinks and 22 beds. The
agents for handwashing are Triclosan soap and Alcare alcohol
foam, both by Steris (Mentor, OH).
Patients
Since September 1999, there has been an ongoing prospective
cohort study of nosocomial infections in the PICU. Participants for
this study were patients admitted to the PICU between September
1, 1999, and May 31, 2000, excluding patients who were older than
18 years of age, died within 24 hours of admission, or were
neonatal intensive care unit patients on extracorporeal membrane
oxygenation occupying PICU bed space. Approval was obtained
from the Washington University School of Medicine Institutional
Review Board; a waiver of informed consent was requested and
granted.
Data Collection
All eligible study patients were monitored for the development
of nosocomial infections from the day of PICU admission until 48
hours after PICU discharge. Data on demographics, underlying
medical conditions, surgeries and procedures performed, use of
antibiotics, steroids, stomach acid suppressants and immunosup-
pressants, hospital length of stay, PICU length of stay, PICU
discharge disposition, central venous catheter days, and ventilator
days were collected from the medical records and daily flow
sheets by 1 of the investigators (A.M.E.). The variable “procedures
performed in the PICU” was a composite variable, describing the
location in which procedures such as intubation, arterial and
central venous catheter placement, mediastinal exploration, and
initiation of extracorporeal membrane oxygenation occurred. Ad-
mission severity of illness was calculated using the Pediatric Risk
of Mortality (PRISM III) score, which is a weighted score, esti-
mated using 17 physiologic parameters from the first 24 hours of
PICU admission.12 Information on potential risk factors was col-
lected on both cases and noncases throughout the duration of
PICU stay. Antibiotic-coated central venous catheters are not used
in this PICU. Patients with ⬎1 central venous catheter placed were
defined as having “multiple central venous catheters.” “Transport
out of the PICU” was defined as the physical movement of the
patient out of the intensive care unit to the radiology department,
operating room, or cardiac catheterization laboratory; specific des-
tinations were not evaluated separately in the multivariate anal-
ysis. There were no clusters of infection or outbreaks during the
study period.
Definitions
Centers for Disease Control and Prevention (CDC) definitions
were used to diagnose nosocomial primary bloodstream infec-
tions.13 Primary bloodstream infection cases were diagnosed with
bacteria or fungi in their blood, which were not present or incu-
bating before hospital admission and without evidence of other
localized infections. Microorganisms causing bloodstream infec-
tion were isolated using routine blood cultures and their antibiotic
susceptibility profiles were obtained from laboratory reports. Co-
agulase-negative Staphylococcus species was reported as a cause of
482 NOSOCOMIAL BLOODSTREAM INFECTIONS IN PICU PATIENTS
Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
bloodstream infection only if 2 or more blood cultures drawn on
different occasions were positive for coagulase-negative Staphylo-
coccus sp. Staphylococcal strains were not speciated. In children
with ⬎1 episode of nosocomial bloodstream infection, only the
first episode of bloodstream infection was analyzed.
Data Analysis
SPSS Version 10 (SPSS Inc, Chicago, IL) was used in the statis-
tical analysis. Differences between means were analyzed by Wil-
coxon rank sum for nonnormally distributed variables and differ-
ences in distribution of categorical variables were analyzed using
the ␹2 test. All statistical tests were 2-tailed, and a P value of ⬍.01
was considered significant. Clinically relevant statistically signif-
icant variables from univariate analysis were used to create a
logistic regression model to assess the differences between pa-
tients with and without bloodstream infection. Variables affecting
⬍10% of patients were not considered for entry into the logistic
regression model. Regression diagnostics were used to identify
outliers and colinearities. Outliers were checked and corrected for
mistakes. When colinearity was detected between variables, only
the variable with the highest effect size was kept in the regression
model and others were recoded. The fit of the model was tested
using the Hosmer and Lemeshow test.
RESULTS
A total of 911 patients were admitted to the PICU
between September 1, 1999, and May 31, 2000. Pa-
tient demographics are reported in Table 1. There
was a white predominance (74%). Slightly over half
of the patients were male (58%). Approximately half
of the patient population was under 3 years of age.
Congenital heart disease (29%), lung disease (25%),
and genetic syndrome (18%) were common. Less
than 5% of the patient population were admitted
because of immunodeficiency, diabetes, renal dis-
ease, multiple trauma, or burn. Fifty percent of the
patients had an arterial catheter, and 12% had mul-
tiple central venous catheters. Seventy percent were
mechanically ventilated, and 30% had 1 or more
transfusions during their stay in the PICU.
Fifty-seven children developed 65 episodes of pri-
mary bloodstream infections during their PICU stay.
Five episodes of bloodstream infection were polymi-
crobial, and 7 patients had multiple bloodstream in-
fections. The rate of bloodstream infection in this
population was 13.8 per 1000 central venous catheter
days. The most common causative microorganisms
are reported in Table 2. Gram-positive bacteria were
responsible for most of these infections (55%). Coag-
ulase negative Staphylococcus (n ⫽ 28) was the lead-
ing cause of bloodstream infection, followed by En-
terobacter cloacae (n ⫽ 8). Candida species were
responsible for all 5 episodes of fungemia. There
were insufficient numbers of cases caused by any 1
organism to determine relationships between organ-
ism type and patient characteristics.
The mean time to bloodstream infection was 11.7
days, median 10 days (range: 2–33 days).
Univariate analysis of differences in characteristics
of patients with and without bloodstream infections
is summarized in Table 1. Only factors occurring in
⬎10% of patients are reported in this table. Age,
gender, and ethnicity were not significantly different
between patients with and without bloodstream in-
fections. Severity of illness at admission (PRISM III
score) was higher in patients with bloodstream in-
fections. A higher proportion of patients with blood-
TABLE 1. Patient Demographics and Univariate Analysis of 911 PICU Patients With and Without Bloodstream Infections
Characteristics Total BSI No BSI P
N ⫽ 911 (%) N ⫽ 57 (%) N ⫽ 854 (%) Value
Demographics
Mean age (y) ⫾ SD 5.5 ⫾ 5.9 3.5 ⫾ 6.0 5.6 ⫾ 5.9 .182
PRISM III score ⫾ SD 8.5 ⫾ 6.1 11.2 ⫾ 8.6 6.0 ⫾ 6.2 .001
Caucasian 674 (74) 41 (71.9) 633 (74.1) .548
Male 526 (58) 33 (57.9) 493 (57.7) .409
Underlying illness
Failure to thrive 57 (6.2) 9 (15.8) 48 (5.6) .007
Lung disease 226 (25) 10 (17.5) 216 (25.3) .112
Genetic syndrome 161 (18) 19 (33.3) 142 (16.6) .002
Congenital heart disease 264 (29) 32 (56.1) 232 (27.2) .001
Device utilization
Multiple central catheters 110 (12) 36 (63.2) 74 (8.7) .001
Central venous catheter 281 (30.8) 44 (77.2) 237 (27.8) .001
Arterial catheter 460 (50) 53 (93.0) 407 (47.7) .001
Mechanical ventilation 646 (71) 54 (94.7) 592 (69.3) .001
Surgeries and procedures
Neurosurgery 163 (17.9) 4 (7.0) 159 (18.6) .009
Dialysis 24 (2.6) 7 (12.3) 17 (2.0) .001
Transplant 49 (5.4) 7 (12.3) 42 (4.9) .028
Cardiovascular surgery 180 (19.8) 22 (38.6) 158 (18.5) .001
Transfusion 270 (29.6) 30 (52.6) 240 (28.1) .001
Other minor surgeries 85 (9.3) 14 (24.6) 71 (8.3) .001
Locations of procedures performed
Outside hospitals 84 (9.2) 6 (10.5) 78 (9.1) .432
Cardiac catheterization lab 60 (6.6) 12 (21.1) 48 (5.6) .001
Operating room 526 (57.7) 40 (70.2) 486 (56.9) .032
PICU 212 (23.3) 42 (73.7) 170 (19.9) .001
Medications
Transplant immunosuppression 46 (5.1) 11 (20.3) 35 (4.1) .001
Histamine-2 receptor blockers 207 (22.7) 21 (36.8) 186 (21.8) .009
Steroids 273 (30) 26 (45.6) 247 (28.9) .001
Inotropes 163 (17.9) 28 (49.1) 135 (18.5) .001
Total parenteral nutrition 127 (13.9) 34 (59.6) 93 (10.9) .001
Antimicrobial therapy 698 (76.6) 56 (98.2) 642 (75.1) .007
Others
Readmitted to PICU 58 (6.4) 11 (19.2) 47 (5.5) .001
Transferred 153 (16.8) 18 (31.6) 135 (15.8) .003
Transport out of PICU 123 (13.5) 28 (49.1) 95 (11.1) .001
SD indicates standard deviation.

TABLE 2. Causative Pathogens of Bloodstream Infections TABLE 3. Logistic Regression Analysis: Independent Risk
Factors for Bloodstream Infection
Microorganisms Bloodstream Infections
N ⫽ 65 (%) Risk Factors aOR P Value
(95% CI)
Gram-positive bacteria
Coagulase-negative Staphylococcus 28 (43.0) Multiple venous catheters 5.7 (2.9–10.9) .001
Staphylococcus aureus 3 (4.6) Arterial catheter 5.5 (1.8–16.3) .002
Enterococcus spp 3 (4.6) Procedures performed in PICU 4.0 (2.0–7.8) .001
Gram-negative bacteria Transport out of PICU 3.4 (1.8–6.7) .001
Enterobacter cloacae 8 (12.3)
Pseudomonas aeruginosa 6 (9.2) The Hosmer and Lemeshow test significance was 0.39, and the ⫺2
Klebsiella pneumoniae 4 (6.1) log likelihood was 279.4
Serratia marcescens 4 (6.1)
Escherichia coli 1 (1.5)
Acinetobacter spp 1 (1.5) of bloodstream infection, as there were fewer pa-
Fungus tients with femoral and nontunneled subclavian cen-
Candida spp 5 (7.6)
tral venous catheters, and often these sites were used
to place subsequent central venous catheters.
Logistic regression analysis was used to identify
stream infection received transplants, immunosup- independent risk factors for bloodstream infections
pressive agents, histamine type-2 receptor blockers, (Table 3). Patients who had multiple central venous
total parenteral nutrition, antimicrobial agents, and catheters (adjusted odds ratio [aOR]: 5.7; 95% confi-
steroids. Patients with underlying medical condi- dence interval [CI]: 2.9 –10.9) and arterial catheters
tions, invasive devices, and those who underwent (aOR: 5.5; 95% CI: 1.8 –16.3) were nearly 6 times more
surgeries had an increased risk for developing blood- likely to develop bloodstream infections than pa-
stream infections in the univariate analysis. tients who were not exposed to these factors. Patients
Most central venous catheters were placed in the who had invasive procedures performed in the PICU
internal jugular vein. It was not possible to assess the (aOR: 4.0; 95% CI: 2.0 –7.8) or those who were trans-
relationship between site of catheterization and risk ported out of the PICU (aOR: 3.4; 95% CI: 1.8 – 6.7)

ARTICLES 483
Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
were also at increased risk for acquiring bloodstream
infections. Severity of illness at admission, underly-
ing medical conditions, length of stay before infec-
tion, and medications used before infection were not
independent risk factors for bloodstream infection in
the logistic regression analysis.
Univariate analysis of the outcomes of blood-
stream infection revealed that patients with blood-
stream infections had longer PICU (24.4 ⫾ 26.5 vs
4.1 ⫾ 11.5 days) and hospital (41.2 ⫾ 38.4 vs 13.0 ⫾
24.9 days) length of stay. The crude mortality rate
associated with bloodstream infection was 19.2%.
DISCUSSION
We performed a prospective cohort study to de-
termine the rate, risk factors, and outcomes associ-
ated with bloodstream infection in PICU patients.
The incidence of bloodstream infection is 13.8/1000
central venous catheter days, which is within the
75th to 90th percentile reported by NNIS.2 The dis-
tribution of causative microorganisms for blood-
stream is similar to what has been reported in the
NNIS data.2 These infections are predominantly
caused by Gram-positive organisms, mostly coagu-
lase-negative Staphylococcus species. Enterobacter sp
was the most common Gram-negative species re-
ported in PICU patients with bloodstream infections.
In multivariate analysis, risk factors related to pro-
cess of care, specifically multiple central venous cath-
eters, arterial catheters, procedures performed in the
PICU, and transport out of the PICU were associated
with bloodstream infection. Underlying medical con-
ditions, severity of illness at admission, and length of
PICU or hospital stay were not associated with
bloodstream infection in logistic regression analysis.
The presence of an arterial catheter or multiple
central venous catheters also increased the risk for
developing bloodstream infections. Arterial catheters
are frequently used in the management of critically
ill patients for continuous blood pressure monitor-
ing, and to obtain blood gas measurements. Frequent
sampling through stopcocks may lead to increased
opportunity for introduction of microorganisms into
these catheters. Contamination of central venous
catheters at the time of insertion or when accessing
the catheter may lead to subsequent development of
catheter-related infections.14 Measures to reduce
catheter-related bloodstream infection that have
proven effective in adults include adherence to max-
imal sterile and barrier precautions during catheter
placement, meticulous attention to CDC guidelines
for catheter care, adherence to proper hand-washing
practices, minimization of the number of people ma-
nipulating the catheters, and limitation of multiple
uses for central venous catheters.14 –16 The SLCH
PICU has a written policy for central venous catheter
insertion and care that closely adheres to the CDC
guidelines, recommending maximal sterile barrier
precautions for insertion; use of betadine or alcohol
before accessing central venous catheters; keeping
catheters clamped, capped, or connected to running
fluids at all times; and minimizing the number of
times the catheter is accessed when possible. No
484 NOSOCOMIAL BLOODSTREAM INFECTIONS IN PICU PATIENTS
Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
specific policies or procedures exist for the manage-
ment of arterial catheter stopcocks.
Patients who had procedures performed in the
PICU and those who were transported out of PICU
to the radiology or operating room suites were also
at higher risk for bloodstream infection. Breach of
sterile technique during procedures and patient
transport may predispose these patients to the risk of
infections. Adhering to strict aseptic techniques, min-
imizing the number of staff handling a patient, and
increasing access to disinfectants and sterile gloves
during procedures and patient transport may reduce
bloodstream infections.
There are a few limitations to this study. This
study was performed at a single academic tertiary
care center, so results from this study may not di-
rectly apply to other institutions with different pa-
tient populations and medical practices. Because the
data were obtained over the course of only 9 months
between September and May, seasonal variations in
frequency of bloodstream infection and causative mi-
croorganism could not be assessed. Severity of illness
(PRISM III score) was calculated only at admission,
and this score probably does not reflect severity of
illness at the time of infection, especially as the me-
dian time to bloodstream infection was 10 days. The
prospective cohort study design limited our ability to
determine the attributable excess mortality and
length of stay resulting from bloodstream infection.
A more appropriate study design to determine the
attributable morbidity and mortality of bloodstream
infection is a nested case-control study matching pa-
tients on severity of illness at the time of infection,
which is planned.
The risk factors identified in this study are differ-
ent from those described for adults and are more
related to the processes of care. This study identified
several areas where implementation of preventive
strategies could reduce a large proportion of noso-
comial infections. Additional analysis is needed to
estimate the attributable morbidity, mortality, and
economic impact of bloodstream infections in the
PICU.
ACKNOWLEDGMENTS
This work was supported by grants from Zeneca through the
Pediatric Infectious Diseases Society (Dr Elward), and in part by
Centers for Disease Control and Prevention cooperative agree-
ment UR8/CCU715087 (Dr Fraser).
REFERENCES
1. Milliken J, Tait GA, Ford-Jones EL, et al. Nosocomial infections in a
pediatric intensive care unit. Crit Care Med. 1988;16:233–237
2. Richards MJ, Edwards JR, Culver DH, Gaynes RP, and the National
Nosocomial Infections Surveillance System. Nosocomial infections in
the pediatric intensive care units in the United States. Pediatrics. 1999;
103(4). Available at: http://www.pediatrics.org/cgi/content/full/103/
4/e39
3. Pittet D, Terara D, Wenzel RP. Nosocomial bloodstream infection in
critically ill patients: Excess length of stay, extra costs and attributable
mortality. JAMA. 1994;271:1598 –1601
4. Richards MJ, Edwards JR, Culver DH, Gaynes RP, and the National
Nosocomial Infections Surveillance System. Nosocomial infections in
medical intensive care units in the United States. Crit Care Med. 1999;
27:887– 892
5. Centers for Disease Control and Prevention. Monitoring hospital-
 acquired infections to promote patient safety-United States, 1990 –1999.
MMWR Morb Mortal Wkly Rep. 2000;49:149 –153
6. Haley RW, Culver DH, White JW, et al. The efficacy of infection sur-
veillance and control programs in preventing nosocomial infections in
US hospitals. Am J Epidemiol. 1985;12:182–205
7. Pittet D, Harbarth S, Ruef C, et al. Prevalence and risk factors for
nosocomial infections in four university hospitals in Switzerland. Infect
Control Hosp Epidemiol. 1999;20:37– 42
8. Singh-Naz N, Sprague BM, Patel KM, Pollack MM. Risk factors for
nosocomial infection in critically ill children: a prospective cohort study.
Crit Care Med. 1996;24:875– 878
9. Tokars JI, Cookson ST, McArthur MA, Boyer CL, McGeer AJ, Jarvis WR.
Prospective evaluation of risk factors for bloodstream infection in pa-
tients receiving home infusion therapy. Ann Intern Med. 1999;131:
340 –347
10. Velasco E, Thuler L, Martin L, Dias V, Goncalves V. Risk factor for
bloodstream infections at a cancer center. Eur J Clin Microbiol Infect Dis.
1998;17:587–590
11. Wey SB, Mori M, Pfaller MA, Woolson RF, Wenzel PR. Risk factors for
hospital-acquired candidemia: a matched case-control study. Arch In-
tern Med. 1989;149:2349 –2353
12. Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric
risk of mortality score. Crit Care Med. 1996;24:743–752
13. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definition
for nosocomial infections. In: Olmsted RN, ed. Infection Control and
Applied Epidemiology: Principle and Practice. St Louis, MO: Mosby; 1996:
A1–A20
14. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous
catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238
15. Pearson ML, for the Hospital Infection Control Advisory Committee.
Guidelines for prevention of intravascular device-related infections.
Am J Infect Control. 1996;24:262–293
16. Nystrom B. Impact of handwashing on mortality in intensive care:
examination of the evidence. Infect Control Hosp Epidemiol. 1994:15:
435– 436

HEARING LOSS AND CONNEXIN 26

“In the industrialized world, deafness of infective and/or environmental origin

has become less frequent, with a consequent rise in the proportion of hereditary
hearing impairment. Deafness occurs in 1:1000 neonates and the cause is hereditary
in about half. This type of hearing impairment is sometimes referred to as prelin-
gual, as it affects the child before the age of speech development. A distinction can
be made between syndromic deafness, in which the deafness is accompanied by
other specific abnormalities, and nonsyndromic deafness (approximately 75%), in
which there are no additional abnormalities. Approximately three-quarters of the
nonsyndromic forms are caused by a recessive disorder. . .On the Hereditary
Hearing Loss Home page all these currently know forms of hereditary deafness are
summarized.”

Kemperman MH, Hoefsloot LH, Cremers CWRJ. Hearing loss and connexin 26. J Royal Soc Med.
2002;95:171–177
Van Camp G, Smith RJH. Hereditary Hearing Loss Homepage. Available at: http://dnalab-www.
uia.ac.be/dnalab/hhh. Accessed January 22, 2002

ARTICLES 485
Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014
Rate, Risk Factors, and Outcomes of Nosocomial Primary Bloodstream Infection
in Pediatric Intensive Care Unit Patients
Jeya S. Yogaraj, Alexis M. Elward and Victoria J. Fraser
Pediatrics 2002;110;481
DOI: 10.1542/peds.110.3.481
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/110/3/481.full.ht
ml
Citations This article has been cited by 17 HighWire-hosted articles:
http://pediatrics.aappublications.org/content/110/3/481.full.ht
ml#related-urls
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Infectious Diseases
http://pediatrics.aappublications.org/cgi/collection/infectious_
diseases_sub
Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xht
ml
Reprints Information about ordering reprints can be found online:
http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright © 2002 by the American Academy of Pediatrics. All rights
reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Eccles Health Sciences Lib on November 30, 2014