Healthcare-Associated Infections in Pediatric Intensive Care Units in Turkey: a National Point-Prevalence Survey

Abstract

Health care-associated infections (HCAIs) cause considerable morbidity and mortality in pediatric intensive care units (PICUs). The objective of this point prevalence study was to assess the burden of HCAIs in PICUs in Turkey. Fifty PICUs participated in this study. Data regarding demo-graphics, microbiological findings, therapeutic interventions, and outcomes were collected for all PICU inpatients. A total of 327 patients participated in the study: 122 (37z) experienced 1 or more HCAI. The most frequently reported site of infection was lower respiratory tract (n＝77, 63z). The most frequently isolated pathogens were Pseudomonas aeruginosa, Acinetobacter species, and Candida species. Two hundred and forty-seven patients (75z) were receiving antimicrobial therapy at the time of the survey , and the most frequently administered antimicrobials were third generation cephalosporins. Hospital type, male, PICU stay ＞7 days, and mechanical ventilation were found to be independent risk factors for HCAIs. At the 4-week follow up, 43 (13z) patients had died, 28 (65z) of whom died of HCAIs. Endotracheal intubation, urinary catheter, male, and HCAIs were independent risk factors for mortality. This national, multicenter study documented a high prevalence of HCAIs in Turkey. In light of thèprimum non nocere' principle, the prevention of these infections should be a priority of public health policy.

Full text

381
Received September 3, 2014. Accepted November 17, 2014.
J-STAGE Advance Publication March 13, 2015.
DOI: 10.7883/yoken.JJID.2014.385
*Corresponding author: Mailing address: Division of
Pediatric Infectious Diseases, Department of Pediatrics,
Marmara University Pendik Training and Research
Hospital, Mimar Sinan Street, No:41, Fevzi Cakmak
Mah. Ust Kaynarca, Pendik, Istanbul, Turkey. TEL:
＋
90-216-625-4725, FAX:
＋
90-216-625-4712, E-mail:
asoysal
＠
marmara.edu.tr
**Members of Study Group are listed in the Appendix.
381
Jpn. J. Infect. Dis., 68, 381–386, 2015
Original Article
Healthcare-Associated Infections in Pediatric Intensive Care Units in Turkey:
a National Point-Prevalence Survey
Eda Kepenekli
1
, Ahmet Soysal
1
*, Nilufer Yalindag-Ozturk
2
, Ozlem Ozgur
3
, Ismail Ozcan
4
,
Ilker Devrim
5
, Selahattin Akar
6
,MustafaBakir
1
, and Turkish PICU-HCAI Study Group**
1
Division of Pediatric Infectious Diseases;
2
Pediatric Intensive Care Unit, Department of Pediatrics, Marmara University Pendik Training and
Research Hospital, Istanbul;
3
Diyarbakir Children's Hospital, Diyarbakir;
4
Bursa Dortcelik Children's Hospital, Bursa;
5
Behcet Uz Children's Hospital, Izmir; and
6
Mus State Hospital, Mus, Turkey
SUMMARY: Health care-associated infections (HCAIs) cause considerable morbidity and mortality in
pediatric intensive care units (PICUs). The objective of this point prevalence study was to assess the bur-
den of HCAIs in PICUs in Turkey. Fifty PICUs participated in this study. Data regarding demo-
graphics, microbiological findings, therapeutic interventions, and outcomes were collected for all PICU
inpatients. A total of 327 patients participated in the study: 122 (37
z
) experienced 1 or more HCAI.
The most frequently reported site of infection was lower respiratory tract (
n
＝
77, 63
z
). The most fre-
quently isolated pathogens were
Pseudomonas aeruginosa, Acinetobacter
species, and
Candida
species.
Two hundred and forty-seven patients (75
z
) were receiving antimicrobial therapy at the time of the sur-
vey, and the most frequently administered antimicrobials were third generation cephalosporins.
Hospital type, male, PICU stay
＞
7 days, and mechanical ventilation were found to be independent risk
factors for HCAIs. At the 4-week follow up, 43 (13
z
) patients had died, 28 (65
z
) of whom died of
HCAIs. Endotracheal intubation, urinary catheter, male, and HCAIs were independent risk factors for
mortality. This national, multicenter study documented a high prevalence of HCAIs in Turkey. In light
of the `primum non nocere' principle, the prevention of these infections should be a priority of public
health policy.
INTRODUCTION
Healthcare-associated infections (HCAIs), or nosoco-
mial infections, are a significant cause of morbidity and
mortality. HCAI surveillance is important for effective
infection control. Although cross-sectional prevalence
studies cannot establish causality, these types of studies
can help characterize the epidemiology of HCAIs and
their associated risk factors. HCAIs are more common
in intensive care units than in any other hospital ward
(1–3). Because of more frequent medical device use and
contact with healthcare workers. Most of the current
HCAI literature focuses on adults, therefore, data re-
garding pediatric intensive care unit (PICU)-acquired
HCAIs and related risk factors are limited. Previous
studies have shown that prevalence of PICU-acquired
infections ranges from 9.1
z
to 42.5
z
(2,4–8).
Although its HCAI surveillance system has been in
place since 2003, data regarding infection rates, device
utility rates, and antimicrobial resistance rates in Tur-
key, a country that is still developing, are limited. Fur-
thermore, HCAI risk factors and related co-morbidities
and mortalities have not been examined. In addition, no
nationwide, multicenter studies have investigated
HCAIs and risk factors in PICU patients.
In light of this gap in the literature, this study investi-
gated the prevalence and risk factors associated with
PICU-acquired HCAIs in Turkey. We also examined
microbiological data, antimicrobial usage, and device
utilization. This represents the first PICU-focused, mul-
ticenter, point-prevalence survey of HCAIs in Turkey.
MATERIALS AND METHODS
A point-prevalence survey was conducted in PICUs
certificated by the Ministry of Health and part of the
Pediatric Emergency and Intensive Care Association.
Pediatric specialists and pediatric infectious disease
specialists at all 58 PICUs in state, university, or
training/research hospitals in Turkey were invited to
participate. Among them, 50 PICUs agreed to partici-
pate in the study, while 8 were excluded because of non
satisfactory compliance. Neonatal intensive care units,
pediatric surgery intensive care units, adult intensive
care units, and private hospitals were also excluded
from the study. Parental informed consent forms and
PICU-acquired HCAI questionnaires were sent to all
participating PICUs. Guidelines regarding the defini-
tion of HCAIs and criteria for specific types of infec-
tions in the acute care setting outlined by the Center for

382
Table 1. Therapeutic interventions on survey date
Therapeutic
intervention
No. of
patients
n
(
z
)
Mean duration
day
Median
duration
day
Device
utility
ratio
1)
Central venous
catheter 100 (30.6) 5
±
19
(range, 0–280) 90.084
Urinary catheter 102 (31.2) 4
±
11
(range, 0–102) 70.063
Endotracheal tube 114 (34.9) 12
±
90
(range, 0–1,490) 90.203
Mechanical
ventilation 158 (48.3) 52
±
199
(range, 0–1,825) 18 —
Tracheostomy 48 (14.7) 29
±
153
(range, 0–1,825) 58 —
Total parenteral
nutrition 73 (22.3) 4.8
±
18
(range, 0–244) 9—
Nasogastric feeding
tube 202 (61.8) 25
±
140
(range, 0–1,825) 4—
Chest tube 12 (3.7) 8
±
13
(range, 1–49) 2—
Gastrostomy 23 (7.0) 384
±
555
(range, 0–2,190) 210 —
Port catheter 7 (2.1) 67
±
73
(range, 3–210) 60 —
Peritoneal dialysis
catheter 6(1.8) 2
±
13
(range, 1–39) 8—
Hemodialysis
catheter 10 (3.1) 36
±
71
(range, 1–237) 13 —
Ventriculoperitoneal
shunt 10 (3.1) 748
±
1,753
(range, 17–5,700) 125 —
H2 blocker 120 (36.7) 25
±
62
(range, 1–545) 9—
Steroid treatment 72 (22.0) 15
±
25
(range, 1–180) 5—
Extracorporeal mem-
brane oxygenation 0(0.0) — — —
1)
: Device utility ratio, device utility day(s)/patient day(s).
382
Disease Control and Prevention (CDC) were used to
identify the type of infection (9). All hospitals that par-
ticipated in this study had a hospital infection control
committee for the prevention and follow up of HCAIs.
The survey was conducted on September 27, 2012.
The study population was defined as all patients
occupying a bed in the PICU on the day of the survey.
Data were collected via questionnaire. Demographic
information (i.e. age and sex), primary diagnosis, date
of hospital and PICU admission, co-morbidities (e.g.,
renal or hepatic insufficiency, malignancy, or surgical
wound), type of therapeutic intervention (e.g., central
intravascular catheters, urinary catheters, endotracheal
intubation/mechanical ventilation, tracheostomy, naso-
gastric or nasoduodenal feeding tubes, chest tubes,
extracorporeal membrane oxygenation, or dialysis
catheters), total parenteral nutrition (TPN), the types of
antimicrobial agent administered, total PICU patient-
days, and hospital patient-days were recorded for each
patient. The standard definition for HCAI was used (9).
The data were collected by a pediatric, PICU, or
pediatric infectious disease specialist. All data were
reviewed by a HCAI control program-certificated
pediatric infectious disease specialist prior to the final
analysis. The data were re-evaluated by participating
authorsifnecessary.Patient outcomes were evaluated 1
month post-survey by comparing the number of overall
and HCAI-related deaths among the study participants.
Informed consent forms were signed by the parents of
each participating patient. No parent refused to partici-
pate in this non-interventional study. Records, ques-
tionnaires, and informed consent forms were centrally
collected. The Marmara University Medical Faculty
Ethical Committee and Review Board served as the
central ethics committee and approved the study for all
participating hospitals on September 20, 2012.
Statistical analysis: Data were entered into Microsoft
Office Excel 2007 (Microsoft, Redmond, WA, USA)
and analyzed using Stata 10.0 Statistics/Data Analysis
(StataCorp, Lakeway Drive, TX, USA). The prevalence
of PICU-acquired HCAIs was calculated by dividing
the number of infections by the total number of
patients. Chi-square and Fisher's exact tests were used
for univariate analyses of categorical variables. A mul-
tivariate analysis to evaluate the effects of potential con-
founders was performed using stepwise forward logistic
regression modeling. The device utility ratio was calcu-
lated by dividing the total number of device use-days by
the number of patient-days.
RESULTS
Hospital and PICU profiles: Fifty hospitals from 27
different cities, serving 67
z
of the Turkish population
participated in this study. Eleven (22
z
) were state hos-
pitals, 29 (58
z
) were university hospitals, and 10 (20
z
)
were training/research hospitals. All hospitals had 1
general PICU with a median of 7 beds (range, 3–22;
mean, 9).
Patient demographics: At the time of the survey, 327
patients were hospitalized in the 50 participating
PICUs. All 327 PICU patients were surveyed. The me-
dian age of the patients was 20 months (range, 1–216
months; mean, 48 months) and more than half (56
z
)
were male. One hundred and two patients (31
z
)were
treated at state hospitals, while 225 (69
z
) were treated
at university or training/research hospitals. The most
frequently reported primary diagnostic categories were
lower respiratory tract infections with concomitant dis-
eases (38
z
) (e.g., neuromuscular disorders, congenital
heart diseases, immune deficiencies, or malignancy),
neuromuscular disorders (15
z
) (e.g., epilepsy, my-
opathy, encephalitis, or meningitis), and sepsis (5
z
).
On the day of the survey, the participating patients had
been in the hospital for a median of 14 days (range,
1–1,825 days; mean, 61 days) and in the PICU for a me-
dian of 10 days (range, 1–1,825 days; mean, 54 days).
Therapeutic interventions: The type of therapeutic in-
tervention is presented in Table 1. One-third of patients
received at least 1 major therapeutic intervention (e.g., a
central venous catheter (
n
＝
100, 31
z
), urinary
catheter (
n
＝
102, 31
z
), or endotracheal tube (
n
＝
114, 35
z
) and half of the patients (
n
＝
158, 48
z
)
received mechanical ventilation.
Prevalence of PICU-acquired HCAIs: PICU-ac-
quired infections were reported by all participating hos-
pitals. A total of 122 patients (37
z
) were diagnosed
with PICU-acquired HCAIs at the time of the survey
(9). Of these, 17 (14
z
) patients had more than 1 type of
infection. The most common HCAI was ventilator-as-
sociated pneumonia (VAP). Table 2 shows the preva-
lence of each type of HCAI.
HCAI microbiological data: Causative microorgan-

383
Table 2. Pediatric intensive care unit-acquired healthcare-associ-
ated infection (HCAI) prevalences on survey date
HCAI No. of patients
(total, 327)
n
(
z
)
Lower respiratory
tract infection Lower respiratory tract
infection other than
pneumonia
2(0.6)
Pneumonia 32 (9.8)
1)
Ventilator-associated
pneumonia 43 (13.1)
1)
Blood stream
infection (BSI) Laboratory-confirmed BSI 24 (7.3)
1)
Clinical sepsis 10 (3.1)
Central line-associated BSI 4 (1.2)
1)
Urinary tract
infection (UTI) Symptomatic UTI 3 (0.9)
Asymptomatic bacteriuria 2 (0.6)
Catheter-associated UTI 5 (1.5)
1)
Gastrointestinal system infection 3 (0.9)
1)
Skin and soft tissue infection 5 (1.5)
1)
Eye, ear, nose, throat, or mouth infection 2 (0.6)
1)
Surgical site infection 1 (0.3)
Central nervous system infection 3 (0.9)
1)
Cardiovascular system infection 0 (0.0)
Systemic infection 0 (0.0)
Reproductive tract infection 0 (0.0)
Total 139 infections/
122 patients
1)
1)
: Seventeen patients had more than 1 type of HCAI.
383
PICU-acquired HCAIs in Turkey
isms were isolated in 71 (58
z
) patients with HCAIs. A
single causative agent was responsible for the infection
in 52 patients (43
z
), whereas the infection was poly-
microbial for 19 patients (16
z
). The most frequently
reported isolates for PICU-acquired HCAIs were:
Pseu-
domonas aeruginosa
cases (
n
＝
30, 25
z
),
Acinetobac-
ter
species cases (
n
＝
18, 15
z
), and
Candida
species
cases (
n
＝
9, 7
z
) (Table 3). The carbapenem suscepti-
bility rate of
Pseudomonas
isolates was 71
z
. According
to the antimicrobial susceptibility test results, 10 of 12
Acinetobacter
isolates were susceptible to colistin, while
2 were found to be intermediately susceptible. Causative
microorganisms were isolated in 14 of 32 pneumonia
patients and in 23 of 43 VAP patients. The most com-
monisolatesinbothcaseswere
Pseudomonas
species.
In addition, the most common isolates in laboratory-
confirmed bloodstream infections were
Candida
spe-
cies.
Antimicrobial interventions: At the time of the suvey,
247 patients (76
z
) were receiving antimicrobial ther-
apy. Of these, 101 received antibiotic monotherapy
while 73 received 2 different antibiotics, 55 received 3,
15 received 4, and 3 received 5. The most frequently
administered antibiotics were third-generation cephalo-
sporins (
n
＝
61, 19
z
), followed by carbapenems (
n
＝
44, 13
z
), and glycopeptide antibiotics (
n
＝
31, 9
z
).
Risk factors for PICU-acquired HCAI: The univari-
ate analysis and multivariate analysis identified signifi-
cant risk factors for PICU acquired-HCAIs (Table 4).
Hospital type, PICU stay (
＞
7 days), central venous
catheter, central venous catheter duration (
＞
7 days),
urinary catheter, urinary catheter duration (
＞
7 days),
endotracheal tube, mechanical ventilation, TPN, TPN
duration (
＞
7 days), nasogastric feeding tube, and
nasogastric feeding tube duration (
＞
7 days) were iden-
tified as risk factors for PICU acquired-HCAIs in the
univariate analysis. Hospital type, male, PICU stay (
＞
7
days), and mechanical ventilation were identified as in-
dependent risk factors for PICU acquired-HCAIs in the
multivariate analysis.
PICU-acquired HCAI-related mortality and associ-
ated risk factors: Mortality data were available for all
327 patients. Forty-three patients (13
z
)diedinthe
PICU within 1 month of the survey date; of these, 28
(65
z
) died because of HCAI. The presence of HCAI,
male, endotracheal intubation, and urinary catheter
were found to be significant, independent risk factors
for HCAI-related mortality in the univariate and mul-
tivariate analyses (Table 5).
DISCUSSION
This national, multicenter, point-prevalence study
documented the burden of PICU-acquired HCAIs in
Turkey. At the time of the survey, 122 of 327 patients
(37
z
)in50PICUswerereportedtohave

1PICU-
acquired HCAI. The HCAI rates in PICUs reported in
other regions such as the United States of America
(USA), Europe, Hong Kong, and Canada (6–12
z
,
23
z
,15
z
, and 8.7
z
, respectively) are markedly lower
than the HCAI rates in Turkish PICUs (2,3,5,6,10).
Since the early 2000s, Turkey has increased the amount
of infection control training programs and infection
control studies in hospitals nationwide. However, the
National Hospital Infections Surveillance Network has
been operational since 2008 (11), while a similar net-
work in the USA (the National Nosocomial Infections
Surveillance System [NNIS]), has been active since the
1970s in the USA, where it has led to a 30–40
z
decrease
in HCAI rates (4,12). Therefore, the delayed awareness
regarding infection control and prevention as well as the
late adoption of HCAI surveillance may have contrib-
uted to the high HCAI rates in Turkey.
In this study, the median length of the PICU stay was
10 days (range, 1–1,825; mean, 54). In comparison, in a
similar study conducted in the USA, the median stay
was 6 days (range, 1–358). It should be noted that
although similar studies have been conducted in Italy
and Hong Kong, they have been conducted in pediatric
wards other than PICUs, making the USA study the
most relevant comparison. The length of PICU stay in
Turkey was longer than that reported n the USA study,
however, length of stay was not a statistically significant
risk factor for HCAI in the present study. Furthermore,
most patients with a prolonged intensive care stay ex-
perienced neuromuscular problems and chronic respira-
tory failure. In Turkey, there are no intermediate/pal-
liative health care centers or hospices, nor is there a ``do
not resuscitate'' or ``withdrawal of care'' policy. When
the families do not consent for tracheostomy and/or
home ventilation (due to lack of capacity at home), the
duration of the stay can be considerably long, which
may account for the increased length of stay in this
study.
Causative microorganisms were isolated in 71 of 122
HCAIs (58
z
). A previous study of adult ICU-acquired
HCAIs in Turkey reported an isolation rate of 91
z
for
all HCAIs (13). In the USA study, an isolation rate of

384
Table 3. Causative microorganisms and isolation sites in patients with PICU-acquired health-care associated infections
Isolation site (
n
＝
no. of patients) [infection type]
1),2)
Causative
microorganism
2)
Respiratory specimen (broncho-
alveolary lavage fluid or
endotracheal aspirate) Blood Cerebrospinal
fluid Urine Conjunctiva swab/
wound swab
Pseudomonas
spp.
3[PNEU]
13 [VAP]
2 [LRTI]
1[PNEU]
2[VAP]
4 [LCBSI]
1[CLABSI]
1[CNS]
1 [CR-UTI]
2[SUTI]
1 [ABU]
Acinetobacter
spp. 9 [VAP]
3[PNEU]
1[VAP]
5 [LCBSI]
1 [CR-UTI]
1 [ABU]
Serratia
spp. 1 [PNEU] 1 [CR-UTI]
E. coli
1[PNEU]
2 [LCBSI] 1 [ABU]
Stenotrophomonas
maltophilia
2[PNEU]
1[VAP]
1[PNEU]
2[CLABSI]
1 [LCBSI]
1[CNS]
Klebsiella
spp. 2 [VAP]
2[PNEU]
1[VAP]
4 [LCBSI]
1[EI]
Enterococcus
spp. 1[PNEU]
1 [LCBSI] 2 [CR-UTI]
Proteus vulgaris
1 [CR-UTI]
Pantoea
spp. 1 [PNEU]
Enterobacter
spp. 1 [VAP]
Burkholderia
spp. 1[VAP]
1 [LRTI]
Methicilline-resistant
coagulase-negative
Staphylococcus
(bilaterally)
1[VAP]
1[CLABSI]
5 [LCBSI]
1[EI]
1[SSI]
Candida
spp. 6 [LCBSI] 2 [CNS] 1 [CR-UTI]
1)
: Infection types are given in paranthesis; PNEU, pneumonia; VAP, ventilator-associated pneumonia; LRTI, lower respiratory tractiInfec-
tion excluding pneumonia; LCBSI, laboratory confirmed blood stream infections; CLABSI, central-line associated blood stream infection;
CNS, central nervous system infection; EI, eye infection; CR-UTI, catheter-related urinary tract infection; SUTI, symptomatic urinary
tract infection; ABU, asymptomatic bacteriuria; SSI, surgical site infection.
2)
: There were more than one type of infection in 17 patients, and the infections were polymicrobial in 19 patients.
384
96
z
was reported for all HCAIs (2). However, in our
study, the causative microorganism isolation rate was
lower than in other studies. This may be because of
insufficiently equipped laboratories in participant hos-
pitals as well as reluctance to obtain culture samples.
Failure to identify causative microorganism may
prolong the use of empiric antibiotics and thus increase
the risk of downstream resistance.
Pseudomonas aeruginosa
is a common cause of se-
vere infections (e.g., pneumonia, sepsis, and wound in-
fections) in ICUs and has been consistently reported as
the most frequent cause of pneumonia in Canadian and
European studies (5,10). In this study,
P. aeruginosa
was the most frequently isolated microorganism in all
HCAIs, including cases of pneumonia and VAP.
Furthermore, antimicrobial resistance among
Pseudo-
monas
species is increasing. Surprisingly, carbapenem
susceptibility rates among
P. aeruginosa
isolates in this
study were higher than those in previous national
studies (71
z
versus 48–64
z
, respectively) (13,14).
However, these findings may vary according to ICU and
patient profiles.
Acinetobacter
infection rates in ICUs
are also increasing due to resistance to commonly used
antibiotics (15).
Acinetobacter
species isolated from
pneumonia patients represented the second most
common causative agent in this study. Ten of 12
Acinetobacter
isolates tested were susceptible to
colistin, and 2 were intermediately susceptible.
However, the uncontrolled use of colistin may limit its
effectiveness against
Acinetobacter
infections in the
future.
The widespread use of antibiotics is associated with
the development of resistance to antimicrobial agents
(16). In our study, 247 of the 327 patients (75
z
)re-
ceived antibiotics, and 146 patients (44
z
) were treated
with more than 1 agent. These rates were similar to anti-
biotic use ratios reported in other contries (38–79
z
)
(2,6,8,17,18). In addition, third-generation cephalo-

385
Table 4. Risk factors for PICU-acquired healthcare-associated
infections
Risk factor OR
1)
95
z
CI
2)
P
value
3)
Univariate analysis
Hospital type (university or training/
research hospital versus state hospital)
3.4 1.9–6.2 0.0001
3)
Sex (male) 1.4 0.9–2.3 0.14
Age (

12 months) 1.1 0.7–1.7 0.6
PICU stay (
＞
7 days) 4.9 2.9–8.4
＜
0.00001
3)
Central venous catheter 3.3 1.9–5.5 0.00001
3)
Central venous catheter duration
(
＞
7days) 3.3 1.4–7.7 0.004
3)
Urinary catheter 2.2 1.3–3.6 0.001
3)
Urinary catheter duration (
＞
7 days) 4.4 1.9–10.1
＜
0.00001
3)
Endotracheal tube 4.4 2.6–7.2 0.00001
3)
Endotracheal tube duration (
＞
7 days) 1.4 0.6–3.1 0.3
Mechanical ventilation 4.4 2.7–7.3 0.00001
3)
Mechanical ventilation duration
(
＞
7days) 1.1 0.5–2.2 0.6
Total parenteral nutrition (TPN) 2.5 1.4–4.5 0.0005
3)
TPN duration (
＞
7 days) 6.2 2.2–17.1
＜
0.00001
3)
Nasogastric feeding tube 3.4 2.0–6.0 0.00001
3)
Nasogastric feeding tube duration
(
＞
7days) 2.5 1.4–4.6 0.001
3)
Multivariate analysis
Hospital type (university or training/
research hospital versus state hospital) 2.7 1.3–5.5 0.005
3)
Sex (male) 2.2 1.1–4.2 0.015
3)
PICU stay (
＞
7 days) 5.0 2.6–9.6
＜
0.00001
3)
Mechanical ventilation 3.9 2.0–7.4
＜
0.00001
3)
1)
:Oddsratio.
2)
: Confidence interval.
3)
:
P

0.05.
Table 5. Risk factors for PICU-acquired healthcare-associated
infections related mortality
Risk factor OR
1)
95
z
CI
2)
P
value
3)
Univariate analysis
Hospital type (university or training/
research hospital versus state hospital) 1.6 0.7–3.8 0.22
Sex (male) 0.5 0.2–1.0 0.04
3)
Age (

12 months) 1.6 0.8–3.1 0.14
PICU stay (
＞
7 days) 2.1 1.1–4.5 0.03
3)
Central venous catheter 2.0 1.0–4.0 0.03
3)
Central venous catheter duration
(
＞
7days) 0.9 0.3–2.5 0.89
Urinary catheter 3.0 1.5–6.0 0.0007
3)
Urinary catheter duration (
＞
7 days) 2.6 0.9–6.8 0.05
3)
Endotracheal intubation 4.8 2.3–10.4 0.00001
3)
Endotracheal intubation duration
(
＞
7days) 0.9 0.3–2.1 0.82
Mechanical ventilation 4.9 2.2–11.9 0.00001
3)
Mechanical ventilation duration
(
＞
7days) 0.6 0.3–1.5 0.35
TPN 2.1 1.0–4.3 0.03
3)
TPN duration (
＞
7 days) 1.1 0.3–3.7 0.77
Nasogastric feeding tube 10.0 3.1–51.0 0.00001
3)
Nasogastric feeding tube duration
(
＞
7days) 0.9 0.4–1.9 0.9
Hepatic insufficiency 4.4 1.5–12.2 0.0008
3)
Presence of HCAI 3.4 1.6–7.0 0.0002
3)
Multivariate analysis
Presence of HCAI 3.9 1.5–10.0 0.005
3)
Sex (male) 0.3 0.2–0.9 0.021
3)
Endotracheal intubation 2.6 1.1–6.4 0.038
3)
Urinary catheter 3.0 1.2–7.1 0.013
3)
1)
:Oddsratio.
2)
: Confidence interval.
3)
:
P

0.05.
385
PICU-acquired HCAIs in Turkey
sporins were the most frequently administered antibi-
otics (19
z
) in this study. This is consistent with the
European Prevalence of Infection in Intensive Care
(EPIC) study results which also reported cephalosporins
as the most commonly used antibiotics (17). However, a
study among Turkish adults found that the most com-
monly used antibiotics were aminoglycosides, while
amoxicillin-clavulanate was the most common in a
Hong Kong study, and penicillin was the most common
in Canadian and Italian studies (6,7,10,13). Thus, the
excessive use of antibiotics in PICUs in Turkey should
be examined given that it is related to increased
healthcare costs, the risk of drug interactions, adverse
side effects, and the predominance of resistant microor-
ganisms in ICU floras. The characterization of antibi-
otic communities and mandatory consultations with an
infectious disease specialist may help to reduce the ex-
cessive use of antimicrobials.
Hospital type (university or training and research hos-
pital versus state hospital), male , PICU stay (
＞
7 days)
and mechanical ventilation were identified as indepen-
dent risk factors for PICU acquired-HCAIs in our
study. In addition, surgical procedures, medical devices,
antibiotic therapy, tracheostomy, diabetes, length of
hospital or PICU stay, and placement in isolation were
reported as risk factors for HCAI in many other studies
(2,5,6,8,13,19).
Forty-three (13
z
) patients had died by the 1-month
follow-up. Patients with HCAI were more likely to die
within this time interval than their uninfected counter-
parts, and 65
z
(
n
＝
28) of these deaths were directly
related to HCAIs. In addition, the PICU mortality rate
in our study was markedly higher than rates reported in
American and European studies (5–10
z
) (2,5). Given
that this study reported a high rate of HCAIs in par-
ticipating PICUs, and that HCAI was found to be an in-
dependent risk factor for mortality, the HCAI related
mortality rate could be reduced if effective prevention
measures were implemented.
PICU nursing personnel and doctor staffing ratio
data were not available in our study. However, reduced
nursing personnel levels have been associated with an in-
creased risk of PICU-acquired infections in the previous
studies (2,20). The recommended ratio of patients to
bedside nurses is typically 2:1. This allows the critical
care nursing staff to spend several hours per patient per
shift collecting information and incorporating it into
meaningful patient care (21). Unfortunately, observa-
tion of infection-control compliance in 50 PICUs was
not possible during this study. There are few studies
evaluating hand hygiene compliance in Turkey. For ex-
ample, Karabey et al. reported that the frequency of
hand washing among medical personnel in a Turkish in-
tensive care unit was 12.9
z
(22). In addition, Sacar et
al. observed that hands were washed both before and
after venipuncture procedures in 45
z
of cases (23). In
reaction to these low rates, the Turkish Ministry of
Health began a national hand hygiene campaign in

386386
2009. Named ``Danger In Your Hands'', the campaign
aims to increase hand hygiene compliance.
In conclusion, this study represents the first national,
multicenter, and point-prevalence survey of PICU-
acquired HCAIs in Turkey. The results of this study
revealed a high prevalence of HCAI in Turkey and
identified both
P. aeruginosa
and
Acinetobacter
species
in participating PICUs. Given these results, awareness
of infection control and prevention methods should
become a major part of intensive care procedures.
However, the high rate of antibiotic use underscores the
need to review current antibiotic therapy policies. In
light of the `primum non nocere' principle, the preven-
tion of PICU-acquired HCAI should be a priority for
public health policy.
Conflƒct of ƒnterest
None to declare.
Appendix
The members of Turkish PICU-HCAI Study Group are
as follows: Hasan Agin, Rana Isguder, Demet Demirkol, Suleyman
Bayraktar, Cevdet Yildirim, Sultan Karagoz, Melek Hamidanoglu,
Gunhur Basibuyuk, Ozden Ozgur Horoz, Dincer Yildizdas, Solmaz
Celebi, Benhur Sirvan Cetin, Esra Sevketoglu, Bulent Karapinar,
Pinar Yazici, Muhterem Duyu, Servet Yel, Ener Cagri Dinleyici, Aziz
Polat, Basak Nur Akyildiz, Sonay Aslan, Benan Bayrakci, Selman
Kesici, Mehmet Turgut, Fatma Levent Istifli, Muhammed Sukru
Paksu, Nazik Asilioglu Yener, Mehmet Davutoglu, Halit Cam, Zey-
nep Seda Uyan, Agop Citak, Guntulu Sik, Emine Polat, Yasemin
Duzceker, Tanil Kendirli, Bilge Aldemir-Kocabas, Caglar Odek, Em-
biya Dilber, Mehmet Bosnak, Leyla Telhan, Etem Piskin, Nilay Bas,
Zahide Yalaki, Yildiz Bilge Daglar, Okan Tugral, Fatih Turna, Yasar
Bildirici, Gokhan Kalkan, Oguz Dursun, Tolga Koroglu, Mehmet Bu-
rhan Oflaz, Ali Ertug Arslankoylu, Mehmet Cengiz Yakinci, Fesih
Aktar, Tugrul Karakus, Metehan Ozen, Tamer Kuyucu, Kadir Ser-
afettin Tekgunduz, Dost Zeyrek, Melike Keser, and Canan Kuzdan.
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