Nosocomial respiratory syncytial virus infection: Impact of prospective surveillance and targeted infection control

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Abstract

Background

Nosocomially acquired respiratory syncytial virus (RSV) infections cause serious problems in hospitalized patients. An increased effort should be made to describe the problems connected with such infections in pediatric hospitals, with the aim of reducing the occurrence of nosocomial RSV infections (NI).

Methods

A specialized database was introduced for surveillance and a multifaceted barrier concept based on the CDC recommendations was developed for the control of NI in a university children's hospital in Germany.

Results

Between 1999 and 2002 (November 1–April 30), 283 RSV infections (general population) were prospectively documented. Thirty-nine cases (13.8%) were nosocomial infections (NI) with an incidence density (ID) of 0.99/1000 patient days; 48.7% of all NI were found in prematurely born infants. Following the introduction of a surveillance and prevention policy, a 9-fold decrease of the ID (1.67 vs. 0.18/1000 patient-days) was found when comparing the first and the last season. Intensive care treatment was required in 18% of all documented RSV-infections, in 48.7% of all NI cases and in 43.5% of all RSV-infected prematurely born infants. Overall RSV-related mortality was 0.71%.

Conclusions

Early diagnosis, a strict cohorting and contact isolation policy, and prospective surveillance contribute to the reduction of nosocomial RSV infection.

Introduction

Respiratory syncytial virus (RSV) (Black, 2003, Ogra, 2004) is responsible for the majority of episodes of acute wheezing triggered by infection (Jennings et al., 2004), for up to 75% of all cases of bronchiolitis (Fitzgerald and Kilham, 2004) and up to 40% of pneumonias (McIntosh, 2002) during the first 24 months of life. About 2% of all RSV-infected children require hospital care. The RSV-related hospitalization rate and the risk of severe complications are increased in prematurely born infants (PB) with chronic lung disease (Meissner, 2003), in children with hemodynamically relevant congenital heart disease (Buckingham et al., 2001; Feltes et al., 2003), other forms of chronic lung disease or severe neuromuscular impairment (Panitch, 2004). Forster et al., (2004) estimated a total of 26,524 (CI95 23,812–29,432) RSV-related hospitalizations per year in children<3 years of age in Germany (38% of all pediatric hospitalizations for viral lower respiratory tract infection). The median cost of a hospitalized case of RSV-pneumonia was calculated at about $ 14,200 in 1995 (Howard et al., 2000) and specific therapeutic agents are still not available (Black, 2003; Fitzgerald and Kilham 2004).

The high prevalence of nosocomial RSV infections deserves special attention (Berner et al., 2001). RSV can cause life-threatening epidemics in neonatal (Abadesso et al., 2004; Cox et al. 2001; Gelber and Ratner, 2002; Heerens et al., 2002; Kang and Kim, 1997; Kilani 2002) or pediatric intensive care units (Lanari et al., 2004; Thorburn et al., 2004) and in pediatric oncology departments (Bredius et al., 2004; Simon et al., 2000; Small et al., 2002). RSV replicates on the respiratory and conjunctival epithelium of contact persons and is therefore easily transmitted by health care staff or visitors, even to patients who are on mechanical ventilation for other reasons (Hall, 2000; Agah et al., 1987; Karanfil et al., 1999; Leclair et al., 1987; Madge et al., 1992).

As an enveloped virus RSV is highly susceptible to hygienic hand disinfection and to antimicrobial hand washing but survives for hours on unwashed hands, on contact surfaces in the inanimate environment of the patient and on health care items like stethoscopes (Hall, 2000).

Consequently, meticulous hand hygiene after patient contact together with other barrier precautions is considered to be of utmost importance for the prevention of nosocomial transmission (Thorburn et al., 2004). Nosocomial RSV infection significantly increases the length of stay in hospital (Howard et al., 2000; Thwaites and Piercy, 2004) and thus the total cost of treatment. Systematic efforts to reduce the incidence of nosocomial RSV infections have been shown to be cost effective (Macartney et al., 2000). In order to prevent nosocomial infection and its complications and to optimize resource utilization related to RSV infection, the surveillance and management of RSV infection from admission to discharge should be a high priority issue (Adcock et al., 1998).

In November 1999, a specific software tool developed at our institution for the targeted surveillance of hospitalized RSV-infected pediatric patients was made available for data entry (DSM RSV Paed) at the University Children's Hospital in Bonn, Germany. The purpose of the protocol was to facilitate the collection and analysis of detailed information on the population of hospitalized children with RSV infection in three consecutive RSV seasons (1999–2002). The resulting data on the incidence density of nosocomially acquired RSV infections were reported to the treatment teams on the participating wards to increase vigilance and adherence to the isolation procedures.

The primary objective of the study was to achieve a better understanding of the local epidemiology (pre-existing risk factors, clinical symptoms, severity of illness and outcome) of nosocomial RSV infections. In addition, the global efficacy of the complex intervention programme to contain nosocomial transmission had to be evaluated.

Section snippets

Inclusion criteria, surveillance methods, ethics

All inpatients treated for at least 24 hours with confirmed RSV infection were included irrespective of age or underlying illness. The prospective surveillance period covered 6 months of each year (November 1–April 30). For the primary data collection it did not matter whether the RSV infection had been acquired outside or in the hospital. A standardized set was extracted from the medical records of all RSV-infected patients. The resulting data sheets were checked by a pediatric infective

General study population and subgroups

In three consecutive RSV seasons (November 1999–April 2002), 283 RSV infections were documented in 278 hospitalized pediatric patients. Five patients acquired more than one RSV infection after a symptom-free interval (NPA antigen test negative) of at least 4 weeks. The number (%) of RSV-infected males and females was 109 (38.5%) and 174 (61.5%), respectively. The 283 RSV infections were defined to be the ‘general population’, which included patients with risk factors and previously healthy

Reduction of nosocomial RSV infections

Assisted by the rapid laboratory confirmation of RSV infection, the multi-factorial prevention strategy probably contributed significantly to the reduced risk of nosocomial RSV infections in our institution. This effect was most impressive in prematurely born infants treated in the neonatal intensive care unit (Gelber and Ratner, 2002).

In neonatal and pediatric intensive care units, nosocomial RSV infections can cause epidemic illness and increased mortality. Although some case reports suggest

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