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 ::  Abstract
 ::  Material and method
 ::  Results
 ::  Discussion
 ::  Conclusions
 ::  Acknowledgment
 ::  References
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Year : 2000  |  Volume : 46  |  Issue : 1  |  Page : 18-22

Bacterial nosocomial pneumonia in Paediatric Intensive Care Unit.

Department of Paediatrics,Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India

Correspondence Address:
M S Tullu
Department of Paediatrics,Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India.
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Source of Support: None, Conflict of Interest: None

PMID: 0010855072

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 :: Abstract 

AIMS: To determine the incidence, risk factors, mortality and organisms causing nosocomial pneumonia (NP) in intubated patients in Paediatric Intensive Care Unit (PICU). MATERIALS & METHODS: All patients with endotracheal (ET) tube with or without mechanical ventilation (MV) in a PICU of a tertiary care teaching hospital were included in this prospective study. Clinical parameters and investigations were evaluated in patients who developed nosocomial pneumonia (NP). Colonisation of the ET tube tip was studied by culture and the antibiotic susceptibility pattern of the isolates was determined. RESULTS: Sixty-nine patients had an ET tube inserted and fifty-nine of these underwent MV. ET tube tip colonisation was seen in 70 out of 88 ET tubes inserted. The incidence of NP in patients with ET tube was 27.54% (7.96/100 days of ET intubation). NP developed only in patients undergoing MV. The main risk factors for developing NP were - duration of MV and duration of stay in the PICU. Age, sex, immunocompromised status and altered sensorium did not increase the risk of NP. The mortality in cases with NP was 47. 37%. E. coli and Klebsiella were the commonest organisms isolated from the ET tube tip cultures with maximum susceptibility to amikacin and cefotaxime. CONCLUSIONS: NP developed only in patients undergoing MV. Duration of MV and duration of stay in the PICU increased the risk of developing NP.

Keywords: Chi-Square Distribution, Child, Child, Preschool, Cross Infection, etiology,Female, Human, Incidence, Infant, Intensive Care Units, Pediatric, Intubation, Intratracheal, adverse effects,Length of Stay, Male, Microbial Sensitivity Tests, Pneumonia, etiology,Probability, Respiration, Artificial, adverse effects,Risk Factors, Time Factors,

How to cite this article:
Tullu M S, Deshmukh C T, Baveja S M. Bacterial nosocomial pneumonia in Paediatric Intensive Care Unit. J Postgrad Med 2000;46:18-22

How to cite this URL:
Tullu M S, Deshmukh C T, Baveja S M. Bacterial nosocomial pneumonia in Paediatric Intensive Care Unit. J Postgrad Med [serial online] 2000 [cited 2023 Mar 20];46:18-22. Available from:

Nosocomial pneumonia (NP) is a major concern in the management of patients who require ventilatory support. NP contributes to the morbidity and mortality in mechanically ventilated patients[1],[2],[3],[4],[5]. A knowledge of the risk factors and common causative organisms can help in decreasing the incidence of NP.

This study aimed to determine the incidence, risk factors, mortality, and causative organisms of NP in patients with endotracheal (ET) tube (with or without mechanical ventilation).

  ::   Material and method Top

This prospective study was conducted over a period of six months in the Paediatric Intensive Care Unit (PICU) of a tertiary care teaching hospital. Patients less than one month, trauma cases and surgical cases were not included as they are not admitted to our PICU.

All patients with ET intubation were included in the study. Those with pre-existing pneumonia were excluded from the study. The patients had a portex ET tube inserted and removed using strict aseptic technique. The common indications for ET tube insertion were for - maintenance of airway patency, respiratory failure and mechanical ventilation (MV), elective ventilation, etc. The frequency of suctioning of the ET tube was every two hourly or more frequently if required and all aseptic precautions were followed while suctioning. Patients were extubated as per the clinical need.

After extubation, the tip of the ET tube was cut with a sterile blade and sent in a sterile tube for aerobic bacterial culture. We did not study the role of viruses, fungi, and anaerobic organisms in the development of NP. The qualitative method used for culture included incubation in glucose broth for 4 hours followed by smear examination and culture on sheep blood agar and Mac Conkey's agar. The culture plates were incubated overnight and examined for growth. Organisms were identified on the basis of colony characteristics and biochemical reactions. The antibiotic susceptibility pattern of organisms was determined using Kirby-Bauer method by disk diffusion technique and the results were interpreted as per the National Committee for Clinical Laboratory Standards guidelines[6].

‘Colonization’ of ET tube was defined as isolation of organisms from the tip of the ET tube. ‘Nosocomial Pneumonia’ was diagnosed when all of the following 4 criteria were met[7] -

1. New and persistent infiltrates more than 48 hours (not otherwise explained) appearing on chest radiograph.

2. Positive bacterial culture growth from the ET tube tip.

3. Fever-temperature more than 380C.

4. Elevated leucocyte count (more than 10,000 cells per cubic mm).

Following risk factors were studied to evaluate their significance in developing NP - age, sex, immunocompromised status (protein energy malnutrition-grade III/IV by IAP classification and HIV positive cases), altered sensorium, duration of MV and duration of stay in the PICU. All patients kept in the PICU for 3 days or lesser were followed up subsequently for 1 week (after discharge from the PICU) to look for development of NP. The chest radiograph and other investigations were repeated as indicated by the clinical profile of each patient. Chi Square test[8] was applied for studying the significance of these risk factors in causing NP. The probability value (‘p’ value) was obtained using standard charts and considered significant if below 0.05.

  ::   Results Top

In the study, 69 patients (49 males : 20 females) had an ET tube inserted. The mean age was 2.95 years (range - 1 month to 11 years). The average duration of stay in the PICU was 7.23 days per patient (range - 1 to 39 days; median - 5 days). Fifty-nine out of 69 patients underwent MV via the ET tube. The average duration of MV was 3.675 days per patient (range - 8 hours to 15 days; median - 2 days). The total number of ET tubes inserted was 88 (in 69 patients). The ET tube was changed once in 11 patients and twice in 4 patients and lasted for an average of 3.46 days (range - 12 hours to 15 days; median - 3 days). The average duration of change of each ET tube was 2.713 days.

ET tube colonisation with bacteria was seen in 70 out of 88 ET tube tips cultured. Eighteen ET tube tip cultures did not show any growth. The total number of organisms isolated from 70 ET tube tips was 96. Two organisms were isolated from 26 ET tube tips.

NP developed in 19 out of 59 patients with MV (32.20%; 8.92/100 days of MV; 3.65/100 patient-days). NP developed in 19 out of the 69 patients with ET intubation (27.54%; 7.96/100 days of ET intubation). All these 19 patients had undergone MV. Patients with ET tube without MV did not develop NP. The incidence of NP was significantly higher in intubated patients with MV as compared to those who were not ventilated.

Of the 10 patients who were intubated but not ventilated, 2 had ET tube colonisation (E. coli & Klebsiella grown from 1 ET tube each) and 8 were not colonized. None of these developed NP.

Age, sex, altered sensorium and immunocompromised status (including 3 HIV positive cases) did not increase the incidence of NP. MV for more than 48 hours and a PICU stay of more than 3 days significantly increased the incidence of NP [Table - 1].

Nine out of 19 mechanically ventilated patients with NP died (mortality - 47.37%) and 18 out of 40 mechanically ventilated patients without NP died (mortality - 45%). The difference was not statistically significant and mortality was not found to be higher in patients with NP as compared to those without it.

The various organisms isolated from ET tube tips and their antibiotic susceptibility pattern is given in [Table - 2]. The organisms commonly isolated were E. coli (34.4%), Klebsiella (30.2%), Pseudomonas (11.5%), Proteus (11.5%), and Acinetobacter (5.2%). Other organisms isolated included 2 isolates each of Enterobacter and Citrobacter, and 1 isolate each of coagulase negative Staphylococci, Non-lactose fermentors and  Salmonella More Details. E. coli and Klebsiella had maximum susceptibility to amikacin and cefotaxime.

  ::   Discussion Top

Endotracheal (ET) intubation is frequently done in critically ill paediatric patients as an emergency or elective procedure. Pneumonia developing after ET intubation with MV is known despite meticulous care of the ET tube. An infective, highly viscous and adhesive layer is formed inside the ET tube as determined by factors like surface properties of the ET tube, humidity of ventilatory gases, mode of ventilation and nursing care[9]. ET tube can contribute to the pathogenesis of NP when the infective particles of this adhesive layer are dislodged into the lower airways by shear forces imparted by the respiratory gas flow during MV[9]. Colonisation of the ET tube occurs frequently in the PICU but all patients do not develop NP. Colonisation was seen in 70 out of 88 ET tube tips (79.54%) in our study. This was higher than that (51.8%) reported by Albert S et al[10].

The incidence of NP in patients with ET intubation was 27.54% (7.96/100 days of ET intubation, 8.92/100 days of MV) in our study. This was lower than the study by Albert S et al (45%)[10] and Ruiz-Santana S et al (38%)[11]. Other studies have reported an incidence varying from 9.6% to 28 .9% [12],[13],[14],[15].

The incidence of NP was significantly higher in intubated patients who were mechanically ventilated as compared to those who were not ventilated. Patients without MV did not develop NP. Similar findings have been reported previously[4],[12],[16].

Factors like age, sex, immunocompromised status and altered sensorium did not affect the incidence of NP in our study. Mosconi P et al[17], Joshi N et al[18] and George DL[19] have suggested that an altered mental status or depressed level of consciousness with impaired airway reflexes predispose the patients to aspiration of gastric or oropharyngeal secretions, increasing the risk of NP in mechanically ventilated patients.

Our study showed a significantly higher incidence of NP in patients with MV for more than 48 hours. Similar results were shown by Torres A et al[6] and Mosconi P et al[17]. Fagon JY et a1[20] showed an acturial risk of NP to be 6.5% at 10 days, 19% at 20 days and 28% at 30 days of MV. The risk of development of ventilator-associated pneumonia is said to be 1-3% per day of MV[19],[20]. Thus, longer the duration of MV, higher is the risk of NP. Prolonged stay in PICU (more than 3 days) significantly increased the risk of acquiring NP in our study and patients with a PICU stay of 3 days or lesser did not develop NP. This finding was similar to that previously reported[12],[14],[18].

The mortality in cases with NP was 47.37% in our study and has ranged from 33% to 71% in various studies[5],[6],[11],[18],[20],[21]. It was not significantly higher than the patients without NP as previously reported[6],[17],[18],[20],[21].

The microbial flora associated with NP reflects the common organisms present in gut, oropharynx and the environment i.e. the gram negative organisms[3],[4],[6],[22],[23],[24]. E. coli was the commonest organism isolated by us. Most of the previous studies had isolated  Pseudomonas aeruginosa Scientific Name Search  the commonest organism[3],[5],[8],[10],[20],[25]. Pseudomonas was the third common organism in the present study. Others have reported Staphylococcus aureus Scientific Name Search  as an important aetiological agent of NP[3],[6],[10],[13],[20],[25]. The knowledge of the common organisms and their antibiotic susceptibility pattern is important for institution of appropriate antimicrobial therapy.

We could not study the effect of antibiotics and H2-blockers on development of NP. We were unable to employ sophisticated techniques like bronchoscopic aspiration, bronchoalveolar lavage and protected specimen brushings[3],[10],[19],[20],[25],[26] for the diagnosis of NP. These studies have better accuracy in diagnosing the aetiological agent of NP but have the disadvantages of being costly and requiring special equipment and expertise.

  ::   Conclusions Top

Mechanically ventilated patients have a higher risk of developing NP. The duration of MV of more than 48 hours and a PICU stay of more than 3 days significantly increased the risk of developing NP in the present study. Mortality was not significantly higher in patients with NP as compared to those without NP. E. coli and Klebsiella were the common organisms isolated from the ET tube tip cultures with maximum susceptibility to amikacin and cefotaxime.

  ::   Acknowledgment Top

The authors thank the Dean, Seth G. S. Medical College and K. E. M. Hospital for granting permission to publish this article.

 :: References Top

1. Causey WA, Gardner P. Nosocomial infections. In: Feigin RD, Cherry JD, editors. Textbook of Pediatric Infectious Diseases, 1st ed. Philadelphia: W.B. Saunders Company; 1981; pp 1655-1670.  Back to cited text no. 1    
2.Craven DE, Steger KA. Ventilator-associated bacterial pneumonia: Challenges in diagnosis, treatment, and prevention. New Horiz 1998; 6:S30-45.  Back to cited text no. 2    
3.Grap MJ, Munro CL. Ventilator-associated pneumonia: Clinical significance and implications for nursing. Heart Lung 1997; 26:419-429.  Back to cited text no. 3    
4.Kollef MH, Silver P, Murphy DM, Trovillion E. The effect of late-onset ventilator associated pneumonia in determining patient mortality. Chest 1995; 108:1655-1662.  Back to cited text no. 4    
5.Torres A, Aznar R, Gatell JM, Jimenez P, Gonzalez J, Ferrer A et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990; 142:523-528.  Back to cited text no. 5    
6.Bauer AW, Kirby WMM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Path 1966; 45:493-496.  Back to cited text no. 6    
7.Salata RA, Lederman MM, Shlaes DM, Jacobs MR, Eckstein E, Tweardy D et al. Diagnosis of nosocomial pneumonia in intubated, intensive care unit patients. Am Rev Respir Dis 1987; 135:426-432.  Back to cited text no. 7    
8.Park K. editor. Park's Textbook of Preventive and Social Medicine. 15th ed. Jabalpur: M/S Banarsidas Bhanot Publishers; 1997; pp 572-585.  Back to cited text no. 8    
9.Koerner RJ. Contribution of endotracheal tubes to the pathogenesis of ventilator-associated pneumonia. J Hosp Infect 1997; 35:83-89.  Back to cited text no. 9    
10.Albert S, Kirchner J, Thomas H, Behne M, Schur J, Brade V. Role of quantitative cultures and microscopic examinations of endotracheal aspirates in the diagnosis of pulmonary infections in ventilated patients. J Hosp Infect 1997; 37:25-37.  Back to cited text no. 10    
11.Ruiz-Santana S, Garcia-Jimenez A, Esteban A, Guerra L, Alvarez B, Corcia S et al. ICU pneumonias: A multi-institutional study. Crit Care Med 1987; 15:930-932.  Back to cited text no. 11    
12.Legras A, Malvy D, Quinioux AI, Villers D, Bouachour G, Robert R et al. Nosocomial infections: Prospective survey of incidence in five French intensive care units. Intensive Care Med 1998; 24:1040-1046.  Back to cited text no. 12    
13.Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in coronary care units in the United States. National Nosocomial Infections Surveillance System. Am J Cardiol 1998; 82:789-793.  Back to cited text no. 13    
14.Velasco E, Thuler LC, Martins CA, Dias LM, Goncalves VM. Nosocomial infections in an oncology intensive care unit. Am J Infect Control 1997; 25:458-462.  Back to cited text no. 14    
15.Jimenez P, Torres A, Rodriguez-Roisin R, de la Bellacasa JP, Aznar R, Gatell JM et al. Incidence and etiology of pneumonia acquired during mechanical ventilation. Crit Care Med 1989; 17:882-885.  Back to cited text no. 15    
16.Inglis TJ, Millar MR, Jones JG, Robinson DA. Tracheal tube biofilm as a source of bacterial colonisation of the lung. J Clin Microbiol 1989; 27:2014-2018.  Back to cited text no. 16    
17.Mosconi P, Langer M, Cigada M, Mandelli M. Epidemiology and risk factors of pneumonia in critically ill patients. Intensive Care Unit Group for Infection Control. Eur J Epidemiol 1991; 7:320-327.  Back to cited text no. 17    
18.Joshi N, Localio AR, Hamory BH. A predictive risk index for nosocomial pneumonia in the intensive care unit. Am J Med 1992; 93:135-142.  Back to cited text no. 18    
19.George DL. Epidemiology of nosocomial pneumonia in intensive care unit patients. Clin Chest Med 1995; 16:29-44.  Back to cited text no. 19    
20.Fagon JY, Chastre J, Domart Y, Trouillet JL, Pierre J, Darne C et al. Nosocomial pneumonia in patients receiving continuous mechanical ventilation. Prospective analysis of 52 episodes with use of a protected specimen brush and quantitative culture techniques. Am Rev Respir Dis 1989; 139:877-884.  Back to cited text no. 20    
21.Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986; 133:792-796.  Back to cited text no. 21    
22.Bowen-Jones J, Wesley A, van den Ende J. Nosocomial colonisation and infection in a paediatric respiratory intensive care unit. S Afr Med J 1992; 82:309-313.  Back to cited text no. 22    
23.Apte, NM, Karnad DR, Medhekar TP, Tilve GH, Morye S, Bhave GG. Gastric colonisation and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: A randomized, controlled trial. Crit Care Med 1992; 20:590-593.  Back to cited text no. 23    
24.Torres A, El-Ebiary M, Soler N, Monton C, Fabregas N, Hemandez C et al. Stomach as a source of colonisation of the respiratory tract during mechanical ventilation: Association with ventilator-associated pneumonia. Eur Respir J 1996; 9:1729-1735.  Back to cited text no. 24    
25.Rello J, Ausina V, Ricart M, Castella J, Prats G. Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 1993; 104:1230-1235.  Back to cited text no. 25    
26.Griffin JJ, Meduri GU. New approaches in the diagnosis of nosocomial pneumonia. Med Clin North Am 1994; 78:1091-1122.   Back to cited text no. 26    


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