Editorial Commentary: Healthcare-Associated Infections: One Size Does Not Fit All

(See the Original Articles by McCullers et al, on pages 26–34, and Adler et al, on pages 35–43.) Healthcare-associated infections (HAI) have emerged as one of the most pressing problems in patient safety [1]. Our intuition and many studies demonstrate the negative impact HAI exert on patient outcomes, healthcare costs, and public perceptions of the quality and safety of healthcare. To date, adult HAI have received the greatest scrutiny. The majority of epidemiologic studies that define the burden of, risk factors for, and outcomes associated with HAI are primarily based upon adult patients. Because hospitalized children differ from hospitalized adults in the prevalence and array of underlying comorbid conditions, exposure to medical devices, and carriage of resistant organisms [2, 3], we must have pediatric-specific data on the epidemiology of HAI in children. Prevention of HAI in children is no less important than the prevention of HAI in adults [4]. In fact, when one examines the potential impact of HAI upon quality-adjusted life years, a pediatric patient might reasonably be considered to bear a greater risk than an adult patient. To date, most consensusand evidencebased guidelines for the prevention of specific HAI have been adult focused. Efforts to infuse pediatric knowledge into these guidelines have been hampered by the paucity of high-quality studies that evaluate the impact of HAI preventive interventions in pediatric populations and the limited representation of pediatric clinicians on writing groups. Additional factors, including limited availability of devices in pediatric sizes (such as antiseptic-coated catheters), absence of safety data in young populations (such as for chlorhexidine gluconate preparations), and developmental issues have also impeded the evaluation and adoption of many HAI prevention practices in pediatrics [5]. In this issue of the Journal of the Pediatric Infectious Diseases Society, 2 articles shed light on HAIs in high-risk subpopulations of children: those being treated for cancer and those undergoing cardiothoracic surgical procedures [6, 7]. McCullers and colleagues have provided us with an unprecedented portrayal of the HAI experienced by children hospitalized for cancer care over 21⁄2 decades [6]. These data provide us a deeper understanding of the microbiology and types of HAI encountered on pediatric oncology services, demonstrating the distinct epidemiology of HAI in this pediatric patient population. For example, 82 of the HAI identified were caused by common community-associated viral pathogens, such as rotavirus and respiratory syncytial virus, suggesting the unique reservoir of potential pathogens associated with the young families that typically visit hospitalized children. In addition, McCullers et al found that the incidence of HAI in children with severe neutropenia (absolute neutrophil count [ANC] nadir <100 per mm) was 2.5 times higher than in those with lesser degrees of neutropenia (ANC nadir 100–499 per mm). Nearly 60% of all HAIs occurred in children with severe neutropenia. While the finding is not surprising, it may be of particular importance in pediatrics, where children suffer disproportionately from cancers that require intensive cytoablative chemotherapy, which causes severe neutropenia. Finally, McCullers et al demonstrate that the incidence of HAI in their patients has decreased substantially to a level similar to that of other hospitalized patients. As reflected by the list in Table 1 of their article, many interventions likely contributed to this reduction [6]. While it is impossible to determine the role of individual interventions, it would have be informative to better understand the relative impact of Editorial Commentary