title: Burden, spectrum, and impact of healthcare-associated infection at a South African children's hospital.
abstract: BACKGROUND
  In most African countries the prevalence and effects of paediatric healthcare-associated infection (HCAI) and human immunodeficiency virus (HIV) infection are unknown.
  
  
  OBJECTIVE
  To investigate the burden, spectrum, risk factors, and impact of paediatric HCAI by prospective clinical surveillance at a South African referral hospital.
  
  
  METHODS
  Continuous prospective clinical and laboratory HCAI surveillance using Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) definitions was conducted at Tygerberg Children's Hospital, South Africa, from May 1stto October 31stin 2014 and 2015. Risk factors for HCAI and associated mortality were analysed with multivariate logistic regression; excess length of stay was estimated using a confounder and time-matching approach.
  
  
  RESULTS
  HCAI incidence density was 31.1 per 1000 patient-days (95% CI: 28.2-34.2); hospital-acquired pneumonia (185/417; 44%), urinary tract infection (UTI) (45/417; 11%), bloodstream infection (BSI) (41/417; 10%), and surgical site infection (21/417; 5%) predominated. Device-associated HCAI incidence in the paediatric intensive care unit (PICU) was high: 15.9, 12.9 and 16 per 1000 device-days for ventilator-associated pneumonia, central line-associated BSI and catheter-associated UTI, respectively. HCAI was significantly associated with PICU stay (odds ratio: 2.0), malnutrition (1.6), HIV infection (1.7), HIV exposure (1.6), McCabe score 'fatal' (2.0), comorbidities (1.6), indwelling devices (1.9), blood transfusion (2.5), and transfer in (1.4). Two-thirds of paediatric deaths were HCAI-associated, occurring at a median of four days from HCAI onset with significantly higher crude mortality for HCAI-affected vs HCAI-unaffected hospitalizations [24/325 (7.4%) vs 12/1022 (1.2%); P<0.001]. HCAI resulted in US$371,887 direct costs with an additional 2275 hospitalization days, 2365 antimicrobial days, and 3575 laboratory investigations.
  
  
  CONCLUSIONS
  HCAI was frequent with significant morbidity, mortality, and healthcare costs. Establishment of HCAI surveillance and prevention programmes for African children is a public health priority.
authors.affiliation: Department of Pediatrics and Child Health, Division of Pediatric Infectious Diseases, Stellenbosch University, Cape Town, South Africa. Electronic address: dramowski@sun.ac.za.
authors.forename: A
authors.initials: A
authors.lastname: Dramowski
authors.affiliation: Department of Medical Microbiology, Stellenbosch University and the National Health Laboratory Service (NHLS), Cape Town, South Africa.
authors.forename: A
authors.initials: A
authors.lastname: Whitelaw
authors.affiliation: Department of Pediatrics and Child Health, Division of Pediatric Infectious Diseases, Stellenbosch University, Cape Town, South Africa.
authors.forename: M F
authors.initials: MF
authors.lastname: Cotton
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003428:Cross Infection / Q000191:economics / Q000453:epidemiology* / Q000401:mortality / Q000473:pathology; D005260:Female; D017048:Health Care Costs; D006776:Hospitals, Pediatric; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008297:Male; D015995:Prevalence; D011446:Prospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis
keywords: Antimicrobial resistance; Healthcare-associated infection; Infection prevention; Nosocomial infection; Paediatrics; Sub-Saharan Africa