Reviews of pediatric research

September 1, 2007

Diarrheal infection * Urinary tract infection * Respiratory syncytial virus ... and more

• State-of-the-art equipment reduces infections in child-care centers

Installation of equipment for changing diapers, washing hands, and preparing food that is specifically designed to reduce transmission of infections does decrease the rate of diarrheal illness among children and their teachers in child-care centers, according to a new study.

Investigators assigned one of each of 23 pairs of child-care centers in North Carolina to the intervention group, and one to the control group. They gave the centers in the intervention group diapering, hand washing, and food preparation equipment that incorporated cast polymer tabletops with impermeable, seamless surfacing. Separate equipment was provided for each of these three functions to reduce the risk of contamination. In addition, automatic faucets and foot-activated rollout waste bins for diaper disposal minimized hand contact with the equipment. Staff in the centers in both the intervention and control group centers received sanitation and hygiene training to standardize and improve diapering, hand washing, and food preparation procedures. Investigators followed 388 children under the age of 3 and their caregivers in the 46 child-care centers for seven months, using data provided by the centers and parental telephone interviews.

Commentary

These improvements did not come about by magic. The intervention centers improved their hygiene practices by changing the child-care center environment, not just staff behaviors alone. But this intervention was not cheap. Equipment and modifications to the child-care centers cost, on average, more than $10,000 per room.

• Prophylactic antibiotics for recurrent UTIs may not be a good idea

The American Academy of Pediatrics (AAP) recommends that children younger than 2 years who are found to have vesicoureteral reflux (VUR) after a first urinary tract infection (UTI) receive daily antimicrobial prophylaxis to prevent recurrent UTIs. Yet the first large study of children with a first UTI in a primary-care setting found that voiding cystourethrograms (VCUGs) frequently are not performed and that antimicrobial prophylaxis does not lower the risk of recurrent UTIs, and increases the risk of resistant infections when UTIs do recur.

Investigators analyzed data for a group of 611 children 6 years or younger who were diagnosed with a first UTI within a five-year period. The children were part of a network of 27 primary care pediatric practices in urban, suburban, and semirural areas in three states. Most patients were female (89%), from 2 to 6 years of age (61%), and had not had a VCUG (66%) or antimicrobial prophylaxis (79%). For patients who did receive such prophylaxis, prescriptions were for cotrimoxazole (61%), amoxicillin (29%), and nitrofurantoin (7%), among other agents. About 14% of the children experienced a recurrent UTI; more than half of these infections (61%) were caused by a pathogen with antimicrobial resistance. Pathogens included Escherichia coli (78%), other gram-negative rods (16%), Enterococcus (4%), and other organisms (2%).

Antimicrobial prophylaxis had no significant effect on the risk of recurrent UTI. In addition, exposure to antimicrobial prophylaxis significantly increased the risk of resistant infection when UTI recurred. Age, race, and VUR grade, on the other hand, not only played a role in the likelihood of resistant infections but in the risk of recurrent UTIs as well. Specifically, children from 2 to 6 years old, especially those aged 3 to 5 years, were at increased risk of recurrent UTI. And more than half of recurrent UTIs in the 2-to-6 age group represented resistant infections. Nonwhites were at decreased risk of recurrent UTIs, but their risk of resistant infections increased. In fact, all nine recurrent UTIs in nonwhites exposed to prophylactic antimicrobials were caused by a resistant organism. Children with grade 1 to 3 VUR were not at increased risk of UTI recurrence, but in those with grade 4 to 5 VUR risk was increased. Not being circumcised increased the likelihood of a male child's having a recurrent UTI (Conway PH et al: JAMA 2007;298:179).