Background: Blood stream infection is a serious problem that needs immediate attention and treatment. We aim to identify the frequency of common organisms in blood culture of febrile pediatric patients so that empirical antibiotic therapy can be started timely.Methods: This cross-sectional study was conducted in pediatric ward Civil Hospital Sukkur from 1st May 2013 to 31st October 2014. Children of both genders who are between the age of one month to 15 years admitted to the pediatric ward with a fever of \u3e 38.0 c and with a history of fever ËÂƒ two days and whose blood culture has been sent were included in this study. Informed consent was taken prior to enrollment. The patient’s blood culture was taken under aseptic technique. Samples were sent to microbiology lab civil hospital Sukkur. 1st culture on admission to be taken to avoid confounding with hospital-acquired the infection. The frequency of organisms grown in the culture was documented.Results: The median age of enrolled participants was 48.5 (46.6) months, 153 (38.5%) were male and 158 (61.5%) were the female and median weight of enrolled participants was 15.9 (9.7) kg. Overall, 178 (69.3%) cases had a history of prior antibiotic use; blood cultures sent within 24 hours were 117 (45.5%) cases. Twenty-two (8.4%) cases were positive. Six were positive for Salmonella typhi cases followed by E. coli.Conclusions: It was concluded from this study that the frequency of community acquired blood stream infection was 7.6%. Salmonella typhi, E. coli were found to be common pathogens

Ali, Sumera Aziz

Soomro, Tufail

Tikmani, Shiyam Sunder

English

eCommons@AKU

eCommons@AKUCommunity Health Sciences Department of Community Health SciencesJanuary 2016Frequency and Etiology of Community-AcquiredBloodstream Infection in Hospitalized FebrileChildrenTufail SoomroGhulam Mohammad Mahar Medial College, Sukkur, Karachi, PakistanShiyam Sunder TikmaniAga Khan University, shiyam.sunder@aku.eduSumera Aziz AliAga Khan University, sumera.ali@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chsPart of the Bacteria Commons, Bacteriology Commons, Fungi Commons, PathogenicMicrobiology Commons, and the Public Health CommonsRecommended CitationSoomro, T., Tikmani, S. S., Ali, S. A. (2016). Frequency and Etiology of Community-Acquired Bloodstream Infection in HospitalizedFebrile Children. Journal of Medical Diagnostic Methods, 5(3).Available at: https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/365Frequency and Etiology of Community-Acquired Bloodstream Infection inHospitalized Febrile ChildrenTufail Soomro1, Shiyam Sunder Tikmani2 and Sumera Aziz Ali2*1Department of Pediatrics, Ghulam Mohammad Mahar Medial College, Sukkur, Karachi, Pakistan2Department of Community health Sciences, Aga Khan University, Karachi, Pakistan*Corresponding author: Sumera Aziz Ali, Department of Community health Sciences, Aga Khan University, Karachi, Pakistan, Tel: +9234864837; E-mail: sumera.ali@aku.eduReceived date: June 29, 2016; Accepted date: July 15, 2016; Published date: July 22, 2016Copyright: © 2016 Soomro T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.AbstractBackground: Blood stream infection is a serious problem that needs immediate attention and treatment. We aimto identify the frequency of common organisms in blood culture of febrile pediatric patients so that empirical antibiotictherapy can be started timely.Methods: This cross-sectional study was conducted in pediatric ward Civil Hospital Sukkur from 1st May 2013 to31st October 2014. Children of both genders who are between the age of one month to 15 years admitted to thepediatric ward with a fever of > 38.0 c and with a history of fever ˃ two days and whose blood culture has been sentwere included in this study. Informed consent was taken prior to enrollment. The patient’s blood culture was takenunder aseptic technique. Samples were sent to microbiology lab civil hospital Sukkur. 1st culture on admission to betaken to avoid confounding with hospital-acquired the infection. The frequency of organisms grown in the culturewas documented.Results: The median age of enrolled participants was 48.5 (46.6) months, 153 (38.5%) were male and 158(61.5%) were the female and median weight of enrolled participants was 15.9 (9.7) kg. Overall, 178 (69.3%) caseshad a history of prior antibiotic use; blood cultures sent within 24 hours were 117 (45.5%) cases. Twenty-two (8.4%)cases were positive. Six were positive for Salmonella typhi cases followed by E. coli.Conclusions: It was concluded from this study that the frequency of community acquired blood stream infectionwas 7.6%. Salmonella typhi, E. coli were found to be common pathogens.Keywords: Infection; Community acquired; Blood culture;PathogensIntroductionBloodstream infection is a severe problem that needs immediateattention and treatment as it can lead to morbidity and mortality. Feveris often the most common reason for presentation to the hospital indeveloping countries. Most patients with febrile illness have self-limiting viral infections, but some have a serious bacterial infectionthat needs urgent and appropriate antimicrobial therapy [1] advance inblood culture technique have resulted in efficient and reliabletechniques for detection of bacterial and fungal pathogens [1]. Bloodstream infection is a cause of high mortality especially if caused bymultidrug-resistant bacteria. Bacteriologic culture to isolate theoffending pathogen and knowledge about sensitivity pattern of isolatesremains the mainstay of definitive diagnosis and management ofbloodstream infection. However, blood culture is time-consuming andtakes at least 2 to 5 days until the identification of organism [2] one keydeterminant in the ultimate outcome of a patient with sepsis is aninstitution of early empirical and appropriate antimicrobial therapy.This is only possible with knowledge of community-acquired bacteriaand their likely susceptibility to antibiotics in a given set up. There arelimited reports on community-acquired bacteremia in children,particularly from developing countries. This could be due to eitherpoor lab infrastructure or poor health seeking behavior and treatmentof febrile illnesses mostly by primary care physicians without abacteriologic diagnosis. A study done in developing countries shows8% children had blood stream infection [3] several studies have shownthat rate of isolation of pathogens from blood culture increases withthe quantity of blood submitted [4]. Small study of community-acquired infections from Pakistan revealed five hundred and eightblood culture samples were positive for bacterial growth. Of these 465(91.5%) having monomicrobial growth and 43 (8.5%) havingpolymicrobial growth. Among them, Klebsiella spp (24.1%) were mostcommon amongst gram negative and staph aureus (24.1%) amongstgram positive [5]. An interesting finding in the subcontinent is theisolation of more gram negative bacteria than gram positive there is ahigh prevalence of enteric fever caused by Salmonella typhi andSalmonella paratyphi in Pakistan. More than 51% pediatric bloodculture isolates contained S. typhi or S. paratyphi A, S. typhi alone wasdetected in 43% of positive blood culture. The other organismsidentified were coagulase-negative Staphylococci (20%), Acinetobacterspecies (5.1%), E. coli (4.5%), and Pseudomonas species (11.4%) [6,7].There are limited number of studies from Pakistan, despite the highincidence of community-acquired bacteremia and case fatality amonghospitalized bacteremic children [8,9]. We aim to conduct this study toidentify the frequency of common organisms in blood culture ofSoomro et al., J Med Diagn Meth 2016, 5:3 DOI: 10.4172/2168-9784.1000217Research Article Open AccessJ Med Diagn MethISSN:2168-9784 JMDM, an open access journal Volume 5 • Issue 3 • 1000217Journal of Medical DiagnosticMethodsISSN: 2168-9784Journal of Medical DiagnosticMethodsfebrile pediatric patients so that empirical antibiotic therapy can bestarted with bacteriology of community-acquired bacteremia. Theobjective of this study was to determine the frequency of communityacquired blood stream infection in febrile children and to identify thecommonly isolated organisms.Material and MethodsThis cross-sectional study was conducted at pediatric ward off civilhospital Sukkur from 1st May 2013 to 31st October 2014. Children ofboth genders who are between the age of one month to 15 yearsadmitted to the pediatric ward with recorded temperature of > 38.0 cand with a history of fever more than two days and whose bloodculture has been sent. Neonates, post-surgical patients, patients onchemotherapy and on antibiotic therapy, children with congenitalanomaly, those children who have central line for antibioticadministration over long periods, children who are referred fromanother hospital or health care center for further management.Cases diagnosed with HIV and tuberculosis, and children ofprolonged course of prophylactic antibiotics for any associated co-morbid condition like repeated UTI were excluded. Community-acquired bacteremia was defined as bloodstream infection with thegrowth of pathogenic bacteria in a blood culture obtained within first48 hours after admission in febrile children between the age of 01months to 15 years. Children who fulfilled study criteria were enrolledin the study after taking informed consent was taken from the parents.The demographic information of patient was taken on structuredproforma by the investigator.The patient’s blood cultures were performed in microbiology labaccording to standard guidelines at civil hospital Sukkur. 1st culture onadmission to be taken to avoid confounding with hospital-acquired theinfection. The culture was followed by the primary researcher. Thefrequency of organisms grown in the culture was documented.Non-probability consecutive sampling was done. The frequency ofbloodstream infection in febrile pediatrics patients is 8%, consideringthe bond on the error of estimation of 3% and 95% confidence intervalthe estimated sample size was 257. Data was analyzed using SPSSversion 20 (SPSS Inc. Chicago, IL, USA). All quantitative variables likeage, weight, were expressed as median (interquartile range).Qualitative variables like gender, commonly isolated community-acquired bloodstream organisms, and history of prior antibiotics wereexpressed in percentages. Chi-square or Fisher exact test was used tocompare categorical variables and Man-Whitney U test was used tocompare median age and weight. Effect modifiers like age, gender,weight and history of prior antibiotics were stratified to see their effecton the final outcome. The study is approved by ethical review of theinstitute (Figures 1 and 2).Figure 1: Independent samples Mann Whitney U Test.Figure 2: Frequency of isolated cultures from blood culture.ResultsA total of 257 patients were enrolled in this study during the studyperiod. The median age of enrolled participants was 48.5 (46.6)months, 153 (38.5%) were male and 158 (61.5%) were the female andmedian weight of enrolled participants was 15.9 (9.7) kg. Overall, 178(69.3%) cases had a history of prior antibiotic use; blood cultures sentwithin 24 hours were 117 (45.5%) cases. Twenty-two (8.4%) cases werepositive. Six were positive for Salmonella typhi cases followed by E.coli. Comparative analysis is shown in Table 1 and stratified analysissummarized in Table 2. Stratified analysis showed, of children <30months of age, 10 (6.5%) had positive blood culture compared to 12(11.5%) cases among children of age ≥ 30 months (p>0.120); of femalechildren, 10 (10.1%) had positive blood culture compared to 12 (7.6%)cases among male children (p>0.079); of children weigh <13 kg, 10(6.4%) had positive blood culture compared to 12 (11.9%) cases amongchildren weigh ≥ 13 kg (p>0.138) and of children with no historytaking antibiotics prior to culture, 17 (21.5%) has positive bloodculture compare to 5 (2.8%) cases children who had history of takingantibiotics prior to blood culture.Citation: Soomro T, Tikmani SS, Ali SA (2016) Frequency and Etiology of Community-Acquired Bloodstream Infection in Hospitalized FebrileChildren. J Med Diagn Meth 5: 217. doi:10.4172/2168-9784.1000217Page 2 of 4J Med Diagn MethISSN:2168-9784 JMDM, an open access journal Volume 5 • Issue 3 • 1000217  Negative blood culture (n=235) Positive blood culture (n=22) Totaln % n %Age Months (Mean) 42.6 ± 4.7 61 ± 5.5less than 30 months 143 60.9% 10 45.5% 153More than 30 months 92 39.1% 12 54.5% 104GenderMale 146 62.1% 12 54.5% 99Female 89 37.9% 10 45.5% 158Weight kg (Mean) 10.2 ± 10.2 15.1 ± 9Less than 13 kg 146 62.1% 10 45.5% 156More than 13 Kg 89 37.9% 12 54.5% 101Blood sample takenWithin 24 hr 97 41.3% 20 90.9% 11724-48 hr 138 58.7% 2 9.1% 140History of antibiotic use 173 73.6% 5 22.7% 178Table 1: Comparison of baseline characteristics between children with positive or negative blood culture.Blood culture Age Gender Weight Prior use of antibioticsless than 30monthsMore than 30monthsFemale Male Less than 13kgMore than13 KgNo YesNegative 143 92 89 146 146 89 62 17393.5% 88.5% 89.9% 92.4% 93.6% 88.1% 78.5% 97.2%Positive 10 12 10 12 10 12 17 56.5% 11.5% 10.1% 7.6% 6.4% 11.9% 21.5% 2.8% Total 153 104 99 158 156 101 79 178p>0.120 p>0.316 p>0.079 p>0.001Table 2: Stratified analysis by age, sex, weight and prior use of antibiotics.DiscussionFebrile illness is a leading reason for admission to hospital inPakistan [10-12]. Despite the major contribution of infectious diseasesto hospital admission, the availability of diagnostic microbiologyservices for bloodstream infections other than malaria is often limitedby cost, infrastructure, and personnel constraints [11] consequently,health-care workers must often rely on syndrome-oriented empiricalapproaches to treatment and might underestimate or overestimate thelikelihood of certain diseases, risking poor clinical outcomes and thepromotion of antimicrobial resistance [12,13] understanding thecauses and prevalence of community-acquired bloodstream infection,which is associated with high risk of death, can inform efforts toimprove health outcomes in Pakistan and promote the meeting ofmillennium development goals for the reduction of child mortality,malaria, and tuberculosis.Blood cultures are vital for recognizing pathogens causing severeinfections and in leading appropriate antibiotic therapy. Furthermore,they remain the standard method for identifying bacteraemia in theassessment of sick patients [14] inappropriately; blood culturecontamination is a common event and may lead to confusionregarding the significance of a positive blood culture. The mostcommon contaminants are coagulase-negative staphylococcus specieswhich are also becoming more prevalent as a primary pathogen inimmunocompromised patients and in patients with indwellingintravascular devices [9,15] the uncertain clinical significance ofpotential contaminants leads to longer hospital stays, unnecessaryantibiotic therapy, and additional laboratory testing; as a result, thecost incurred by a hospital is many times that incurred by thelaboratory.Citation: Soomro T, Tikmani SS, Ali SA (2016) Frequency and Etiology of Community-Acquired Bloodstream Infection in Hospitalized FebrileChildren. J Med Diagn Meth 5: 217. doi:10.4172/2168-9784.1000217Page 3 of 4J Med Diagn MethISSN:2168-9784 JMDM, an open access journal Volume 5 • Issue 3 • 1000217In this study 184 patients were enrolled during the study periodwith a median age of 48.52±46.6 months, the majority was females’59.8% and median weight of 15.9±9.7 kg. Overall, 118 (64.1%) caseshad a history of prior antibiotic use blood cultures sent within 24 hourswere 175 (95.1%) cases. Fourteen (7.6%) cases were positive. In ourstudy Salmonella, enteric serotype typhi was the most commonbacterial pathogen accounting for 4.9% of cases followed by E.coli andPseudomonas spp. Similar findings had been reported in the systemicreview where salmonella is most common pathogen isolated.In another study from Cambodia, it was reported that salmonella ismost common infection followed by E.coli [15].We also did a stratified analysis of positive blood cultures based onage and weight. We did not found statistically significant differenceacross strata. Children <30 months of age, 5.4% had positive bloodculture compared to 9.9% cases among children of age ≥ 30 months(p>0.191) and children weigh <13 kg, 5.7% had positive blood culturecompared to 10.5% cases among children weigh ≥ 13 kg (p>0.138).There are some important limitations to this study. We examinedhospital-based cohorts to define community-acquired bloodstreaminfections, and thereby might have included patients with more severeillness and included only those who have access to health-carefacilities.This study presents a strong case for the importance of consideringbloodstream infections in patients admitted to civil hospital Sukkur,particularly those with fever. Our findings underscore the importanceof continuous re-evaluation of who's integrated management ofchildhood illness and other empirical treatment algorithms for febrileillness in view of changing patterns of disease. When used, empiricaltreatment with antimicrobial drugs should include coverage for gram-negative, especially against Salmonella, E.coli and Pseudomonas.It was concluded from this study that the frequency of bloodstreaminfections was 7.6%. Salmonella typhi, E.coli, and Pseudomonas werefound to be common pathogens. No relationship of positive bloodculture or pathogen was found with age, weight, and gender.References1. Deen J, Seidlein LV, Anderson F, Elle N, White JW, et al. (2012)Community-acquired bacterial blood stream infections in developingcountries in south and southeast Asia: a systematic review. Lancet Inf Dis12: 480-487.2. Latif S, Anwar MS, Ahmad I (2009) Bacterial pathogens responsible forblood stream infections (bsi) and pattern of drug resistance in a tertiarycare hospital of Lahore. Biomedica 25: 101-105.3. Gonsalves WI, Cornish N, Moore M, Chen A, Varman M (2009) Effectsof volume and site of blood drawn on blood cultures results. J ClinMicrobiol 47: 3482-3485.4. Podda A, Saul A, Arora R, Bhutta Z, Sinha A, et al. (2010) Conjugatevaccines for enteric fever: proceedings of a meeting organized in newDelhi, India in 2009. J Infect Dev Ctries 4: 404-411.5. Sigauque B, Roca A, Mandomando I, Morais L, Quinto L, et al. (2009)Community-acquired bacteremia among children admitted to a ruralhospital in Mozambique. Pediatr Infect Dis J 28: 108-113.6. Blomberg B, Manji KP, Urassa WK, Tamim BS, Mwakagile DS, et al.(2007) Antimicrobial resistance predicts death in Tanzanian childrenwith bloodstream infections: a prospective cohort study. BMJ Infect Dis 7:43.7. Claudias I, Barray LJ (2010) Pediatric emergencies associated with fever.Emerg Med Clin North Am 28: 67-84.8. Wilson M, Mitchell M, Morris AJ, Murray PR, Reimer LG, et al. (2007)Principles and procedures for blood cultures: approved guideline. Clinicaland laboratory standards institute 27.9. Zhou L, Pollard AJ (2010) A fast and highly sensitive blood culture PCRmethod for clinical detection of salmonella enteric serovar typhi. AnnClin Microbiol Antimicrob 9: 14.10. Mintegi S, Benito J, Sanchez J, Azkunaga B, Iturralde I, et al. (2009)Predictors of occult bacteremia in young febrile children in the era of theheptavalent pneumococcal conjugate vaccine. Eur J Emerg Med 16:199-205. 11. Wilkinson M, Bulloch B, Smith M (2009) Prevalence of occult bacteremiain children aged 3 to 36 months presenting to the emergency departmentwith fever in the post-pneumococcal conjugate vaccine era. Acad EmergMed 16: 220-225. 12. Brauner M, Goldman M, Kozer E (2010) Extreme leukocytosis and therisk of serious bacterial infections in febrile children. Arch Dis Child 95:209-212. 13. Huppler AR, Eickhoff JC, Wald ER (2010) Performance of low-riskcriteria in the evaluation of young infants with fever: a review of theliterature. Pediatrics 125: 228-233. 14. Herz AM, Greenhow TL, Alcantara J, Hansen J, Baxter RP, et al. (2006)Changing epidemiology of outpatient bacteremia in 3- to 36-month-oldchildren after the introduction of the heptavalent conjugatedpneumococcal vaccine. Pediatr Infect Dis J 25: 293-300. 15. Whitney CG, Farley M, Hadler J, Harrison LH, Bennett NM, et al. (2003)Decline in invasive pneumococcal disease after the introduction ofprotein-polysaccharide conjugate vaccine. N Engl J Med 348: 1737-1746.  Citation: Soomro T, Tikmani SS, Ali SA (2016) Frequency and Etiology of Community-Acquired Bloodstream Infection in Hospitalized FebrileChildren. J Med Diagn Meth 5: 217. doi:10.4172/2168-9784.1000217Page 4 of 4J Med Diagn MethISSN:2168-9784 JMDM, an open access journal Volume 5 • Issue 3 • 1000217

Frequency and Etiology of Community-Acquired Bloodstream Infection in Hospitalized Febrile Children

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Frequency and Etiology of Community-Acquired Bloodstream Infection in Hospitalized Febrile Children

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