Neonatal and paediatric bloodstream infections: Pathogens, antimicrobial resistance patterns and prescribing practice at Khayelitsha District Hospital, Cape Town, South Africa

Abstract

Background. The epidemiology of neonatal and paediatric community-acquired and healthcare-associated bloodstream infections (BSI) at South African (SA) district hospitals is under-researched. Objective. Retrospective review of neonatal and paediatric BSI (0 -13 years) at Khayelitsha District Hospital, Cape Town, SA, over 3 years (1 March 2012 -28 February 2015. Methods. We used laboratory, hospital, patient and prescription data to determine BSI rates, blood culture yield and contamination rates, pathogen profile, antimicrobial resistance, patient demographics, BSI outcome and antibiotic prescribing practice. Results. From 7 427 blood cultures submitted, the pathogen yield was low (2.1%, 156/7 427) while blood culture contamination rates were high (10.5%, 782/7 427). Paediatric and neonatal BSI rates were 4.5 and 1.4/1 000 patient days, respectively. Gram-positive BSI predominated (59.3%); Staphylococcus aureus (26.8%) and Escherichia coli (21.6%) were common pathogens. The median patient age was 3 months, with a predominance of males (57.7%) and a 12.8% prevalence of HIV infection. Crude BSI-associated mortality was 7.1% (11/156), the death rate being higher in neonates than in infants and children (6/40 (15.0%) v. 5/116 (4.3%), respectively; p=0.03) and in patients with Gramnegative compared with Gram-positive bacteraemia (6/66 (9.1%) v. 5/89 (5.6%), respectively; p=0.5). Most BSI episodes were communityacquired (138/156; 88.5%), with high levels of extended-spectrum β-lactamase (ESBL) carriage among Klebsiella pneumoniae and E. coli isolates (5/5 (100%) and 8/33 (24.2%), respectively). Antimicrobial management of BSI was inappropriate in 30.6% of cases (45/147), including incorrect empirical antibiotic (46.7%), dual antibiotic cover (33.3%) and inappropriately broad-spectrum antibiotic use (17.8%). Conclusions. Antimicrobial-resistant pathogens (notably ESBL-producing Enterobacteriaceae) were common in community-acquired BSI. Paediatric clinicians at district hospitals require ongoing training in antibiotic stewardship and blood culture sampling.

Surveillance of antimicrobial resistance in low- and middle-income countries: a scattered picture

“…and up to 30% ESBL-producing K. pneumoniae [143]. While most of the surveillance is generated from teaching hospitals a study comparing district and tertiary facilities in KwaZulu-Natal province demonstrated AMR increasing from the district level to the tertiary facility, but with those referred upward having higher rates than those treated only in the district facility, but both facilities had increased rates for the longer-stay patients (> 48 h) [144,145].…”

Community-acquired bacteremia among HIV-infected and HIV-exposed uninfected children hospitalized with fever in Mozambique

“…Studies suggest that bacteremia in hospitalized African children exceeds that of high-income countries and that gram-negative organisms, in particular non-typhoidal Salmonella (NTS), are among the most common isolates, especially where the prevalence of HIV and malaria is high (Reddy et al, 2010;Feasey et al, 2012;Mandomando et al, 2009). Other common causes of reported bacteremia in HIVinfected children have included Streptococcus Pneumonia, Staphylococcus Aureus and Enterbacteriaceae (Crichton et al, 2018;Hill et al, 2007). Existing estimates as to the burden of most pathogenic bacterial infections in sub-Saharan Africa is predominantly limited to urban areas, thus the impact of bacteremia in children under-five years of age is largely unknown, as many people live in rural areas (Reddy et al, 2010;Berkley et al, 2005;Sigaúque et al, 2009).…”

“…Bacteremia is a major cause of morbidity and mortality worldwide, with a high disease burden in developing countries and among children under 5 years old ( Crichton et al, 2018 ). Children infected with HIV present with patterns of bacteremia that are different in severity and frequency and are generally associated with poor prognosis ( Jaspen et al, 2008 ; Kolo et al, 2015 ; Musiime et al, 2013 ).…”

Epidemiology of Culture-confirmed Candidemia Among Hospitalized Children in South Africa, 2012–2017

“…1 Although candidemia accounts for 0.6%-6% of all pediatric bloodstream infections in South Africa, the incidence in children is rarely reported. 9,10 There has also been a shift in the Candida species causing candidemia globally, although the dominant species varies by region. 1,11 Single-and multicenter studies in South Africa have shown a shift from Candida albicans to Candida parapsilosis as the major cause of candidemia.…”

“…1 Although candidemia accounts for 0.6%–6% of all pediatric bloodstream infections in South Africa, the incidence in children is rarely reported. 9,10…”