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 ╗  Abstract
 ╗ Introduction
 ╗  Materials and Me...
 ╗ Results
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  Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 403-405
 

Spectrum of systemic bacterial infections during febrile neutropenia in pediatric oncology patients in tertiary care pediatric center


1 Department of Pediatric Hematology Oncology, Rainbow Childrens Hospital, Banjara Hills, Hyderabad, Telangana, India
2 Department of Pediatrics, Rainbow Childrens Hospital, Banjara Hills, Hyderabad, Telangana, India
3 Department of Microbiology, Rainbow Childrens Hospital, Banjara Hills, Hyderabad, Telangana, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Sirisharani Siddaiahgari
Department of Pediatric Hematology Oncology, Rainbow Childrens Hospital, Banjara Hills, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175367

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 ╗ Abstract 

Background: Outcome of pediatric cancers has significantly improved with modern chemotherapy and good supportive care. However, febrile neutropenia remains one of the important limiting factors in these patients especially with the emergence of resistant organisms. Choosing appropriate antimicrobials is possible only if we understand the local microbial spectrum and their sensitivity pattern. Aims: To study the likely etiologic agents and their antibiotic sensitivity pattern among systemic infections in children with cancer. Settings and Design: This is a prospective study. Materials and Methods: The study was conducted at a tertiary care center for pediatrics, in which culture samples representing blood stream infections and others like urinary tract infections sent from the Oncology services of the Hospital during the year of 2013 were analyzed. The microbiological profile and antibiotic sensitivity pattern of these isolates were studied. Results: There were 89 isolates that represented blood and urinary tract infections in neutropenic patients with cancer.Out of 89 positive cultures 76 were gram negative isolates. The most common gram negative bacterial isolates were Escherichia coli 33 (37%), followed by Pseudomonas 21 (23.5%). Acinetobacter grew in 2 patients (2.2%). Extended spectrum beta-lactamases (ESBL's), carbepenem resistant and pan-resistant organisms seen in 28 (31.4%), 5 (5.6%) and 2 cases (2.3%) respectively. Over all Gram-positive organisms were 13/89 (12.3%). Staphylococcus was the most common Gram-positive organism and methicillin resistant Staphylococcus aureus seen in 5each. Conclusion: Gram-negative organism is a common isolate in cancer children with febrile neutropenia, which is resistant to first-line antibiotic cefepime. Meropenem is most sensitive antibiotic and ESBL's are sensitive to piperacillin–tazobactam.


Keywords: Febrile neutropenia, pediatrics malignancies bacterial infections


How to cite this article:
Siddaiahgari S, Manikyam A, Kumar K A, Rauthan A, Ayyar R. Spectrum of systemic bacterial infections during febrile neutropenia in pediatric oncology patients in tertiary care pediatric center. Indian J Cancer 2014;51:403-5

How to cite this URL:
Siddaiahgari S, Manikyam A, Kumar K A, Rauthan A, Ayyar R. Spectrum of systemic bacterial infections during febrile neutropenia in pediatric oncology patients in tertiary care pediatric center. Indian J Cancer [serial online] 2014 [cited 2019 Dec 16];51:403-5. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/403/175367



 ╗ Introduction Top


Febrile neutropenia is a medical emergency that can adversely affect the prognosis of the patient. The mortality rates differ in hematological malignancies (11%) to solid tumors (5%).[1] Even though the numbers are steadily decreasing nevertheless, it remains significant. In particular, with Gram-negative septicemia the mortality may go up to 18%, whereas Gram-positive sepsis causes 5% mortality rate.[2],[3],[4],[5] With prompt treatment of these episodes with empirical antibiotics, mortality can be cut down. The knowledge about the use of these antibiotics is often deduced from the pattern of the local microbiology and its antibiotic sensitivity.

We conducted a study to identify the most likely pathogens and their antibiotic sensitivity in our cohort of febrile neutropenia patients at a single center.


 ╗ Materials and Methods Top


This is a prospective observational analysis of the data obtained from pediatric oncology patients at a single tertiary care center. All the samples (both blood and urine) from febrile neutropenic patients sent from our cohort during the year 2013 were systematically analyzed from the data collected. The pathogens isolated from these samples were identified and recorded. The antibiotic sensitivity pattern of these isolates determined by disc diffusion method as per BSAC guidelines.


 ╗ Results Top


Of the cumulative 207 cultures sent (83 blood and 124 urine) in both hematological and solid tumors, 89 cultures (33 blood and 56urine) isolated organisms in our cohort during the year 2013. Our culture positivity in blood cultures was 39.7%(33/83 sent) and 45% in urine (56/124 sent).

Isolates having identical antibiograms obtained from a single patient during the same hospitalization were considered at once. Among the pathogens isolated in blood cultures, Gram-negative organisms constituted 22 and Gram-positives were 11. And in the urine cultures majority were Gram-negatives 54 and Gram-positives were 2.

The prevalence of the bacterial isolates is shown in the [Table 1] and [Table 2] in blood and urine among hematological malignancies and solid tumors. Of 33 positive blood cultures, the most common bacterial isolate in blood is Pseudomonas 10/33, followed by Escherichia coli 6/33. Acinetobacter was isolated in 1 case.
Table 1: Microbial etiology of bloodstream infections

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Table 2: Microbial etiology of urinary tract infections

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And in urine, it was E. coli and was more common. E. coli isolated in 27/56 positive urine cultures (48.2%), followed by Pseudomonas and Klebsiella 11 each (20% each).

The most common Gram-positive isolate was [2],[3],[4],[5]Staphylococus 10/89. Out of ten, Methicillin sensitive Staphylococcus aureus and methicillin resistant S. aureus (MRSA) were 5 each. Pneumococcus was isolated 2/89 positive cultures (both were blood cultures).

Extended spectrum beta-lactamase (ESBL's) production was tested in isolates from the Enterobacteriaceae group and was detected in 28 of them (n - 28/89, 31.4%). Of 28 ESBL's, 21 were isolated in urine, 7 in blood. Carbepenem resistant organisms were seen in 5 isolates (3 in urine cultures, 2 in blood cultures). Pan-resistant organisms were seen in 2 cases (1 each in blood and urine isolates).

The antibiotic sensitivity pattern of the isolates is shown in [Table 3],[Table 4],[Table 5],[Table 6]. Most of the Gram-negative infections like E. coli, Klebsiella and Pseudomonas were commonly sensitive to Piperacillin + Tazobactam, Carbapenams, Aminoglycosides.
Table 3: Antibiotic susceptibility of common Gram-negative blood isolates in acute leukemia

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Table 4: Antibiotic susceptibility of common Gram-negative isolates in urine in acute leukemia

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Table 5: Antibiotic susceptibility of common Gram-negative isolates in urine of solid tumor patients

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Table 6: Antibiotic susceptibility of common Gram-positive blood isolates in acute leukemia

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Sensitivity in Gram-positive organisms. Staphylococcus and Pnemococcus were commonly sensitive to Amoxycillin + Clavulinic acid, Piperacillin + tazobactam, Carbapenams, 3rd generation Cephalosporins.


 ╗ Discussion Top


Systemic bacterial infections are a significant cause of morbidity and mortality in pediatric oncology patients. The data from the West show a changing trend toward increasing Gram-positive organisms predominantly due to use of more indwelling catheters shifting way from the Gram-negative organisms.[6]

However, our study reconfirms that in a developing world Gram-negative organisms are still predominant organisms as noticed in other studies from similar background.[7],[8],[9],[10],[11] The reasons mainly are due to lower usage of long-term indwelling catheters and also due to lack of prophylactic use of antibiotics in neutropenic patients, which applies even to our set up.

Pseudomonas being the most common isolate in blood in our study with a high degree of resistance to antibiotics is a matter of concern, as it is associated with increased mortality in some studies.[12],[13] A multi-drug resistant organisms like Acinetobacter spp. emergence is not a major concern in our series, however, seen in 2 cases (1 blood and 1 urine). ESBL's in both blood and urine seen in 28 cases (31.4%) is another major concern in our study. Carbepenem resistant and pan-resistant organisms were noticed in 5 (5.6%) and 2 (2.2%) isolates respectively.

Among Gram-positive isolates, the common isolate was Staphylococcus in our series and occurrence of MRSA is high (50% of staphylococci isolated). This figure is higher than the other studies and which prompted us in choosing appropriate Gram-positive cover.[7],[8],[9],[10],[11],[14]

Of 76 Gram-negative negative isolates we noted, 70 of them were sensitive to piperacillin and tazobactum, which is encouraging. However, the activity of the primary empirical agents like ceftazidime and cefepime against pathogens in cancer patients is only 24%. This could be because of the usage of cefepime and amikacin as empirical agents for some time and also indicating the shift of organisms and their sensitivity. Resistance to aminoglycosides like amikacin in ESBL's was seen in 39% of cases.

In our cohort, most of the Gram-negative organisms are piperacillin and tazobactum sensitive. As there is significant resistance to cefepime, there is an urgent need to shift the first line antibiotic policy to piperacillin tazobactum from cefepime. Because of the high incidence of MRSA, vancomycin should be a choice for Gram-positive cover and which can always be changed as per antibiotic sensitivity. The antibiotics like polymyxin, chloramphenicol and cotrimoxazole need to be checked in regular sensitivities, because of their potential chances to be sensitive. Drugs such as doripenem, tigecycline are available in our center though not used in our cohort patients.

Because of the emergence of ESBL's and Pan-resistant microorganisms pattern in most of the hospitals, especially oncology units, should be to adopt a strict infection control policy with the help of infection control team.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ╗ References Top

1.
Kar M, Rakesh R. Indian Guidelines for Febrile Neutropenia http://www.apiindia.org/medicine_update_2013/chap78.pdf.  Back to cited text no. 1
    
2.
Collin BA, Leather HL, Wingard JR, Ramphal R. Evolution, incidence, and susceptibility of bacterial bloodstream isolates from 519 bone marrow transplant patients. Clin Infect Dis 2001;33:947-53.  Back to cited text no. 2
    
3.
Krupova I, Kaiserova E, Foltinova A, Kovacicova G, Kiskova M, Krchnakova A, et al. Bacteremia and fungemia in pediatric versus adult cancer patients after chemotherapy: Comparison of etiology, risk factors and outcome. J Chemother 1998;10:236-42.  Back to cited text no. 3
    
4.
Krcméry V Jr, Spanik S, Krupova I, Trupl J, Kunova A, Smid M, et al. Bacteremia due to multiresistant gram-negative bacilli in neutropenic cancer patients: A case controlled study. J Chemother 1998;10:320-5.  Back to cited text no. 4
    
5.
Ehni WF, Reller LB, Ellison RT 3rd. Bacteremia in granulocytopenic patients in a tertiary-care general hospital. Rev Infect Dis 1991;13:613-9.  Back to cited text no. 5
    
6.
Wisplinghoff H, Seifert H, Wenzel RP, Edmond MB. Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasms in hospitals in the United States. Clin Infect Dis 2003;36:1103-10.  Back to cited text no. 6
    
7.
Figuera Esparza M, Carballo M, Silva M, Figueredo A, Avilán J. Microbiological isolates in patients with febrile neutropenia and hematological neoplasias. Rev Esp Quimioter 2006;19:247-51.  Back to cited text no. 7
    
8.
Butt T, Afzal RK, Ahmad RN, Salman M, Mahmood A, Anwar M. Bloodstream infections in febrile neutropenic patients: Bacterial spectrum and antimicrobial susceptibility pattern. J Ayub Med Coll Abbottabad 2004;16:18-22.  Back to cited text no. 8
    
9.
Chen CY, Tang JL, Hsueh PR, Yao M, Huang SY, Chen YC, et al. Trends and antimicrobial resistance of pathogens causing bloodstream infections among febrile neutropenic adults with hematological malignancy. J Formos Med Assoc 2004;103:526-32.  Back to cited text no. 9
    
10.
Velasco E, Byington R, Martins CS, Schirmer M, Dias LC, Gonçalves VM. Bloodstream infection surveillance in a cancer centre: A prospective look at clinical microbiology aspects. Clin Microbiol Infect 2004;10:542-9.  Back to cited text no. 10
    
11.
Paul M, Gafter-Gvili A, Leibovici L, Bishara J, Levy I, Yaniv I, et al. The epidemiology of bacteremia with febrile neutropenia: Experience from a single center, 1988-2004. Isr Med Assoc J 2007;9:424-9.  Back to cited text no. 11
    
12.
Cherif H, Kronvall G, Björkholm M, Kalin M. Bacteraemia in hospitalised patients with malignant blood disorders: A retrospective study of causative agents and their resistance profiles during a 14-year period without antibacterial prophylaxis. Hematol J 2003;4:420-6.  Back to cited text no. 12
    
13.
Spanik S, Kukuckova E, Pichna P, Grausova S, Krupova I, Rusnakova V, et al. Analysis of 553 episodes of monomicrobial bacteraemia in cancer patients: Any association between risk factors and outcome to particular pathogen? Support Care Cancer 1997;5:330-3.  Back to cited text no. 13
    
14.
Biedenbach DJ, Moet GJ, Jones RN. Occurrence and antimicrobial resistance pattern comparisons among bloodstream infection isolates from the SENTRY Antimicrobial Surveillance Program (1997-2002). Diagn Microbiol Infect Dis 2004;50:59-69.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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