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 ╗  Abstract
 ╗ Introduction
 ╗ Methods
 ╗ Results
 ╗ Discussion
 ╗ Acknowledgments
 ╗  References
 ╗  Article Tables

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  Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 415-417
 

Microbiology, infection control and infection related outcome in pediatric patients in an oncology center in Eastern India: Experience from Tata Medical Center, Kolkata


1 Department of Pediatric Oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Department of Microbiology, Tata Medical Center, Kolkata, West Bengal, India

Date of Web Publication1-Feb-2016

Correspondence Address:
Arpita Bhattacharyya
Department of Pediatric Oncology, Tata Medical Center, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175365

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 ╗ Abstract 

Context: Infection is a major determinant in the outcome of patients with cancer. Aims: The aim was to know the epidemiology and outcome of patients with cancer in a cancer care center in Eastern India. Settings And Design: Retrospective study of pediatric patients in Tata Medical Center, Kolkata, India. Methods: Patients (n = 262) between the age group of 0 and 18 years were reviewed for infections and infection-related outcome (January to December 2013). Statistical Analysis: Modified Wald method was used to determine confidence interval of proportions. RESULTS: Gram-negative bacteria were found to be the most common cause of bloodstream infections (BSIs) (56.4%), followed by Gram-positive cocci (34.5%), and Candida species (9.1%). Carbapenem-resistance was noted among 24% of Gram-negative bacilli (GNB), and extended-spectrum beta-lactamase among 64% of GNBs. A single case of Vibrio cholerae septicemia was also noted. No case of vancomycin-resistant Enterococcus was observed, whereas only two cases of methicillin-resistant Staphylococcus aureus bacteremia (1/3 of all Staphylococcus aureus bacteremia) were detected. Escherichia coli, followed by Klebsiella, Pseudomonas, and Acinetobacter were the predominant organisms detected in BSIs. Among Candida spp. BSIs no resistance to caspofungin, amphotericin B, Voriconazole was noted. Candida tropicalis was the most common isolate, and 1 isolate of Candida glabrata showed dose-dependent sensitivity to fluconazole. Three out of 25 patients died of multi-drug resistant Gram-negative bacteria (12%) in 2013. Seventeen patients had radiological evidence of invasive fungal infections (no mortality was noted). Conclusions: Periodic review of infection-related data, as well as infection control practices, is essential to optimize clinical outcome in patients with pediatric malignancies.


Keywords: Antibiotic resistance, blood stream infections, infections, outcome, Pediatric Oncology


How to cite this article:
Bhattacharyya A, Krishnan S, Saha V, Goel G, Bhattacharya S, Hmar L. Microbiology, infection control and infection related outcome in pediatric patients in an oncology center in Eastern India: Experience from Tata Medical Center, Kolkata. Indian J Cancer 2014;51:415-7

How to cite this URL:
Bhattacharyya A, Krishnan S, Saha V, Goel G, Bhattacharya S, Hmar L. Microbiology, infection control and infection related outcome in pediatric patients in an oncology center in Eastern India: Experience from Tata Medical Center, Kolkata. Indian J Cancer [serial online] 2014 [cited 2019 Dec 14];51:415-7. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/415/175365



 ╗ Introduction Top


The infection continues to be a major problem resulting in morbidity and mortality in patients with malignancies.[1],[2],[3],[4],[5] The epidemiology of infections in patients with various cancers is not known in major parts of the country.[6] The aim of the study was to describe the epidemiology and outcome of infections in pediatric patients in an oncology center in Eastern India.


 ╗ Methods Top


This was a retrospective study of patients in Pediatric Oncology unit in Tata Medical Center, Kolkata, India. Patients between 0 and 18 years of age were reviewed for infections and infection-related outcomes from January to December, 2013. It included patients with hematological malignancies, solid tumors, and stem cell transplant recipients.

Statistics

The proportion of infections was determined after downloading patient reports from the hospital management system on an excel spreadsheet. Confidence intervals of proportion were calculated by modified Wald method using online statistical software from www.graphpad.com.


 ╗ Results Top


The majority of organisms causing infections were found to be Gram-negative bacteria. Fifty-six percent of blood culture isolates were Gram-negative bacilli (GNB), 35% Gram-positive cocci, and 9% were Candida spp. [Table 1]. The proportion of methicillin-resistant Staphylococcus aureus (MRSA) in blood culture was 33% out of Staphylococcus aureus isolates. No vancomycin-resistant Enterococcus (VRE) isolate was detected in blood culture. There was a high prevalence of resistance to third generation cephalosporins (extended spectrum beta-lactamase producing organisms) which comprises 64% of coliforms (Enterobacteriaceae) isolated. Carbapenem-resistance in GNB was significant and comprised 22% of Enterobacteriaceae and 26% of nonfermentative GNB isolates.
Table 1: Microbial etiology of blood stream infections (n=110)

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Among important organisms, Pseudomonas showed 36% resistance to ceftazidime, 26% resistance to piperacillin-tazobactam and amikacin, 36% resistance to amikacin and gentamicin, and 45% resistance to ciprofloxacin. Klebsiella spp. showed 98%, 25%, 17%, 25%, 67%, and 50% resistance to ceftazidime, piperacillin-tazobactam, meropenem, amikacin, gentamicin, and ciprofloxacin, respectively. However, corresponding figures for Escherichia coli were 92%, 50%, 31%, 75%, and 94%, respectively, showing that E. coli are more resistant as compared to Klebsiella and Pseudomonas. Acinetobacter resistance proportions were lesser than Pseudomonas spp. [Table 2].
Table 2: Antibiotic susceptibility of common GNB isolates from blood cultures

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Among Gram-positive cocci high-level of ampicillin resistance was 75% in Enterococcus, and 33% of Staphylococcus aureus were MRSA [Table 3]. Among Candida spp. results of blood cultures showed no resistance to amphotericin-B, Voriconazole, caspofungin. Candida tropicalis was the most common isolate, and 1 isolate of Candida glabrata showed dose-dependent sensitivity (SDD) to fluconazole.
Table 3: Antibiotic susceptibility of common Gram--positive cocci isolates from blood cultures

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Mortality review of patient with infections showed that 3 patients died of multi-drug resistant-Gram-negative bacteria (MDR-GNB) in 2013 (e.g., extended spectrum beta-lactamase, AmpC and carbapenemase producers). The total number of such MDR-GNB in Pediatric Oncology comprised of 12% (3/25).

Review of incidence of invasive fungal infections other than Candida spp. showed that 17 patients had radiological evidence of invasive fungal infections. In the majority of these patients, chest was the site of infection, whereas brain, sino-nasal and hepatosplenic infections were present in 2, 2, and 1 patient, respectively.

In all patients with febrile neutropenia, piperacillin-tazobactam with amikacin was used as first line antibiotics. Antifungal prophylaxis used was Voriconazole or Amphotericin B in AML patients until the end of treatment while posaconazole was used as antifungal prophylaxis in BMT patients.

Infection control measures used after detection of MDR organisms (MDRO) included barrier nursing, which consist of attention to hand hygiene, appropriate use of personnel protective equipments, environment cleaning and disinfection, linen disinfection, biohazard symbol, and safety alert flagging at bed site and electronic medical records, and isolation of patient in separate room in case of VRE/colistin resistant Klebsiella/carbapenem-resistant Enterobacteriaceae (CRE).[7],[8],[9],[10],[11],[12]


 ╗ Discussion Top


Infection with MDRO is now a significant hazard during treatment of children with malignancies.[1],[3],[4],[5] The resulting morbidity, mortality, drug toxicity, and cost escalation are major problems.[13],[14],[15] The antimicrobial treatment options are increasingly becoming limited. Despite advancement in the treatment of various malignancies, the overall survival cost of care, and quality of patient's life will not change significantly unless we are able to prevent or control infections. The presence of resistant strains of GNB in stool surveillance shows the possibility of community acquisition of these organisms.[16]

Because of the high prevalence of MDRO in India, a lot of investment and planning is needed to control infections. Very few hospitals have facilities for infection control including isolation rooms, dedicated infection control nurse, proper infection control procedures, a training system and evaluation. All parts of the system including doctors, nurses, housekeeping, maintenance, engineering, and administrative staff need to be trained and actively involved in infection control.


 ╗ Acknowledgments Top


Laboratory technologists of the Department of Microbiology, and nursing staff of pediatric ward.

 
 ╗ References Top

1.
Gupta A, Kapil A, Kabra SK, Lodha R, Sood S, Dhawan B, et al. Prospective study estimating healthcare associated infections in a paediatric hemato-oncology unit of a tertiary care hospital in North India. Indian J Med Res 2013;138:944-9.  Back to cited text no. 1
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2.
Prabhash K, Medhekar A, Ghadyalpatil N, Noronha V, Biswas S, Kurkure P, et al. Blood stream infections in cancer patients: A single center experience of isolates and sensitivity pattern. Indian J Cancer 2010;47:184-8.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
El-Mahallawy H, Sidhom I, El-Din NH, Zamzam M, El-Lamie MM. Clinical and microbiologic determinants of serious bloodstream infections in Egyptian pediatric cancer patients: A one-year study. Int J Infect Dis 2005;9:43-51.  Back to cited text no. 3
    
4.
Al-Mulla NA, Taj-Aldeen SJ, El Shafie S, Janahi M, Al-Nasser AA, Chandra P. Bacterial bloodstream infections and antimicrobial susceptibility pattern in pediatric hematology/oncology patients after anticancer chemotherapy. Infect Drug Resist 2014;7:289-99.  Back to cited text no. 4
    
5.
Trecarichi EM, Tumbarello M, Caira M, Candoni A, Cattaneo C, Pastore D, et al. Multidrug resistant Pseudomonas aeruginosa bloodstream infection in adult patients with hematologic malignancies. Haematologica 2011;96:e1-3.  Back to cited text no. 5
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6.
Bhattacharya S. Is screening patients for antibiotic-resistant bacteria justified in the Indian context? Indian J Med Microbiol 2011;29:213-7.  Back to cited text no. 6
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7.
Bhattacharya S, Das D, Bhalchandra R, Goel G. Patient isolation in the high-prevalence setting: Challenges with regard to multidrug-resistant gram-negative bacilli. Infect Control Hosp Epidemiol 2013;34:650-1.  Back to cited text no. 7
[PUBMED]    
8.
Goel G, Hmar L, Sarkar De M, Bhattacharya S, Chandy M Colistin-resistant Klebsiella pneumoniae: Report of a cluster of 24 cases from a new oncology center in eastern India. Infect Control Hosp Epidemiol 2014;35:1076-7.  Back to cited text no. 8
    
9.
Van Dalen R, Gombert K, Bhattacharya S, Datta SS. Mind the mind: Results of a hand-hygiene research in a state-of-the-art cancer hospital. Indian J Med Microbiol 2013;31:280-2.  Back to cited text no. 9
    
10.
Goel G, Das D, Mukherjee S, Bose S, Das K, Mahato R, et al. A method for early detection of antibiotic resistance in positive blood cultures: Experience from an oncology centre in eastern India. Indian J Med Microbiol 2015;33 Suppl: 53-8.  Back to cited text no. 10
    
11.
Bhalchandra R, Chandy M, Ramanan VR, Mahajan A, Soundaranayagam JR, Garai S, et al. Role of water quality assessments in hospital infection control: Experience from a new oncology center in eastern India. Indian J Pathol Microbiol 2014;57:435-8.  Back to cited text no. 11
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12.
Das K, Bhattacharyya A, Chandy M, Roy MK, Goel G, Hmar L, et al. Infection control challenges of infrequent and rare fungal pathogens: Lessons from disseminated Fusarium and Kodamaea ohmeri infections. Infect Control Hosp Epidemiol 2015;36:866-8.  Back to cited text no. 12
    
13.
Bhattacharya S. Early diagnosis of resistant pathogens: How can it improve antimicrobial treatment? Virulence 2013;4:172-84.  Back to cited text no. 13
    
14.
Gupta A, Kapil A, Lodha R, Kabra SK, Sood S, Dhawan B, et al. Burden of healthcare-associated infections in a paediatric intensive care unit of a developing country: A single centre experience using active surveillance. J Hosp Infect 2011;78:323-6.  Back to cited text no. 14
    
15.
Rose W, Veeraraghavan B, Pragasam AK, Verghese VP. Antimicrobial susceptibility profile of isolates from pediatric blood stream infections. Indian Pediatr 2014;51:752-3.  Back to cited text no. 15
    
16.
Bhattacharya S, Goel G, Mukherjee S, Bhaumik J, Chandy M. Epidemiology of antimicrobial resistance in an oncology center in eastern India. Infect Control Hosp Epidemiol 2015;36:864-6.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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