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  Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 418-419
 

Bloodstream infections in pediatric patients at cancer institute, Chennai


1 Department of Medical Oncology, Cancer Institute, Adyar, Chennai, Tamil Nadu, India
2 Department of Microbiology, Cancer Institute, Adyar, Chennai, Tamil Nadu, India

Date of Web Publication1-Feb-2016

Correspondence Address:
V Radhakrishnan
Department of Medical Oncology, Cancer Institute, Adyar, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175360

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 » Abstract 

Background: There is paucity of data on the epidemiology of bloodstream infections in pediatric cancer patients from India. Rationale use of antibiotics in febrile neutropenia is important for reducing morbidity and preventing the emergence of drug resistant bacteria. AIMS: The study was conducted to look at the prevalence of bloodstream bacterial infection and the antibiotic resistance profile at Cancer Institute, Chennai. Settings And Design: This was a retrospective study. Materials and Methods: Data on all blood cultures taken from pediatric cancer patients treated at Cancer Institute, Chennai, during the year 2013 were analyzed. The microbiological profile and sensitivity pattern were analyzed. Results: A total of 1045 blood culture samples were taken, and there were 82/1045 (7.5%) positive blood cultures. Gram-negative organisms accounted for 50/82 (61%) of all positive cultures. Klebsiella pneumoniae (32%) was the most common Gram-negative isolate, and Staphylococcus aureus (93.5%) was the most common Gram-positive. There was high resistance to aminoglycosides and beta-lactam/beta-lactamase inhibitor antibodies. Conclusion: Gram-negative organisms are the predominant bacteria isolated. There is high resistance to first-line combination antibiotics used as empiric therapy for treatment of febrile neutropenia.


Keywords: Antibiotics, bacteria, febrile neutropenia, sensitivity


How to cite this article:
Radhakrishnan V, Vijaykumar V, Ganesan P, Rajendranath R, Trivadi G, Tenali S. Bloodstream infections in pediatric patients at cancer institute, Chennai. Indian J Cancer 2014;51:418-9

How to cite this URL:
Radhakrishnan V, Vijaykumar V, Ganesan P, Rajendranath R, Trivadi G, Tenali S. Bloodstream infections in pediatric patients at cancer institute, Chennai. Indian J Cancer [serial online] 2014 [cited 2019 Aug 24];51:418-9. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/418/175360



 » Introduction Top


Infections are an important cause of morbidity and mortality in children with cancer.[1] The alarming rise in the prevalence of multi drug resistant bacteria in hospitals has made it difficult to treat bloodstream infections.[2] This trend is worrying because there has been no new class of antibiotics discovered over the last two decades, thus making our fight against drug resistant bacteria even more difficult.[3] It is important to obtain data on incidence of hospital-acquired infections, type of organisms seen and their resistance, so that policies can be designed at local and national level to rationalize antibiotic use and improve infection-related outcomes in patients.


 » Materials and Methods Top


The study was conducted at Cancer Institute, Chennai. Retrospective data on all blood cultures taken from pediatric oncology patients <18 years of age during the year 2013 were analyzed. Blood culture samples from peripheral and central venous catheters were taken from patients suspected to have bloodstream infection.

Blood culture testing was carried out using Automated Blood Culture System (BacT/ALERT 3D from Biomerieux, Germany). It is a quantitative blood culture system, continuously monitoring the blood for bacteria and fungus every 10 min. It works on colorimetric detection of carbon dioxide (CO2) produced by the organisms inside the blood culture bottles, which is sensed by a CO2 sensor. Positive cultures are recognized by a computer-driven algorithm that monitors both initial and increased concentrations of CO2. The bacterial isolates from the blood culture samples are identified by routine biochemical reactions and if required using VITEK 2, which is an automated microbiology system utilizing growth-based technology. Antibiotic susceptibility profile is determined using Kirby Bauer's disc diffusion method.

The first-line antibiotics used for treatment of febrile neutropenia at our center are cefaperazone/sulbactam with amikacin, this combination is escalated to piperacillin/tazobactum with teicoplanin if there is persistent fever for 48 h on first-line antibiotics or clinical deterioration. Meropenem is used as third line antibiotic if there has been no response to piperacillin/tazobactum and teicoplanin. Patients not responding to meropenem receive colistin. Teicoplanin is added to first-line if the patient presents with septic shock.


 » Results Top


A total of 1045 blood culture samples were taken from pediatric patients less than the age of 18 years during the year 2013. There were 82/1045 (7.5%) positive blood cultures. Gram-negative organisms accounted for 50/82 (61%) of all positive cultures and Gram-positive organisms accounted for 32/82 (39%) of all positive cultures.

Klebsiella pneumoniae (32%) was the most common Gram-negative isolate, followed by Pseudomonas (26%), Acinetobacter (18%) and Escherichia coli (8%). Other Gram-negative bacteria detected on cultures included Burkholderia (2%), Alcaligenes faecalis (4%) and unclassified (10%). Staphylococcus aureus (93.5%) was the most common Gram-positive isolate followed by Enterococcus (6.5%). [Table 1] provides information about the bacteria isolated in the study.
Table 1: Organisms isolated from blood cultures

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Sensitivity to beta-lactam/beta-lactamase inhibitor (BL/BLI) antibiotics like cefaperazone/sulbactam was seen in all Pseudomonas isolates, this decreased to 66% in Acinetobacter and 50% in E. coli isolates. Only 31% of Klebsiella isolates were sensitive to BL/BLI antibiotics.

There was high degree of resistance to aminoglycosides, only 31% of Pseudomonas species and 56% of Klebsiella species were sensitive to aminoglycosides. Highest sensitivity to aminoglycosides was seen with Acinetobacter (77%).

Similar to BL/BLI antibiotic sensitivity, all Pseudomonas isolates were sensitive to Carbapenems. However, only 62% of Klebsiella and 50% E. coli isolates were sensitive to Carbapenems. Sensitivity to Carbapenems was seen in 77% Acinetobacter isolates.

Resistance to Colistin was also seen, with only 81% Klebsiella and 75% E. coli and 75% Acinetobacter isolates sensitive to Colistin. [Table 2] provides information on the antibiotic sensitivity pattern of Gram-negative isolates.
Table 2: Common Gram-negative isolates and their sensitivity in blood-n (%)

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The prevalence of methicillin resistant S. aureus (MRSA) was low (6.6%). No vancomycin resistant Enterococcus (VRE) was seen.


 » Discussion Top


The prevalence of blood stream infection varies across regions and even among hospitals in the same city.[4],[5],[6],[7] Factors such as type of cancer patients treated, use of prophylactic antibiotics and regular use of central venous catheters influence the bacteria isolated in a hospital and the sensitivity of the isolated organisms.

The western literature has shown a shift from Gram-negative organisms to Gram-positive organisms over the past decade.[8] We continue to see more Gram-negative organisms compared to west; however, compared to other tertiary cancer centers in India, our proportion of Gram-positive organisms are higher.[4],[5],[6],[7] We do not use prophylactic antibiotics, but the majority of our pediatric leukemia and non-hodgkins lymphoma patients have central venous access catheters, this could be one of the reasons why we see a higher incidence of Gram-positive infections.

A very high degree of resistance was noticed to BL/BLI antibiotics such as cefaperazone/sulbactam and aminoglycoside antibiotics in our study. These two antibiotics are used as first-line treatment for febrile neutropenia at our center and also at various centers across India and the world.[9] The chance of failure of first-line antibiotics is high based on the current prevalent resistant pattern. This becomes important for patients who are sick at presentation with multi-drug resistant organisms and starting them on empirical BL/BLI antibiotics and aminoglycoside may be detrimental.

It is also interesting to note that the prevalence of MRSA in our patients is very low, and we did not see any case of VRE.

It is worrying that we had two patients with acute myeloid leukemia who developed infections resistant to Colistin, one of the patients had culture positivity for Pseudomonas and E. coli and the other patient had culture positivity for Acinetobacter. Both the patients died due to fulminant sepsis.

There is a paucity of data on the epidemiology of infections in pediatric cancer patients being treated at various centers in India. The spectrum of infection seen among neutropenic pediatric cancer patients tends to be different from what is seen in the general pediatric population, a large proportion of blood stream infections in neutropenic patients originate from the patients' own gut flora. There is an urgent need to have a national policy for management of febrile neutropenia in pediatric cancer patients, and this policy should focus on the threat of drug resistant bacteria.

 
 » References Top

1.
Meckler G, Lindemulder S. Fever and neutropenia in pediatric patients with cancer. Emerg Med Clin North Am 2009;27:525-44.  Back to cited text no. 1
    
2.
El-Mahallawy HA, El-Wakil M, Moneer MM, Shalaby L. Antibiotic resistance is associated with longer bacteremic episodes and worse outcome in febrile neutropenic children with cancer. Pediatr Blood Cancer 2011;57:283-8.  Back to cited text no. 2
    
3.
Devasahayam G, Scheld WM, Hoffman PS. Newer antibacterial drugs for a new century. Expert Opin Investig Drugs 2010;19:215-34.  Back to cited text no. 3
    
4.
Bakhshi S, Padmanjali KS, Arya LS. Infections in childhood acute lymphoblastic leukemia: An analysis of 222 febrile neutropenic episodes. Pediatr Hematol Oncol 2008;25:385-92.  Back to cited text no. 4
    
5.
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. 5
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6.
Prabhash K, Medhekar A, Biswas S, Kurkure P, Nair R, Kelkar R. Comparison of in vitro activities of ceftazidime, piperacillin-tazobactam, and cefoperazone-sulbactam, and the implication on empirical therapy in patients with cancer. Indian J Cancer 2009;46:318-22.  Back to cited text no. 6
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7.
Gupta A, Singh M, Singh H, Kumar L, Sharma A, Bakhshi S, et al. Infections in acute myeloid leukemia: An analysis of 382 febrile episodes. Med Oncol 2010;27:1037-45.  Back to cited text no. 7
    
8.
Lehrnbecher T, Varwig D, Kaiser J, Reinhardt D, Klingebiel T, Creutzig U. Infectious complications in pediatric acute myeloid leukemia: Analysis of the prospective multi-institutional clinical trial AML-BFM 93. Leukemia 2004;18:72-7.  Back to cited text no. 8
    
9.
Pizzo PA. The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Where do we go from here? J Antimicrob Chemother 2009;63 Suppl 1:i16-7.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2]



 

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