|Year : 2020 | Volume
| Issue : 2 | Page : 261-264
Pediatric blood culture isolates and antibiotic sensitivity pattern in a Nigerian tertiary hospital
TO Ogunkunle1, MB Abdulkadir2, OS Katibi2, SO Bello1, RA Raheem3, R Olaosebikan4
1 Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
2 Department of Paediatrics and Child Health, University of Ilorin/University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
3 Department of Microbiology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria
4 Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
|Date of Submission||28-Sep-2018|
|Date of Decision||23-Sep-2019|
|Date of Acceptance||27-Apr-2020|
|Date of Web Publication||26-Jun-2020|
Dr. T O Ogunkunle
Department of Paediatrics, University of Ilorin Teaching Hospital, Ilorin, Kwara State
Source of Support: None, Conflict of Interest: None
Introduction: There is a significant variation in the bacterial pathogens implicated in childhood septicemia and their antibiotic sensitivity pattern from place to place. Sustained monitoring of this dynamics is therefore critical to rational antibiotic use. Materials and Methods: This study was thus conducted to determine the etiology of childhood septicemia and their antibiotic sensitivity pattern. Blood culture results (contaminants excluded), age, and sex of all pediatric patients with suspected septicemia between January 2013 and December 2014 were retrieved. Data were analyzed using SPSS version 20. Results: Over a 2-year period, a total of 3680 blood samples were processed. Pathogenic bacteria were isolated in 701 samples (19%).Staphylococcus aureus was the most common isolate (41.4%) and was most sensitive to ampicillin-sulbactam (89%). Klebsiella species (21.7%), coagulase-negative Staphylococcus (14.7%), and Pseudomonas aeruginosa (11%) were other common organisms isolated. Virtually, all the isolates demonstrated a reliable susceptibility to ciprofloxacin except for S. aureus and Klebsiella species which were most sensitive to ampicillin-sulbactam and imipenem, respectively. Conclusion: In conclusions, S. aureus is the leading cause of childhood septicemia in this locale. The significant rate of isolation of the supposedly less virulent organisms calls for an urgent review of potential risk factors and an appraisal of the hospital infection control policies and structures.
Keywords: Antibiotics, isolates, paediatric
|How to cite this article:|
Ogunkunle T O, Abdulkadir M B, Katibi O S, Bello S O, Raheem R A, Olaosebikan R. Pediatric blood culture isolates and antibiotic sensitivity pattern in a Nigerian tertiary hospital. Niger J Med 2020;29:261-4
|How to cite this URL:|
Ogunkunle T O, Abdulkadir M B, Katibi O S, Bello S O, Raheem R A, Olaosebikan R. Pediatric blood culture isolates and antibiotic sensitivity pattern in a Nigerian tertiary hospital. Niger J Med [serial online] 2020 [cited 2020 Sep 20];29:261-4. Available from: http://www.njmonline.org/text.asp?2020/29/2/261/287932
| Introduction|| |
The bacterial infection is a major cause of morbidity and mortality globally, but the greatest burden is borne by the developing countries. Bacteremia is the predominant cause of sepsis, i.e. systemic inflammatory response syndrome.,,, Delayed recognition and treatment of bloodstream bacterial infection significantly increase the risk of morbidity and mortality as they progress to sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndromes.,
Diagnostic criteria of sepsis (i.e. fever, tachycardia, tachypnea, leucopenia/leukocytosis, or presence of >10% immature neutrophils) are less sensitive and not specific to bacterial infection. Bacterial isolation from blood specimen and antibiotic sensitivity testing thus provides the definitive diagnosis upon which antimicrobial therapy should be based. However, these investigations are either not available or the results are delayed, especially in resource-poor settings; consequently, overuse and misuse of antibiotics are prevalent with the attendant risk of antimicrobial resistance.
There are wide variations in the bacterial pathogens implicated in childhood septicemia as well as their sensitivity pattern to antibiotics.,,,,,,, The knowledge of epidemiology and antimicrobial susceptibility pattern of bacterial isolates in a given area is thus crucial to rational, empirical antibiotic use. The pattern of bacterial isolates and the antibiotic sensitivity of isolated organisms in children with clinical suspicion of bloodstream bacterial infection seen at a tertiary health-care facility in North Central Nigeria is thus presented in this study.
| Materials and Methods|| |
It was a retrospective study of all cases of suspected septicemia in pediatric patients (0–18 years) over a 2-year period (January 1, 2013, and December 31, 2014). The minimum sample size of 363 was calculated with the Fisher formula using a previous prevalence rate of 38.2%. The results of blood culture (contaminants excluded) and antibiotic sensitivity pattern of the subjects were extracted alongside their ages and sex. The extracted information was analyzed using SPSS version 20 (SPSS IBM Corp. New York, USA).
Routine blood culture during the period under review was manual using cooked meat. Aerobic cultures were mounted on the same day and subcultured within 48 h if there was growth. Eosin methylene blue and blood agar plates were used for subculture and incubated at 37°C. Identification of organisms and antibiotic sensitivity patterns of bacterial isolates was made using standard methods.
| Results|| |
A total of 3680 blood culture results of children with suspected bacteremia over a 2-year period were studied. The isolates and sex distribution of the patients are shown in [Table 1]. Bacteria isolation rate was 701 (19%). More males (396 [56.5%]) than females (305 [43.5%]) had a positive blood culture result.
|Table 1: Bacterial isolates and sex of children with suspected bacterial sepsis|
Click here to view
The types and pattern of bacterial isolates in age groups are shown in [Table 2]. Overall, Gram-positive organisms (coagulase-negative Staphylococcus [CoNS], Enterococcus, Staphylococcus aureus, and β-hemolytic and nonhemolytic Streptococcus) accounted for most of the isolates 410 (58.5%). The most frequent isolate across all age groups was S. aureus (41.4%), this is followed by Klebsiella species (21.7%), CoNS (CoNS; 14.7%), Pseudomonas aeruginosa (11%), and Escherichia More Details coli (5.6%). The prevalence of the latter organisms was however nonuniform across all age groups though E. coli septicemia occurred more frequently in the neonatal age group. Septicemia occurred more frequently among under-five (n = 508), notably in the neonatal age group.
Antimicrobial sensitivity pattern of the isolated organisms is displayed in [Table 3]. S. aureus had the highest susceptibility to ampicillin-sulbactam (89%), cefuroxime (86.5%), imipenem (86.5%), amoxicillin-clavulanate (85.8%), ciprofloxacin (82.9%), and gentamicin (77.7%). Klebsiella species was most reliably susceptible to imipenem (70.4%) and to a lesser extent ceftazidime (68.1%). CoNS was most sensitive to Unasyn (ampicillin/sulbactam) (95%), while the susceptibility of P. aeruginosa was highest to imipenem (95.8%), followed by ciprofloxacin (92.8%) and gentamicin (79.4%).
| Discussion|| |
The prevalence rate (19%) of septicemia in this study is comparable to the 15% rate found in a 7-year surveillance study in Kano. However, it was remarkably low compared to the 38.2% rate found by Adedoyin et al. in the same center about 8 years earlier. A higher rate of 35% was also found in Lagos. In the latter studies, however, a smaller study population and shorter span of study may also have resulted in higher rates given the seasonality of bacterial etiology of sepsis.
Gram-positive pathogens predominate in this report with the leading etiologic agent across all age groups being S. aureus (41.4%). This is in consonance with reports from previous studies.,,, However, Obaro et al., in a recent multicenter study, revealed that Salmonella More Details species are the most common cause of childhood bacteremia in the Central (Abuja) and North Eastern (Kano) part of Nigeria. The study, however, did not report the prevalence of associated risk factors (e.g. malnutrition, malaria, HIV infections, and level of hygiene) which could have been responsible for the preponderance of Salmonella species. Nwadioha et al. have previously documented the preponderance of enteric pathogen, i.e. E. coli as the causative agent of bacteremia from the same region, which further suggests a peculiar predisposition to feco-orally acquired pathogens.
Noteworthy is the contribution of Klebsiella species, CoNS, and P. aeruginosa to the burden of septicemia and their pattern of distribution across different age groups. Previous studies have reported the etiologic role of Klebsiella species and P. aeruginosa in childhood septicemia, but the duo has been found to be more common in neonates., In a study by Uzodimma et al.,Klebsiella species accounted for 11.4% of organisms isolated from children with suspected septicemia mostly from the neonatal age group. However, in this report, these organisms were most prevalent among children aged one to 5 years. They also constitute a sizeable proportion of organisms isolated (32.7%; Klebsiella species 21.7% and Pseudomonas 11%) contrary to report by Adedoyin et al. from the same center about a decade earlier.
Increasing rates of antibiotic-resistant bacteria isolates have been observed globally. Most WHO member states have reported up to 60% resistance in Klebsiella pneumoniae against third-generation cephalosporins. In this study, imipenem appears to be the antibiotic of choice when confronted with Klebsiella septicemia, as the resistance to ceftriaxone was as high as 61.3%, a third-generation cephalosporin which had hitherto been the standard intravenous treatment for severe Klebsiella infections in hospitals. Furthermore, imipenem also stood out as the antibiotics of choice against P. aeruginosa ahead of other commonly used antibiotics. The economic cost of the compelling need to use imipenem as a first-line option will certainly be challenging, especially in a resource-poor setting.
| Conclusion|| |
Septicemia constitutes a significant disease burden among children under the age of 5 years. The predominant causative agent is S. aureus but with a significant contribution of supposedly less virulent organisms. This finding might suggest some form of suboptimal immunity or hospital-associated infections. This calls for an urgent review of factors that may be causally related to this development, including an appraisal of the hospital infection control policies and structures.
Ciprofloxacin seems to be a rational initial empirical antibiotic of choice when confronted with a possibility of septicemia among pediatric patients in this environment. The potential danger of the widespread use of ciprofloxacin, however, is the emergence of resistance to Enterobacteriaceae and Mycobacterium tuberculosis due to its association with a high incidence of extended-spectrum β-lactamase enzyme production among these organisms. Therefore, where septicemia due to S. aureus is plausible (i.e. staphylococcal skin infection), the use of ampicillin-sulbactam will be the most rational choice. In addition, the presence of ecthyma gangrenosum in a septicemic child raises a strong suspicion of Pseudomonas infection and would warrant the use of imipenem as a first-line antibiotic.
Limitations: The bacterial yield from culture may have been affected by the volume of blood drawn for analysis, this could however, not be controlled for given the retrospective study design. Also, the clinical correlates were not assessed.
The authors would like to thank Dr. Kehinde O. Aiyenigba and Dr. Adewale A. Bello (Medical interns) who assisted in data entering
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al
. Global, regional, and national causes of child mortality in 2008: A systematic analysis. Lancet 2010;375:1969-87.
Wiens MO, Kumbakumba E, Kissoon N, Ansermino JM, Ndamira A, Larson CP. Pediatric sepsis in the developing world: Challenges in defining sepsis and issues in post-discharge mortality. Clin Epidemiol 2012;4:319-25.
Watson RS, Carcillo JA. Scope and epidemiology of pediatric sepsis. Pediatr Crit Care Med 2005;6:S3-5.
Asindi AA, Ibia EO, Udo JJ. Mortality pattern among Nigerian children in the 1980s. J Trop Med Hyg 1991;94:152-5.
Adedoyin OT, Ibrahim M, Johnson WB, Ojuawo AI, Mokuolu OA, Ernest SK, et al
. Bacterial isolates of blood in children with suspected septicaemia in a Nigerian tertiary hospital. Trop J Health Sci 2013;20:31-6.
Odetola F, Gebremariam A, Freed GL. Patient and hospital correlate of clinical outcomes and resource utilization in severe paediatric sepsis. Paediatrics 2007;119:487-94.
Stormorken A, Powel KR. Sepsis and Shock. 19th
ed. Philadelphia: Elsevier Saunders; 2011.
Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al
. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36:296-327.
World Health Organization. Antimicrobial Drug Resistance. World Health Organization; 2013.
Weber MW, Carlin JB, Gatchalian S, Lehmann D, Muhe L, Mulholland EK. WHO Young Infants Study Group: Predictors of neonatal sepsis in developing countries. Pediatr Infect Dis J 2003;22:711-7.
Uzodimma CC, Njokanma F, Ojo O, Falase M, Ojo T. Bacterial isolates from blood cultures of children with suspected sepsis in an urban hospital in Lagos: A prospective study using BACTEC blood culture system. Internet J Pediatr Neonatol 2013;16:1-8. Available from: http://www.ISPUB.com
. [Last accessed on 2020 May 17].
Meremikwu MM, Nwachukwu CE, Asuquo AE, Okebe JU, Utsalo SJ. Bacterial isolates from blood cultures of children with suspected septicaemia in Calabar, Nigeria. BMC Infect Dis 2005;5:110.
Mokuolu AO, Jiya N, Adesiyun OO. Neonatal septicaemia in Ilorin: Bacterial pathogens and antibiotic sensitivity pattern. Afr J Med Med Sci 2002;31:127-30.
Berkley JA, Lowe BS, Mwangi I, Williams T, Bauni E, Mwarumba S, et al
. Bacteremia among children admitted to a rural hospital in Kenya. N
Engl J Med 2005;352:39-47.
Negussie A, Mulugeta G, Bedru A, Ali I, Damte S, Lema T, et al
. Bacteriological profile and antimicrobial susceptibility pattern of blood culture isolate among septicemia suspected children in selected Hospitals in Addis Ababa, Ethiopia. Int J Biol Med Res 2016;6:4709-17.
Hill PC, Onyeama CO, Ikumapayi UN, Secka O, Ameyaw S, Simmonds N, et al
. Bacteraemia in patients admitted to an urban hospital in West Africa. BMC Infect Dis 2007;7:2.
Stephen JC, Ronald JH, Yvette SM, José HO, Ivonne DR, Robert LS, et al
. Disk diffusion testing. In: Marie BC, editor. Manual of Antimicrobial Susceptibility Testing. American Society for Microbiology: Washington, D.C U.S.A; 2014. p. 39-52.
Obaro SK, Hassan-Hanga F, Olateju EK, Umoru D, Lawson L, Olanipekun G, et al
bacteremia among children in central and Northwest Nigeria, 2008-2015. Clin Infect Dis 2015;61 Suppl 4:S325-31.
Negussie A, Mulugeta G, Bedru A, Ali I, Shimeles D, Lema T, et al
. Bacteriological profile and antimicrobial sensitivity pattern of blood culture isolates among septicemia-suspected children at Tikur Anbessa Specialized Hospital and Yekatit 12 Hospital, Addis Ababa, Ethiopia. Crit Care 2013;17:11.
Church J, Maitland K. Invasive bacterial co-infection in African children with Plasmodium falciparum
malaria: A systematic review. BMC Med 2014;12:31.
Nwadioha SI, Nwokedi EO, Kashibu E, Odimayo MS, Okwori EE. A review of bacterial isolates in blood cultures of children with suspected septicemia in a Nigerian tertiary hospital. Afr J Microbiol Res 2010;4:222-5.
Antimicrobial Resistance: Global Report on Surveillance; 2014. Available from: http://www.who.int
. [Last accessed on 2020 May 16].
Paterson DL, Bonomo RA. Extended-spectrum b-lactamases: A clinical update. Clin Microbiol Rev 2005;18:657-86.
Robert SB. Pseudomonas, burkholderia, stenotrophomonas. In: Kliegman RM, Stanton BF, Joseph WS, Schor NF, Behrman RE, editors. Nelson Textbook of Pediatrics. Philadelphia:Elsevier Saunders; 2011. p. 933-4.
[Table 1], [Table 2], [Table 3]