Bacteremia In Infants Research Articles

Methicillin-resistant Staphylococcus aureus bacteraemia in neonatal intensive care units: an analysis of 90 episodes.

To delineate the clinical features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in infants hospitalized at the neonatal intensive care unit. Episodes of MRSA bacteraemia in Chang Gung Children's Hospital neonatal intensive care unit from 1997 to 1999 were reviewed for incidence, predisposing factors, clinical presentations, treatment and outcome. Ninety episodes of MRSA bacteraemia were identified. The overall rate of MRSA bacteraemia was 1.05 per 1000 patient days during the 3-y period. Most of the patients were premature infants (76%), with prior operation or invasive procedures (39%), had an indwelling intravascular catheter (79%) and exposure to antibiotic therapy (96%). A localized cutaneous infection was found in 53.3% of the episodes. The most common clinical diagnoses were catheter-related infections (54.4%), skin and soft tissue infections (21.1%), bacteraemia without a focus (20%) and pneumonia (16.7%). Metastatic infection occurred in 18% of these infants. Among the patients treated with vancomycin for < or = 14 d, 88.7% did not develop any complications, and 11.3% developed a recurrence. MRSA is an established pathogen in our NICU. MRSA bacteraemia in the neonates predominantly presented as catheter-related infections, and metastatic infections were not infrequently seen. In uncomplicated MRSA bacteraemia, treatment with vancomycin for < or = 14 d seems to be adequate.

Methicillin‐resistant Staphylococcus aureus bacteraemia in neonatal intensive care units: an analysis of 90 episodes

Aim: To delineate the clinical features of methicillin‐resistant Staphylococcus aureus (MRSA) bacteraemia in infants hospitalized at the neonatal intensive care unit. Methods: Episodes of MRSA bacteraemia in Chang Gung Children's Hospital neonatal intensive care unit from 1997 to 1999 were reviewed for incidence, predisposing factors, clinical presentations, treatment and outcome. Results: Ninety episodes of MRSA bacteraemia were identified. The overall rate of MRSA bacteraemia was 1.05 per 1000 patient days during the 3‐y period. Most of the patients were premature infants (76%), with prior operation or invasive procedures (39%), had an indwelling intravascular catheter (79%) and exposure to antibiotic therapy (96%). A localized cutaneous infection was found in 53.3% of the episodes. The most common clinical diagnoses were catheter‐related infections (54.4%), skin and soft tissue infections (21.1%), bacteraemia without a focus (20%) and pneumonia (16.7%). Metastatic infection occurred in 18% of these infants. Among the patients treated with vancomycin for ±14d, 88.7% did not develop any complications, and 11.3% developed a recurrence.Conclusions: MRSA is an established pathogen in our NICU. MRSA bacteraemia in the neonates predominantly presented as catheter‐related infections, and metastatic infections were not infrequently seen. In uncomplicated MRSA bacteraemia, treatment with vancomycin for ±14 d seems to be adequate.

Predictors of bacteraemia among febrile infants in Ibadan, Nigeria.

Fever is a common complaint in infancy, and bacteraemia is one of the more serious causes of such fever. However, there exists scanty data on risk of bacteraemia among febrile infants of developing countries and what clinical predictors, if any, could identify those febrile infants with bacteraemia. To address this issue, 102 infants aged 1-12 month(s) attending the Children's Emergency Ward of University College Hospital, Ibadan, Nigeria, with rectal temperatures of > or = 38 degrees C and with a negative history of antimicrobial use for at least one week prior to presentation, were studied to identify clinical predictors of bacteraemia. Infants, meeting the eligibility criteria of the study, underwent a full clinical evaluation and had blood cultures done for aerobic organisms by standard methods. Over 38% of the infants had bacteraemia. Escherichia coli (35.9%), Staphylococcus aureus (33.3%), and Klebsiella spp. (10.3%) of positive cultures were commonly isolated. Three variables, age of < or = 6 months, restlessness, and a white cell count of >15,000/mm3, were significant independent predictors of bacteraemia. Each of these variables was associated with a 3-6-fold increase in risk of bacteraemia (age of < or = 6 months: odds ratio 3.2, p = 0.017; restlessness: odds ratio 6.3, p = 0.019; and white cell count of >15,000/mm3: odds ratio 5.4, p = 0.024). The variables, in combination, correctly classified 70% of the infants into 'bacteraemia' or 'no bacteraemia'. It is concluded that; in the setting of the study, about 4 in 10 febrile infants would have a positive blood culture for aerobic organisms and that age of < or = 6 months, restlessness, and a white cell count of > or = 15,000/mm3 are associated with a significantly increased risk of bacteraemia. Clinicians practising in such a setting need to be aware of the increased risk of bacteraemia in infants with these clinical features.

Incidence of bacteremia in infants and children with fever and petechiae

We determined the incidence of serious invasive bacteremia caused by Neisseria meningitidis and other organisms in febrile infants and children with a petechial rash. Further, we studied the diagnostic value of laboratory and clinical finding in these patients. We conducted this prospective cohort study in the emergency department of an urban pediatric teaching hospital, during an 18-month period, and enrolled consecutive patients with temperature of 38 degrees C or higher and petechiae. Our measures included (1) laboratory tests (leukocyte count, coagulation profile, blood culture, and cerebrospinal fluid bacterial culture); (2) a questionnaire requesting clinical data including general appearance, number and location of petechiae, and presence or absence of purpura; and (3) a follow-up telephone survey documenting health status. A total of 411 patients were enrolled, with 57.7% between 3 and 36 months of age. Eight patients (1.9%) had bacteremia or clinical sepsis. Six had serious invasive bacteremia: N. meningitidis (two patients), group A streptococcus (one), or sepsis with negative culture results (three). Two had occult bacteremia caused by Streptococcus pneumoniae and no evidence of sepsis. No patient had a positive cerebrospinal fluid culture result. None of the 357 well-appearing patients (95% confidence interval: 0.0%, 1.0%) had serious invasive bacteremia. Fifty-three patients appeared ill, including all six with serious invasive bacteremia. Ill appearance of the child had a sensitivity of 1.00 (95% confidence interval: 0.60, 1.00), and a leukocyte count of 15,000 or greater, or of less than 5000, had a sensitivity of 1.0 (95% confidence interval: 0.53, 1.00) for detecting serious invasive bacteremia. All children with meningococcemia had purpura. Invasive bacteremia occurred less frequently in our study than in previous series and was identified by clinical criteria. Our data support the treatment of selected well-appearing children with fever and petechiae as outpatients.

Frequency of low level bacteremia in infants from birth to two months of age.

The frequency of low level bacteremia (< or = 10 colony-forming units/ml) in infants from birth to 2 months of age and the optimal volume of blood and number of blood cultures to be collected have not been well-documented. During 1991 guidelines at this hospital for collection of blood for culture from these infants were revised. Blood from each infant with suspected bacteremia was usually inoculated into an Isolator 1.5 Microbial Tube (1.5 ml of blood) and a bottle of anaerobic broth (0.5 to 3.0 ml of blood). The use of a second Isolator tube and the total blood volume recommended for culture (2 to 6 ml) depended on the weight and total blood volume of each infant. Forty-four bacterial pathogens were recovered from the blood of 40 (2.5%) of 1589 infants. Of 34 infants from whose blood the concentration of pathogens could be determined, 23 (68%) had low level bacteremia. Of 50 isolates of pathogens recovered from Isolator cultures, 32 (64%) were detected in counts of < or = 10 colony-forming units/ml. When 2 or 3 blood culture devices were inoculated with a total of 2 to 6 ml of blood from each infant, significantly more cases of bacteremia were detected (34 (3.0%) of 1126 infants had positive blood cultures) than when only one culture device containing < or = 1.5 ml of blood was used (2 (0.5%) of 398 infants had positive blood cultures; P = 0.008). However, when 4 or more culture devices were inoculated with a total of > 6 ml of blood from each infant (5 (7.7%) of 65 infants had positive blood cultures), the difference in recovery of pathogens compared with the culturing of from 2 to 6 ml of blood per infant was not significant (P = 0.089). Low level bacteremia was common in our infants' patient population. The culturing of up to 6 ml of blood which represented up to 4.5% of an infant's total blood volume was required for detection of the pathogens.

MAKING INTRAMUSCULAR SHOTS LESS PAINFUL.

Intramuscular injection of ceftriaxone sodium is called for in several clinical situations, such as presumptive bacteremia in infants and uncomplicated

Association of Intravenous Lipid Emulsion and Coagulase-Negative Staphylococcal Bacteremia in Neonatal Intensive Care Units

Coagulase-negative staphylococci are now the chief cause of bacteremia in neonatal intensive care units. To investigate potential risk factors for this nosocomial infection, we conducted a case--control study among 882 infants treated in two neonatal intensive care units during 1982. The 38 case patients and 76 controls were similar with respect to 27 indicators of the severity of the underlying illness. In addition, of the 20 potential risk factors for bacteremia that we investigated, only 2 met conventional criteria for causality. Infants with coagulase-negative staphylococcal bacteremia were 5.8 times as likely as controls (95 percent confidence interval, 4.1 to 8.3) to have received intravenous lipid emulsion before the onset of bacteremia. Because the use of lipids was common, 56.6 percent of all of the cases of nosocomial bacteremia could be attributed to lipid administration. Infants with bacteremia were also 3.5 times as likely as controls (95 percent confidence interval, 1.4 to 8.3) to have had a percutaneously inserted central venous catheter (attributable risk, 14.9 percent). The induction time for bacteremia after lipid administration, usually through peripheral catheters, was often less than one day. In contrast, the average induction period for nosocomial bacteremia associated with the use of central catheters, which were rarely used for lipid administration, was at least 5.5 days. Similar analyses of data on an additional 31 neonates treated in 1988 confirmed the strong and apparently independent association of coagulase-negative staphylococcal bacteremia with the intravenous administration of lipids (adjusted odds ratio, 5.3; 95 percent confidence interval, 3.5 to 6.7). The risk of coagulase-negative staphylococcal bacteremia in infants in neonatal intensive care units can be attributed primarily to the intravenous administration of lipid emulsions. Since lipids are critical for the nutritional support of premature infants, further studies are needed to examine the pathogenesis and prevention of lipid-associated bacteremia.

The Magnitude of Bacteremia in Infants with Group B Streptococcal Disease

The Magnitude of Bacteremia in Infants with Group B Streptococcal Disease

Salvaging the infected central line: limited success of antibiotic therapy without line removal

When an indwelling central venous catheter (CVC) is the source of bacteremia in infants with long-term nutritional problems, CVC removal controls sepsis but a central venous access site is sacrificed. If transcatheter antibiotics could resterilize infected lines, then some of the precious CVCs could be salvaged. We reviewed the management and outcome of CVC line infections at the Children's Hospital of Philadelphia from July 1980 to September 1984. Bacteremia or fungemia occurred 55 times in 47 patients, aged 1 week to 16 years (median 3 mos), an overall rate of 8% for the study period. CVCs were in place 4 to 310 days (median 27 days) at the time of infection. Staphylococcus epidermidis was the most common organism isolated, followed by Candila albicans. CVC removal was the primary mode of controlling bacteremia in 32 patients. Generally, antibiotic coverage was added (21 patients), but removal alone without antibiotics appeared to be adequate therapy in 11 patients, including 5 with Candila fungemia. In 15 patients antibiotics were given, attempting to clear the line of infection. Persistent sepsis or positive repeat cultures led to removal of the CVCs in 9 of the 15 (60%). Line infection cleared on initial antibiotic therapy alone in 6 patients, allowing line salvage. However, bacteremia recurred in 3 and in each an organism different from the one causing the original infection was isolated. Sepsis cleared after the removal in 2, and one died of Candila superinfection during a second attempt at line sterilization. Two patients remained free from sepsis with CVC salvage with antibiotic therapy alone (13%). One patient died of peritonitis not related to catheter infection with the original CVC. Of the 47 patients, 8 received replacement CVCs and 1 received a third CVC. Five (55%) suffered another bout of line sepsis, often with organisms different from the one causing the original infection. CVC removal remains the most reliable means of managing line sepsis. Those receiving another CVC are at risk of infecting their new line, often with an organism different from the original one causing the first septic bout. Although theoretically desirable, “sterilizing” CVCs with transcatheter antibiotics alone has limited success.

Recommendations for Using Pneumococcal Vaccine in Children

A 23-valent pneumococcal polysaccharide vaccine licensed in the United States in 1983 replaces the 14-valent polysaccharide vaccine licensed in 1977. This statement contains new data about pneumococcal vaccine and its effectiveness that have become available since 1977 and new recommendations regarding its use in children. PNEUMOCOCCAL DISEASE Streptococcus pneumoniae (pneumococcus) is the most common cause of acute otitis media, and it is a frequent cause of bacterial pneumonia, bacterial meningitis, and sinusitis in children. Pneumococcus is the most common cause of bacteremia in infants and children aged 1 to 24 months; some of these children with fever and bacteremia have no evidence of a primary focus of infection. Mortality from pneumococcal disease is highest in patients who have bacteremia or meningitis and in patients with certain underlying medical conditions. Patients at increased risk of developing severe pneumococcal disease, because of impaired immunologic response to pneumococcus, are those with sickle cell anemia, Hodgkin disease, congenital or acquired immunodeficiency, nephrotic syndrome, and splenic dysfunction, and those who have had splenectomy or organ transplantation. Certain other patients also may be at greater risk of suffering severe pneumococcal infections, such as some patients with diabetes mellitus, congestive heart failure, chronic pulmonary disease, and renal failure. Patients with CSF leakage complicating skull fracture or neurosurgical procedure may have recurrent pneumococcal meningitis. To date, 83 pneumococcal types have been identified by the serologic properties of their capsular polysaccharides. Certain of these polysaccharides share physicochemical and antigenic properties. Ten serotypes account for the majority of pneumococcal infections in children and adults.

Is coagulase-negative staphylococcal bacteraemia in neonates a consequence of mechanical ventilation?

The clinical symptoms associated with coagulase-negative staphylococcal bacteraemia in infants on a Special Care Baby Unit were investigated. They were compared with those of blood culture—negative controls matched for age and weight. Infants with positive cultures were further sub-divided by judging the isolate to be a contaminant or a pathogen. There was a high incidence of respiratory symptoms in the latter patients, particularly in infants of less than 37 weeks gestation. These symptoms often responded to antimicrobial chemotherapy, particularly in infants given correct antibiotics, as demonstrated by laboratory sensitivity testing. Bacteraemia was usually detected shortly after starting mechanical ventilation, and may be its consequence in premature infants. Gentamicin-resistance occurred in over 50 per cent of blood culture isolates of coagulase-negative staphylococci. We postulate that coagulase-negative staphylococci can be a neonatal pathogen requiring appropriate antimicrobial chemotherapy.

A comparative study of the prevalence, outcome, and prediction of bacteremia in children

We undertook a prospective, concurrent comparison of the prevalence, predictability, and outcome of bacteremia in children from 3 to 24 months of age with temperatures greater than or equal to 39.5 degrees C in three diverse clinical settings: primarily black lower-class children at an inner-city hospital (n = 532), primarily white middle-class children at a suburban hospital (n = 160), and primarily white middle-class children in offices of pediatricians in private practice (n = 94). The prevalence of bacteremia for the entire study sample (3.1% to 7.4%) and outpatients only (1.9% to 5.9%) was not statistically different among the three groups. There were no statistically significant differences among the three groups in identifying children with bacteremia (P greater than 0.05). There was no racial, geographic, or socioeconomic predilection for bacteremia in infants. At the first visit, antibiotics were prescribed (most commonly for otitis media) for 23 of the 25 bacteremic patients who were not initially hospitalized. One patient with otitis media developed meningitis. The others had uncomplicated courses and were well by 96 hours (most by 48 hours). In office settings, private practitioners were no better in predicting bacteremia in familiar patients than they were with first-time patients. Information from blood culture did not appear to alter patient management. We conclude, therefore, that routine blood cultures are unnecessary for all highly febrile infants given antibiotics.

Blood Cultures in Pediatric Practice

Occult pneumococcal bacteremia in infants was recognized as an entity a decade ago, 1.2 but the frequency of its occurrence was not appreciated until Klein and his associates at the Boston City Hospital (BCH) studied 600 consecutive febrile outpatients younger than 2 years of age. 3 They documented bacteremia in 3.2% of them, with Streptococcus pneumoniae the pathogen in nearly 80%. Subsequently, they documented the development of meningitis in 4% of the infants with unsuspected pneumococcemia. 4 Two risk factors, a rectal temperature ≥ 38.9 °C and a WBC count > 15,000/cu mm, present together in only 28% of the patients, were recognized to identify 79% of those with positive blood cultures. The following display presents rates from the BCH data: Of 1,000 febrile infants younger than 2 years of age, 769 have rectal temperature ≥ 38.9 °C. Of these 769 infants, 287 have WBC counts > 15,000/cu

Pneumococcal Bacteremia in Infants and Children: A Ten-Year Experience at the Cook County Hospital with Special Reference to the Pneumococcal Serotypes Isolated

In a ten-year period we identified 305 hospitalized children with a pneumococcal bacteremia. From these children 293 pneumococcal isolates were serotyped, and 90% belonged to a group of 11 "prevalent serotypes." These 11 serotypes were the prevalent serotypes isolated from children in all disease categories, as well as from children with sickle-cell disease. No more than 1% of the isolates belonged to any one of the other serotypes. A pneumococcal vaccine effective against these 11 prevalent serotypes should be optimal for use in children. Our highest case fatality rates were noted in children with meningitis (13%) and children with sickle-cell disease (20%). A polysaccharide pneumococcal vaccine might not have prevented most of our pneumococcal meningitis, as 80% of these children were less than 1 year old, an age when polysaccharide vaccines are poor antigens. On the other hand, many of our children with sickle-cell disease acquired their pneumococcal bacteremia at an older age and should have benefitted from such a vaccine.

Coliform bacteraemia in infants.

The incidence of patients with positive blood cultures from which a single species of coliform bacillus was isolated is given for the years 1962 to 67. There has been an increase during these years particularly in neonatal infants: 91 cases were recorded in babies under 6 months of age, and the bacteriological and clinical findings have been related in 85. Children born either prematurely or as a multiple birth and those with congenital malformations showed a predisposition to this form of infection. Many of the remaining cases had an associated localised infection.Some aspects of the cause of the increase in coliform bacteraemia in babies are discussed and the severity and possible implications of the infection are emphasised.