Bloodstream infections at a tertiary level paediatric hospital in South Africa.

BACKGROUND: Bloodstream infection (BSI) in children causes significant morbidity and mortality. There are few studies describing the epidemiology of BSI in South African children. METHODS: A retrospective descriptive cohort study was conducted at a paediatric referral hospital in Cape Town, South Africa. The National Health Laboratory Service (NHLS) microbiology database was accessed to identify positive blood culture specimens during the period 2011-2012. Demographic and clinical details, antimicrobial management and patient outcome information were extracted from medical and laboratory records. Antibiotic susceptibility results of identified organisms were obtained from the NHLS database. RESULTS: Of the 693 unique bacterial and fungal BSI episodes identified during the study period, 248 (35.8%) were community-acquired (CA), 371 (53.5%) hospital-acquired (HA) and 74 (10.7%) healthcare-associated (HCA). The overall risk was 6.7 BSI episodes per 1000 admissions. Escherichia coli, Staphylococcus aureus and Streptococcus pneumoniae were the most frequent causes of CA-BSI and Klebsiella pneumoniae, Acinetobacter baumanii and S.aureus were most commonly isolated in HA-BSI. On multivariable analysis, severe underweight, severe anaemia at the time of BSI, admission in the ICU at the time of BSI, and requiring ICU admission after BSI was diagnosed were significantly associated with 14-day mortality. CONCLUSION: This study adds to the limited literature describing BSI in children in Africa. Further studies are required to understand the impact that BSI has on the paediatric population in sub-Saharan Africa.

Emergence of vancomycin-resistant Enterococcus at a tertiary paediatric hospital in South Africa.

BACKGROUND: During 2013, the haematology/oncology unit at a tertiary level paediatric hospital in South Africa experienced the emergence of infection with vancomycin-resistant Enterococcus (VRE). OBJECTIVE: To describe the clinical and molecular aspects of the cases identified. METHODS: VRE isolates identified from blood culture specimens processed at the National Health Laboratory Service were screened for the presence of the vancomycin resistance genes vanA, B and C1, 2 and 3. Further characterisation of these isolates was carried out using pulsed-field gel electrophoresis (PGFE) and multilocus sequence typing (MLST). Clinical records of infected patients were reviewed to identify possible risk factors, while surveillance with rectal swabs was performed to identify VRE-colonised patients. RESULTS: Four patients with haematological malignancies were identified with VRE bloodstream infections. Patients were immunocompromised at the time of the bloodstream infection (BSI), with receipt of vancomycin prior to VRE-BSI, and infections were treated with linezolid. Colonisation with VRE was found in 8 of 55 patients screened. Infected and colonised patients were isolated in the unit during their admission and strict contact precaution infection control practices were instituted. The vanA gene was identified in all of the isolates but one. PFGE and MLST results showed a degree of genetic relatedness between certain isolates obtained from rectal swab and blood culture samples, suggesting possible patient-to-patient transmission or persistence of the isolates in the unit. CONCLUSION: Strict infection control practices are necessary to prevent infection and transmission of resistant organisms among vulnerable patients.

A case of emmonsiosis in an HIV-infected child.

Opportunistic fungal infections can cause significant morbidity and mortality in immunocompromised patients. We describe a paediatric case of an unusual disseminated fungal infection. A three-year-old HIV-infected child with severe immunosuppression (CD4+ T-cell count 12 × 106/L) was admitted to hospital with pneumonia, gastroenteritis and herpes gingivostomatitis. Despite antibacterial and antiviral therapy, he experienced high fevers and developed an erythematous maculopapular rash and abdominal tenderness. The child's condition progressively worsened during the admission. A thermally dimorphic fungus was cultured from bone marrow and identified as an Emmonsia species on DNA sequencing. The patient made a good recovery on amphotericin B deoxycholate and antiretroviral therapy. Itraconazole was continued for a minimum of 12 months, allowing for immune reconstitution to occur. This case is the first documented description of disseminated disease caused by a novel Emmonsia species in an HIV-infected child in South Africa.

Blood cultures in sick children.

BACKGROUND: Blood cultures (BCs) are frequently performed in sick children. A recent audit of BCs among adult patients documented high rates of contamination by coagulase-negative staphylococci (CoNS). OBJECTIVES: To describe BC contamination rates and common pathogenic organisms causing bloodstream infection in children at a tertiary- level children's hospital. METHODS: BC results for children admitted to Red Cross War Memorial Children's Hospital from 2008 to 2012 were extracted from the National Health Laboratory Service database. Pathogenic and non-pathogenic (contaminated) growth on BCs in children <1 year of age and >1 year of age, were analysed. Data analysis was performed using Epi Info version 3.5.1. RESULTS: A total of 47 677 BCs were performed in the 5-year period. The proportion of contaminated specimens ranged between 5.9% and 7.2% per year (p=0.4). CoNS was the predominant isolate in 53.8% of all contaminated BCs. Children <1 year of age experienced higher contamination rates than children >1 year of age (8.7% v. 4.7%; relative risk 1.84; 95% confidence interval (CI) 1.71 - 1.97). Pathogenic organisms were isolated in 6.2% (95% CI 6.0 - 6.4) of all BC specimens. Among Gram-positive organisms, the proportion of Streptococcus pneumoniae isolates declined from 14.3% to 4.7% (p<0.00001), while there was a significant increase in Gram-negative organisms (51.8% - 57.9%; p=0.04) over the 5-year period. Klebsiella pneumoniae, the predominant Enterobacteriaceae isolated, decreased from 45.8% to 31.7% (p=0.004). CONCLUSION: This study identified unacceptably high BC contamination rates, emphasising the importance of collecting BC specimens under sterile conditions.