Bacteremia in children: etiologic agents, focal sites, and risk factors

A prospective study was carried out on 210 cases of children under 10 years of age with fever. Cases of gastroenteritis, respiratory tract infections, and suspected sepsis in children seen or admitted to the pediatric hospital were studied. Clinical and microbiological data were recorded in a questionnaire or obtained from patient medical records. Most of the children with septicemia (71.3 per cent) were less than 1 year old. Focal source of bacteremia was gastroenteritis (40.4 per cent), pneumonia or bronchopneumonia (20 per cent), meningitis (7.4 per cent), and urinary tract infections (7.4 per cent). The predominant pathogens isolated from blood or stool specimens were gram-positive bacteria (53.3 per cent), mainly Streptococcus pneumoniae and coagulase-negative Staphylococcus spp. The gram-negative bacteria (45.6 per cent) were mainly Escherichia coli, Klebsiella pneumoniae, Haemophilus influenzae, Neisseria meningitidis, and Yersinia spp. One case of Candida albicans (1.1 per cent) was reported. Pasteurella pneumotropica was reported in two cases for the first time. The mortality rate was 4 per cent, mostly from septicemia cases. Long duration of hospitalization (> 10 days) and parenteral feeding were identified as risk factors. Resistance of the isolated pathogens to several commonly used antibiotics was observed. Empirical treatment with antibiotics is recommended only in life-threatening cases.     

The Present Status of Sepsis of Children and Its Chemotherapy in Japan

The present status of etiology and chemotherapy of sepsis of children in Japan is reported. In newborns and infants less than 3 months of age, the most common pathogens in sepsis and purulent meningitis are Escherichia coli and group B Streptococci, although Staphylococcus aureus becomes the second most important bacteremic pathogen after the 3rd day of life. In order infants and children, S. aureus, Haemophilus influenzae and Streptococcus pneumoniae are the most common bacteremic pathogens. Listeriosis is increasing in Japan, yet is responsible for only 1.4% of cases of purulent meningitis and 0.5% of sepsis in children at present. The chemotherapy of sepsis and purulent meningitis has been changed from the old standard ampicillin therapy (with gentamicin in neonates) to mono-therapy with a new cephem, especially cefotaxime in Japan, since over 50% of strains of E. coli are already resistant to ampicillin.     

The bacteriology of neonatal septicaemia in Ile-Ife, Nigeria.

The incidence of septicaemia among neonates categorized as being at high risk was 55 per cent in Ile-Ife, Nigeria. Gram-positive organisms, specifically Staphylococcus aureus, were predominant (33.8 per cent) among bacteria cultured from proven cases of septicaemia. Other coagulase-negative staphylococci also contributed 21 per cent, with Staphylococcus epidermidis occurring in 5 per cent of the isolates. Listeria monocytogenes was cultured from 8.4 per cent of septic neonates. Pseudomonas aeruginosa was cultured from 3 per cent, Klebsiella pneumoniae from 14 per cent, and Escherichia coli from 7 per cent. Other Gram-negative bacilli cultured were Enterobacter aerogenes (5 per cent), Citrobacter freundii, Salmonella sp., and Proteus sp. (2 per cent each). The bacterial isolates were relatively resistant to antibiotics traditionally employed to treat cases of septicaemia. The study shows a high prevalence of neonatal bacterial sepsis at the centre and the emerging role of Listeria monocytogenes in the aetiology of neonatal sepsis. It highlights the preponderance of multiple antibiotic resistant organisms among these neonates early in life which is of epidemiological importance in the control of the infectious agents.     

Bacteremia in childhood cancer

Infection-related mortality affects the overall survival rates of children who are receiving treatment for cancer. The leading cause of mortality is bacteremia and sepsis related to it in febrile neutropenic patients. All positive blood cultures of febrile neutropenic patients treated in the Department of Pediatric Hematology-Oncology, Cerrahpasa Medical School, between January 1995 and January 2001 were reviewed. Cultures grew 159 micro-organisms, 95 (60 per cent) of which were Gram-positive bacteria, 56 (35 per cent) were Gram-negative bacteria and eight (5 per cent) were fungi. Coagulase-negative staphylococci (63, 40 per cent) and S. aureus (8, 5 per cent) were the most frequent Gram-positive pathogens. Klebsiella, E. coli, Enterobacter and Pseudomonas infections were the primary Gram-negative pathogens. Twenty cases were lost because of sepsis: in 11 cases (55 per cent) Gram-negative bacteria, in eight cases (40 per cent) Gram-positive bacteria, and in only one case a fungus were the causative organisms. Although vancomycin was not included in the first-line treatment, the mortality rate of Gram-positive bacteremia was 8 per cent. In Gram-negative bacteremia it was 20 per cent. Gram-negative pathogens, which were resistant to multiple antibiotics, caused the mortality. Drug resistance and mortality due to micro-organisms must be taken into consideration while febrile neutropenia protocols are prepared.     

Increase of Enterobacter in neonatal sepsis: a twenty-two-year study

BACKGROUND: Data on the incidence of Enterobacter infections in neonates over prolonged periods of time are scant. We determined the epidemiology of Enterobacter sepsis and/or meningitis and the trends of infection in a neonatal unit. METHODS: Retrospective review of sepsis and/or meningitis in inborn neonates admitted to Son Dureta University Hospital during a 22-year period. Molecular study by ribotyping of the Enterobacter strains isolated from 1995 to 1997. RESULTS: There were 513 cases of culture-proved sepsis and/or meningitis in neonates. In late onset infections Klebsiella pneumoniae and Staphylococcus epidermidis were the most frequent isolates in the period 1977 through 1991. Enterobacter was the most common isolate in the period 1992 through 1998. During this latter period Candida infections also increased, and the resistance rate of Enterobacter to cefotaxime was higher (59.2%). Decrease in early onset infections and increase in late onsets (4.6/1,000 live births) were observed in the second period. From 1977 to 1998, 45 episodes of sepsis and/or meningitis by Enterobacter species were identified in 44 patients (8.7% of all neonatal bacteremias). Three patients with Enterobacter bacteremia died (6.6%, 0.03/1,000 live births). During 1995 through 1997 5 different clones causing sepsis were identified and 3 were predominant. In 1997 there was an outbreak of Enterobacter disease. After cleaning, cohort nursing and hygiene reinforcement, Enterobacter was not isolated in the next 2 years. No change in the antibiotic policy was made. CONCLUSIONS: We observed a resurgence of Enterobacter infections in our neonatal intensive care unit. The sudden disappearance of this microorganism after reinforcement of hygienic measures, without withdrawing cefotaxime, confirms the importance of patient-to-patient transmission of this nosocomial infection. Further studies are needed to establish the role of antibiotics in the emergence of microorganisms in neonatal intensive care units.     

Bacterial meningitis in the newborn: a Kuwaiti experience

Forty-five neonates with bacterial meningitis admitted to a regional hospital in Kuwait over a 5-year period are reported. The attack rate was 6.7/10,000 live births. Listeria monocytogenes was the most common bacteria isolated (31 per cent), followed by Streptococcus agalactiae (15 per cent), and Escherichia coli (11 per cent). Gram negative pathogens constituted 38 per cent of the total. Ten patients died (22 per cent) and 10 (28 per cent of the survivors) developed severe neurological sequelae.     

Haemophilus influenzae type b still remains a leading cause of meningitis among unvaccinated children--a prospective CSF analysis study

A prospective, hospital-based cerebrospinal fluid (CSF) analysis study was undertaken in 65 children who had diagnostic lumbar puncture on admission for suspected central nervous system infections. Twenty-three children were clinically diagnosed to have had sepsis and/or meningitis. CSF bacterial culture grew Haemophilus influenzae type b (Hib) in four cases and Streptococcus pneumonia (SP) was cultured in another child. Bacterial antigen was detected in 13 other CSF specimens and the pathogens were Hib (n = 9), SP (n = 3) and Group B Streptococcus (n = 1). No etiologic cause was identified to explain the abnormal CSF pleocytosis and biochemistry in the remaining five cases. In contrast, the CSF analysis was normal in 42 other children with probable viral and non-infectious neurological condition, mostly febrile convulsions. The overall frequency rate for all types of meningitis and especially for Hib meningitis were 43 and 31 cases per 100,000 children < 5 years of age, respectively. These findings support our earlier observations that Hib meningitis still remains the leading cause of childhood meningitis in our region. Also it reaffirms the observation that bacterial meningitis may often be under-reported if CSF positive culture alone is considered for the diagnosis.     

Neonatal group B streptococcal meningitis

Bacteriological and clinical data on 68 children with neonatal group B streptococcal meningitis were analysed as part of a wider study of bacterial meningitis undertaken between 1976 and 1982. Twenty five per cent of patients died and there was no difference in the mortality rate between early and late onset disease. Sixteen per cent of the infants weighed less than 2500 g at birth but in 50% no predisposing aetiological factor was found. Streptococcus agalactiae type III was isolated in 57% of the patients.     

Choriophobia: a 1-act play

The management of a newborn born to a mother with chorioamnionitis is controversial. By using data collected on neonates born in the era of routine maternal screening for Group B Streptococcus, we calculate that the risk of early-onset sepsis in a hypothetical infant born at term to a mother with chorioamnionitis, who has a normal physical examination at birth, is likely substantially <1% if the mother's screen for Group B Streptococcus was negative. This low rate of sepsis calls into question current guidelines recommending treatment of all such newborns with intravenous antibiotics for 48 hours pending the results of a blood culture. Current guidelines for the management of infants born to mothers with chorioamnionitis also raise an important ethical issue; the recommendation to treat these infants with intravenous antibiotics is, in essence, a de facto determination of what constitutes unacceptable risk to the newborn. We argue that this determination is ultimately value-based and therefore requires broader deliberation than that which frequently occurs among medical experts who develop medical guidelines.     

Enterobacter aerogenes outbreak in a neonatal intensive care unit

BACKGROUND: Enterobacter aerogenes, a Gram-negative bacterium, is an important, although infrequent, cause of nosocomial bacteremia in the hospitalized pediatric and neonatal population. Enterobacter aerogenes was isolated for the first time in our neonatal intensive care unit (NICU) from blood culture of a 5-day-old neonate; 12 more cases were discovered in the next 70 days. The present report summarizes the clinico-bacteriological spectrum and outcome of the affected neonates. Efforts made to find the source of infection and curb the outbreak are also presented. METHODS AND RESULTS: Thirteen newborns, including seven preterms, acquired E. aerogenes septicemia. Perinatal risk factors were present in all the neonates. The mean birthweight of affected infants was 1880 +/- 540 g. Symptoms appeared at a mean age of 3.5 +/- 1.5 days (range 3-8 days). The clinical presentation was indistinguishable from septicemia caused by other Gram-negative organisms. Complications encountered included sclerema, bleeding diathesis, meningitis and shock. The organism, isolated from blood in all and from the cerebrospinal fluid in two cases, was found to be resistant to all antibiotics in the first five cases, but turned sensitive to gentamicin, cefotaxime and amikacin during the latter half of the epidemic. The bacterium in the last case (no. 13) was again found to be resistant to all the antibiotics. Overall mortality was 46.2%; the mean interval between onset of symptoms and death being 2.3 +/- 1.8 days. The organism was traced to the rubber pipe attached to a foot-operated suction machine in the NICU. The neonatal unit was temporarily closed, fumigated and reopened with strict instructions to follow proper hand washing protocol and ensure cohort nursing of infected infants. CONCLUSIONS: Enterobacter aerogenes is capable of causing nosocomial outbreaks of septicemia in NICU. Low birthweight infants with associated perinatal risk factors appear to be predisposed. The sensitivity patterns of the isolates highlight the capability of E. aerogenes to acquire or lose resistance to antibiotics rapidly during treatment. A high mortality rate coupled with a short interval between onset of symptoms and death, suggested high virulence of the strain.     

Infektionen durch Gruppe-B-Streptokokken in der Neonatalperiode

Streptococcus agalactiae (group B streptococcus) is the leading cause of neonatal sepsis and meningitis.A current surveillance study in Germany indicates an incidence of 0.5 per 1000 live births. GBS early-onset sepsis presents with a fulminant clinical course within the first 24 h of life.Late-onset sepsis presents as meningitis with a delayed onset. Of the newborns with GBS sepsis 75% will recover uneventfully, while 6% die.The pathophysiology of GBS sepsis has become better understood in recent years.Pattern recognition receptors of the innate immune system recognize cell wall components and proteins released from GBS, which results in a proinflammatory cytokine response leading to septic shock.Prevention of neonatal GBS infection both in a screening and a risk-based approach of maternal antimicrobial prophylaxis have reduced the rate of cultureproven invasive disease.This strategy raises considerable concern since antibiotic resistance is increasing worldwide.Furthermore, preterm delivery and late-onset sepsis due to GBS cannot be prevented. Since the incidence of GBS infections depends on the level of maternal serotype-specific antibodies, prevention strategies might be based on maternal immunization.Several advances in the development of conjugate vaccines have been accomplished.     

Neonatal gram negative pyogenic meningitis: therapeutic evaluation

Thirty babies with gram negative neonatal pyogenic meningitis were studied for therapeutic evaluation of various drug combinations. Group I received ampicillin and gentamycin and group II received ampicillin with chloramphenicol all intravenously. These drugs were continued for 2 wk after bacteriological cure. Group III include those from group I and II who did not show bacteriological cure even after 7 days of therapy and were given sulphamethoxazole—trimethoprim preparation intravenously for 3 to 4 days and continued orally for another 2 wk. Mortality was 75 per cent (9 cases) in group I compared to 16·6 percent (9 cases) in group II. Group III children developed more complications like cerebral palsy and hydrocephalus.     

Neonatal meningitis: mortality, cerebrospinal fluid, and microbiological findings

This study describes the bacteriology, cerebrospinal fluid (CSF) findings, and mortality of neonatal meningitis over an 11-year period. The minimum incidence of neonatal meningitis at Tygerberg Hospital is 0.72/1000 live births/year. Eighty-eight patients were included in the study. Median birthweight and age at diagnosis were 2320 g and 12 days, respectively. CSF culture was positive in 77 (88 per cent), blood culture was positive in 51 (57 per cent), and Gram stain was positive in 58 (66 per cent). The most frequently cultured organisms were Group B Streptococcus, Klebsiella pneumoniae, and E. coli. Thirty (34 per cent) patients died, the majority within 72 h after admission. The death rate was significantly increased in babies with a birthweight of less than 1500 g (59 per cent). Increased total CSF protein was associated with an increased risk of death. Normal CSF cell count, total CSF protein and CSF glucose were found in six infants.     

Cerebrospinal fluid C-reactive protein measurement--a bedside test in the rapid diagnosis of bacterial meningitis

C-reactive protein (C-RP) determinations were performed by the Latex agglutination method on the cerebrospinal fluid (CSF) samples of 212 patients with clinical features suggestive of meningitis. Patients were grouped as follows Group I: bacterial meningitis and partially treated bacterial meningitis (n = 22). Group II: viral encephalitis (n = 11). Group III: tuberculous meningitis (n = 18). Group IV: (i) febrile convulsions (n = 87); (ii) epileptic seizures (n = 70); (iii) intracranial haemorrhage (n = 4). C-RP was a better indicator of bacterial meningitis (sensitivity 91 per cent) than the Gram's stain (sensitivity 46 per cent). C-RP was positive in 91 per cent of patients in Group I, none in Groups II and III and 0.6 per cent in Group IV. C-RP determination in CSF proved to be a useful indicator of bacterial meningitis and served to distinguish it from viral encephalitis, tuberculous meningitis, febrile convulsions and other central nervous system disorders.     

Acute bacterial meningitis in The Gambia: a four-year review of paediatric hospital admissions

Over a 4 year period, 1991 to 1994, 420 patients with acute bacterial meningitis were admitted to a tertiary urban hospital in The Gambia. Organisms were isolated from the cerebrospinal fluid in 64 per cent of cases. In the neonatal period Streptococcus pneumoniae was the single most common organism isolated. Amongst infants and children the two major pathogens were Haemophilus influenzae and S. pneumoniae. In the first year of life, children with S. pneumoniae meningitis were younger than those with H. influenzae infection (median age 3 months versus 6 months, p < 0.00003) and they had a higher case fatality rate (37 per cent versus 17 per cent, p = 0.002). In view of the high case fatality rate, there is a need to review overall case management. This will include a review of more effective antibiotics, the possible role of dexamethasone, and the inclusion of efficacious vaccines against H. influenzae and S. pneumoniae disease.     

Group B Streptococcal Meningitis in a 5-year-old boy

Group B Streptococcus (Streptococcus agalactiae) is a well-known cause of early and late onset infections in neonates and very young infants. Recently attention has focused on the changing spectrum of invasive Group B Streptococcus (GBS) disease, including children beyond early infancy and non-pregnant adults. There is very little information available on invasive GBS infection especially meningitis in pediatric population older than three months of age. We report a case of uncomplicated meningitis due to GBS in a previously healthy 5-year-old boy. The literature on infection especially meningitis caused by Group B Streptococcus beyond infancy is reviewed.     

Late and ultra late onset Streptococcus B meningitis: clinical and bacteriological data over 6 years in France

Background:  Group B Streptococcus (GBS) is one of the leading causes of sepsis and meningitis in newborn. The objective of this study was to describe the characteristics of GBS meningitis in children aged between 7 and 89 days (late onset disease – LOD group) and to compare them with children aged more than 3 months (ultra late onset disease – ULOD group).
Methods: Clinical and biological data were gathered by ACTIV/GPIP (a nationwide active surveillance network). The study population included 242 children hospitalized between 2001 and 2006 for GBS meningitis (220 in the LOD group and 22 in the ULOD group).
Results:  Univariate analysis revealed that gestational age (GA) was significantly lower in the ULOD group as compared with the LOD group (respectively 35.6 weeks vs. 37.9 weeks, p = 0.002). Prevalence of early preterm birth (before the 32nd week GA) was significantly higher in the ULOD group than in the LOD group (32% vs. 7%, p = 0.002). No significant difference was found between the two groups for biological characteristics of lumbar puncture, GBS serotypes, complications and survival rate.
Conclusion: These data suggest that LOD and ULOD would be the same clinical and bacteriological entity, except for prematurity, which seems significantly associated with ULOD.     

Gastroschisis and late-onset neonatal sepsis in a tertiary referral center in Southeastern Brazil

ObjectivesTo analyze late-onset sepsis and to describe the etiological agents in newborns with gastroschisis.MethodsA retrospective cohort, including newborns with gastroschisis whose admissions occurred in the period between January 2012 to December 2018 in a tertiary referral center. Maternal and newborn characteristics, surgical procedures and evolution in hospitalization were verified. A bivariate analysis was performed with patients with proven late-onset neonatal sepsis and according to the simple or complex gastroschisis category, the prevalent microorganisms in positive cultures were identified, statistical tests were carried out and the significance level adopted was p < 0,05. Results are presented in proportions, averages and standard deviation or medians. The level of significance adopted was p < 0.05.Results101 newborns were analyzed, 45 (44.5%) were confirmed late-onset sepsis. The median birth weight was 2285+498 grams, and the gestational age was 35.9 +1.74weeks. The incidence of complex gastroschisis was 17.8%, the hospitalization time was 48.2+29.67 days and mortality was 9.9%. The newborns were divided into 2 groups: Group 1: late-onset sepsis (44.6%), and Group 2: no late-onset sepsis. The presence of complex gastroschisis was a factor associated with infection (p < 0.009). Fasting time (p < 0.001), parenteral nutrition time (p < 0.001), time to achieve full diet (p < 0.001), and hospitalization stay (p < 0.001) were higher in group 2. Gram-positive were the most frequent (51.1%), followed by Gram-negative (20%), and fungi (4.4%).ConclusionsNewborns with gastroschisis have a higher risk of evolving with late-onset sepsis, despite this study did not calculate the risk of sepsis statistically, and the main germs detected by cultures were gram-positive bacteria, specifically Staphylococcus epidermidis.     

Streptococcus pneumoniae sepsis in the newborn

Background: Streptococcus pneumoniae (SP) is an uncommon cause of neonatal sepsis. Aims: To report on the spectrum of morbidity associated with SP infections in the neonatal period. Methods: A case series of SP infection in the neonatal period was studied. Maternal and neonatal outcomes were noted. Results: Four cases of neonatal SP infection are reported, one of which was due to a strain with reduced susceptibility to penicillin. All four cases had very early onset of severe clinical disease with bacteremia and pneumonia. In one case a retrospective diagnosis of meningitis was made as well. Maternal illness was a feature in one of these infants. Conclusions: Although less common now than in the pre‐antibiotic era, Streptococcus pneumoniae remains a rare but important cause of neonatal sepsis and can mimic early onset Group B streptococcal sepsis. It is unclear whether current infant or adult pneumococcal immunisation programs might influence its incidence in the neonatal period. The potential for strains with reduced susceptibility to β‐lactam antibiotics to cause neonatal infection needs to be considered in relevant settings.