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Rates of health care-associated, antibiotic-resistant bacteremia increase in ED
Bacteremia among children presenting to the ED is becoming increasingly health care-associated and resistant to empirical antibiotics, according to study findings in Pediatrics.
“Immediately before the introduction of the pneumococcal vaccine in the United Kingdom, 20% of childhood mortality was infection related, with ‘septicemia’ the most commonly documented cause of death,” study researcher Adam D. Irwin, MRCPCH, of the University of Liverpool, and colleagues wrote. “The etiology of pediatric bacteremia in the United Kingdom has evolved substantially as the immunization schedule has expanded. The incidence of vaccine-preventable infections has declined, while that of gram-negative infections has increased.”
Researchers conducted a retrospective analysis of clinically significant bacteremia cases that occurred at the Alder Hey Children’s Hospital ED from 2001 to 2011. If a significant bacteremia pathogen was identified in a blood culture taken within 48 hours of presentation to the ED, it was considered community-acquired. If this occurred among children with an indwelling device, primary or acquired immunodeficiency, those who required regular hospital-based intervention or preterm infants, it was considered health care-associated bacteremia.
During the study, 692 clinically significant blood cultures were identified among children who gave samples within 48 hours of ED presentation, representing 575 episodes of bacteremia among 525 children. Streptococcus pneumoniae (n = 109), Neisseria meningitidis (n = 96) and Staphylococcus aureus (n = 89) were the most common isolates.
The rate of clinically significant bacteremia was 1.42 per 1,000 ED visits (95% CI, 1.31-1.53).
From 2001 to 2011, the rate of bacteremia caused by vaccine-preventable isolates decreased by an annual reduction of 10.6% (95% CI, 6.6%-14.5%). Vaccine-preventable bacteremia was strongly seasonal (P < .001), according to researchers, and peaked in the winter.
The rate of gram-negative bacteremia increased from 0.24 to 0.53 per 1,000 ED attendances (P = .007), and had a seasonal effect, peaking in summer, that was not significant.
Community-acquired bacteremia decreased from 0.93 in 2001 to 0.57 per 1,000 ED attendances in 2011 (P = .005), while health care-associated bacteremia grew from 0.17 to 0.43 per 1,000 ED attendances (P = .002).
Empirical antibiotic protocol was confirmed in 563 of 575 clinical cases, and indicated that 217 of 219 vaccine-preventable isolates were susceptible to empirical therapy, while 29 of 131 gram-negative isolates were resistant (P < .001).
Adjusted analysis showed time to antibiotics was 57 minutes longer for gram-negative infections vs. vaccine-preventable infections, and older children received antibiotics later than younger children.
Compared with children with community-acquired bacteremia, length of stay was 3.9 days longer for children with health care-associated bacteremia (95% CI, 2.3-5.8).
“Our analysis illustrates the changing characteristics of children presenting to the ED with bacteremia,” the investigators wrote. “Increasingly, these infections are considered [health care-associated]. They are more likely to be resistant to empirical therapy, more difficult to recognize, and are associated with a prolonged [length of stay]. Prompt and effective antimicrobial treatment of bacteremia requires improved diagnostic tools in addition to continued etiological surveillance.” – by Amanda Oldt
Disclosure: The researchers report no relevant financial disclosures.
