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Insights into bloodstream infections in South African paediatric burn patients: implications for antimicrobial
Michael Christie1, Theunis Avenant2, Masindi Nembudani2
1Department of Paediatrics and Child Health, Faculty of Health Sciences, Kalafong Provincial Tertiary Hospital, University of Pretoria, Pretoria, South Africa. michael.christie@up.ac.za.
Insights
Bloodstream infections (BSIs) in paediatric burn patients are common, with multidrug-resistant (MDR) bacteria frequently identified. Early broad-spectrum antibiotic use is often necessary, followed by de-escalation based on culture results to combat antimicrobial resistance.
Area of Science:
- Medical Microbiology
- Infectious Diseases
- Paediatric Surgery
Background:
- Bloodstream infections (BSIs) are a major cause of mortality in paediatric burn patients, particularly in low- and middle-income countries.
- Common pathogens like Staphylococcus aureus and Pseudomonas aeruginosa often exhibit multidrug resistance (MDR).
- Rising MDR BSIs necessitate improved antimicrobial stewardship and potentially more targeted initial treatments.
Purpose of the Study:
- To investigate the aetiology and timing of burn-associated BSIs in paediatric burn patients.
- To identify the prevalence of multidrug-resistant (MDR) infections in this vulnerable population.
- To inform antimicrobial stewardship strategies in paediatric burn care.
Main Methods:
- A multi-centre retrospective review of paediatric burn patients (0-12 years) admitted between January 2020 and December 2022.
- Data collected from patient records and the National Health Laboratory System TrakCare database.
- Bloodstream infections (BSIs) defined using CDC criteria.
Main Results:
- 18.8% of 245 admitted patients developed BSIs.
- Staphylococcus aureus (30%), Acinetobacter baumannii (29%), and Pseudomonas aeruginosa (16%) were the most common isolates.
- 56% of pathogens were MDR, including MRSA and carbapenem-resistant A. baumannii; gram-negative bacteria predominated.
Conclusions:
- Gram-positive and gram-negative infections occur early, while polymicrobial infections are later, precluding initial narrow-spectrum antibiotic use.
- Antimicrobial de-escalation post-culture is crucial; prevention through wound care and infection control is paramount.
- Judicious use and rapid de-escalation of broad-spectrum antibiotics are essential to minimize antimicrobial resistance.
Introduction:
Bloodstream infections (BSIs) significantly contribute to the morbidity and mortality in paediatric burn patients from low- and middle-income countries; with common pathogens like Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa frequently being multidrug resistant (MDR). Due to the growing prevalence of MDR BSIs, antimicrobial stewardship needs to be improved with perhaps more targeted initial antimicrobial use. The study describes the aetiology, and timing of burn-associated BSIs and MDR infections in paediatric burn patients admitted to two paediatric surgery units in Tshwane District, South Africa.
Methods:
This multi-centre retrospective review analysed paediatric burn patients (ages 0-12 years) admitted between January 2020 and December 2022 to two public hospitals in Tshwane District, South Africa. Collected data was from patient records and the National Health Laboratory System TrakCare database. BSIs were defined according to the CDC criteria.
Results:
Of 245 burn patients admitted, 18.8% (n = 46) developed BSIs. From 63 positive blood cultures, the most common isolates were S. aureus (n = 19; 30%), Acinetobacter baumannii (n = 18; 29%), and P. aeruginosa (n = 10; 16%). Collectively, gram negative bacteria were responsible for most BSIs (n = 41; 65%). Candida spp accounted for 9% (n = 5). Thirty-five pathogens (56%) were MDR; this included methicillin-resistant S. aureus (MRSA) (n = 7; 11%), carbapenem-resistant A. baumannii (n = 16; 25%), and P. aeruginosa (n = 6; 10%). The median time to the first positive blood culture was 5 days (IQR: 3-12) (gram positive organisms: median: 5 days [IQR: 3-15}); gram negative organisms: median: 8 days [IQR: 4-20]; Fungal: median: 9 days [IQR: 8-27]; p-value 0.37). In the first week, S. aureus caused 32% of infections, including five MRSA cases. Gram negative bacteria dominated weeks two and three, with fungal and polymicrobial infections mainly in weeks two and four.
Conclusion:
Our findings show that as gram positive and gram negative infections predominantly occurred early in the admission period, while polymicrobial infections are more frequently observed later. Consequently, initial targeted narrow-spectrum antimicrobial use is not possible. Instead, antimicrobial de-escalation should be prioritized once culture results are available. Efforts should shift from a focus on treating BSIs to preventing them through wound care and infection control measures. Broad-spectrum antibiotics should be used judiciously and quickly de-escalated to minimise antimicrobial resistance development.
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