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Park, Youn, Im, Kim, Seo, and Moon: Risk Factors of Bloodstream Infection Associated Mortality in Pediatric Patients with Hemato-oncologic Disease
Original Article

Korean J Hematol 2007;42(4):343-352.

Published online: 19 January 2007

DOI: https://doi.org/10.5045/kjh.2007.42.4.343

Risk Factors of Bloodstream Infection Associated Mortality in Pediatric Patients with Hemato-oncologic Disease

Hye Won Park, M.D., Hoi Soo Youn, M.D., Ho Joon Im, M.D., Mi-Na Kim, M.D.1, Jong Jin Seo, M.D., Hyung Nam Moon, M.D.

Departments of Pediatrics, Seoul, Korea

1Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to：Jong Jin Seo, M.D. Department of Pediatrics, Asan Medical Center 388-1, Pungnap 2-dong, Songpa-gu, Seoul 138-736, Korea Tel: ＋82-2-3010-3383, Fax: ＋82-2-473-3725 E-mail: jjseo@amc.seoul.kr

Received 30 August 2007       Revised 27 September 2007       Accepted 4 October 2007

Copyright © 2007 Korean Society of Hematology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background:

Bloodstream infection is one of the important causes of mortality, and morbidity in pediatric patients with hemato-oncologic disease. The purpose of this study was to identify the risk factors related to mortality in patients who suffered from a bloodstream infection.

Methods:

We retrospectively reviewed and analyzed the medical records of 133 pediatric patients with hemato-oncologic diseases who had episodes of bloodstream infection documented at Asan Medical Center from June 2002 through May 2005.

Results:

A total of 288 pathogens were isolated, and there were 17 episodes of polymicrobial infections. Among the episodes of bloodstream infection, 93.4% were caused by bacteria of which 60.1% were gram-positive bacteria, and 33.3% were gram-negative bacteria. Fungal infections accounted for 6.6% of the infections. The main pathogens included Staphylococcus epidermidis (31.3%), Pseudomonas aeruginosa (8.3%), and Klebsiella pneumoniae (7.3%). Gram-positive organisms were isolated more frequently than gram-negative organisms, and non-albicans Candida species were documented more frequently than C. albicans in our study. Infection related mortality was 8.3% (11 of 133 patients). The pulmonary infiltration on chest X-ray (CXR) (P=0.001), and a low absolute neutrophil count (≤500/μL) (P=0.017) at the time of blood culture were significantly associated with mortality. Gram-negative bacterial infection (especially with Stenotrophomonas maltophilia) and fungal infection often progressed to the septic shock or death.

Conclusion:

This study revealed that the presence of pulmonary infiltration on a CXR, neutropenia (≤ 500/μL), and gram-negative bacterial infection might be important risk factors of mortality in pediatric patients with hemato-oncologic diseases necessitating more aggressive and vigilant supportive care.

Keywords: Bloodstream infection, Childhood cancer, Risk factors, Mortality

REFERENCES

1). Krupova I., Kaiserova E., Foltinova A, et al. Bacteremia and fungemia in pediatric versus adult cancer patients after chemotherapy: comparison of etiology, risk factors and outcome. J Chemother. 1988. 10:236–42.
crossref
2). Hann I., Viscoli C., Paesmans M., Gaya H., Glauser M. A comparison of outcome from febrile neutropenic episodes in children compared with adults: result from four EORTC studies. Br J Haematol. 1997. 99:580–8.
3). Alexander S., Walsh T., Freifeld A., Pizzo P. Infectious complications in pediatric cancer patients. Pizzo PA, Poplack DG, editors. Principles and practice of pediatric oncology. 4th ed.Philadelphia: Lippincott Williams and Wilkins;2002. p. 1239–83.
4). Pizzo PA. Evaluation of fever in the patient with cancer. Eur J Cancer Clin Oncol. 1989. 25:9–16.
5). McCullers J., Shenep J. Assessment and management of suspected infection in neutropenic patients. Patrick C, editor. Clinical management of infections in immunocompromised infants and children. 1st ed.Philadelphia: Lippincott Williams and Wilkins;2001. p. 413–49.
6). Hughes WT., Armstrong D., Bodey GP, et al. 1997 guidelines for the use of antimicrobial agents in neutropenic patients with unexplained fever. In-fections diseases society of America. Clin Infect Dis. 1997. 25:551–73.
7). Weinstein MP. Current blood culture methods and systems: clinical concepts, technology, and interpretation of results. Clin Infect Dis. 1996. 23:40–6.
crossref
8). El-Mahallawy H., Sidhom I., El-Din NH., Zamzam M., El-Lamie MM. Clinical and microbiologic determinants of serious bloodstream infections in Egyptian pediatric cancer patients: a one-year study. Int J Infect Dis. 2005. 9:43–51.
crossref
9). Velasco E., Thuler LC., Martins CA., Dias LM., Goncalves VM. Risk factors for bloodstream infections at a cancer center. Eur J Clin Microbiol Infect Dis. 1998. 17:587–90.
crossref
10). Viscoli C., Castagnola E., Giacchino M, et al. Bloodstream infections in children with cancer: a multi-centre surveillance study of the Italian association of pediatric hematology and oncology. Supportive therapy group-infectious disease section. Eur J Cancer. 1999. 35:770–4.
11). Cho SM., Lee DG., Choi JM., Yoo JH., Sin WS., Kim CC. Septic shock in hematology oncology patients with neutropenic fever. Int J Infectious Dis. 2002. 6:531–2.
12). Apisarnthanarak A., Mayfield JL., Garison T, et al. Risk factors for Stenotrophomonas maltophilia bacteremia in oncology patients: a case-control study. Infect Control Hosp Epidemiol. 2003. 24:269–74.
13). Velasco E., Byington R., Martins CS., Schirmer M., Dias LC., Goncalves VM. Bloodstream infection surveillance in cancer centre: a prospective look at clinical microbiology aspects. Clin Microbiol Infect. 2004. 10:542–9.
14). Wu PS., Lu CY., Chang LY, et al. Stenotrophomonas maltophilia bacteremia in pediatric patients-a 10-year analysis. J Microbiol Immunol Infect. 2006. 39:144–9.
15). Abi-Said D., Anaissie E., Uzun O., Raad I., Pinzcowski H., Vartivarian S. The epidemiology of hematogenous candidiasis caused by different Candida species. Clin Infect Dis. 1997. 24:1122–8.
crossref
16). Simoneau E., Kelly M., Labbe AC., Roy J., Laverdiere M. What is the clinical significance of positive blood cultures with Aspergillus sp in hematopoietic stem cell transplant recipients? A 23 year experience. Bone Marrow Transplant. 2005. 36:85–6.
crossref
17). Kami M., Murashiqe N., Fujihara T., Sakagami N., Tanaka Y. The mechanism for low yield of blood culture in invasive aspergillosis; the clinical importance of antigen detection tests revisited. Bone Marrow Transplant. 2005. 35:303–6.
crossref
18). Velasco E., Thuler LC., Martins CA., Nucci M,?Dias LM., Goncalves VM. Epidemiology of bloodstream infections at a cancer center. Sao Paulo Med J. 2000. 118:131–8.
crossref
19). Tsiotou AG., Sakorafas GH., Anagnostopoulos G., Bramis J. Septic shock; Current pathogenic concepts from a clinical perspective. Med Sci Monit. 2005. 11:RA76–85.
20). Kutko MC., Calarco MP., Flaherty MB, et al. Mortality rates in pediatric septic shock with and without multiple organ system failure. Pediatr Crit Care Med. 2003. 4:333–7.
crossref
21). Black CT., Hennessey PJ., Andrassy RJ. Short-term hyperglycemia depresses immunity through nonenzymatic glycosylation of circulating immunoglobulin. J Trauma. 1990. 30:830–2.
crossref
22). Palmblad J. Intravenous lipid emulsions and host defense- a critical review. Clin Nutr. 1991. 10:303–8.
23). Shou J., Lappin J., Minnard EA., Daly JM. Total parenteral nutrition, bacterial translocation, and host immune function. Am J Surg. 1994. 167:145–50.
crossref
24). Stoll BJ., Temprosa M., Tyson JE, et al. Dexamethasone therapy increases infection in very low birth weight infants. Pediatrics. 1999. 104:63.
crossref
25). Barsic B., Beus I., Marton E., Himbele J., Klinar I. Nosocomial infections in critically ill infectious disease patients: results of a 7-year focal surveillance. Infection. 1999. 27:16–22.
crossref

Table 1.
Distribution of the underlying diseases of 133 pediatric patients with bloodstream infections
Underlying diseases No. of patients Fr requency (%)
Hematologic diseases　    
  Acute lymphocytic leukemia 34 25.56
  Lymphoma 18 13.53
  Acute myeloid leukemia 18 13.53
  Mixed lineaged leukemia 9 6.77
  Myelodysplastic syndrome 5 3.76
  Aplastic anemia 3 2.26
  Chronic myeloid leukemia 2 1.50
  Hemophagocytic lymphohistiocytosis 2 1.50
Total 91 68.42
Solid tumors
  Neuroblastoma 14 10.53
  Medulloblastoma 7 5.26
  Rhabdomyosarcoma 5 3.76
  Hepatoblastoma 4 3.01
  Oligodendrocytoma 2 1.50
  Osteosarcoma 2 1.50
  Germ cell tumor 2 1.50
  Others∗ 6 4.52
Total 42 31.58

∗Include PTLD, PNET, Ewing's sarcoma, ganglioneuroma, hepatocellular carcinoma, other carcinoma. Abbreviations: PTLD, post-transplantation lymphoproliferative disorder; PNET, primitive neuroectodermal tumor.

Table 2.
Main pathogens (288 organisms) responsible for 271 episodes of bloodstream infection
Gram (+) bacteria (n=173)
Staphylococcus epidermidis 90
Enterococcus faecium 14
Staphylococcus hominis 10
Staphylococcus aureus 9
Enterococcus faecalis 6
Enterococcus cloacae 6
Streptococcus mitis 5
Micrococcus spp. 4
Strepcococcus pneumoniae 4
Others∗ 25
Gram (-) bacteria (n=96)
Pseudomonas aeruginosa 24
Klebsiella pneumoniae 21
Stenotrophomonas maltophila 14
Burkholderia cepacia 12
Escherichea coli 11
Acinetobacter baumanii 4
Klebsiella oxytoca 3
Others† 7
Fungi (n=19)
Candida tropicalis 9
Candida parapsilosis 5
Candida albicans 3
Candida krusei 2
Table 3.
Documented organisms of bloodstream infections in patients with septic shock and in mortality cases
Documented organisms No. of mortality cases No. of septic shock episodes
　Aeromonas hydrophila 1 1
　Candida albicans 1 1
　Candida krusei 0 2
　Candida tropicalis 2 2
　E. coli 1∗ 2†
　Enterococcus faecium 2 6†
　Klebsiella pneumonia 2∗ 3†
　Pseudomonas aeruginosa 1 4
　S. aureus 0 1
　S. hominis 0 1
　Staphylococcus epidermidis 0 1
　Stenotrophomonas maltophilia 2 5†
　Total 12 29

∗Include 1 polymicrobial episode: K. pneumoniae/E. coli (1),

† Include 2 polymicrobial episodes: K. pneumoniae/E. coli (1), Enterococcus faecium/Stenotrophomonas maltophilia (1).

Table 4.
Analyzed variables for bloodstream infectionassociated mortality
Variables Episodes Mortality (%) P-value
Pulmonary infiltration on CXR 0.001
  Yes 73 9 (12.3)  
  No 159 2 (1.3)  
Indwelling central line 0.528
  Yes 256 11 (4.3)  
  No 15 0 (0)  
Total parenteral nutrition 0.326
  Yes 61 5 (8.2)  
  No 210 6 (2.9)  
Use of steroid 0.219
  Yes 74 2 (2.7)  
  No 197 9 (4.6)  
Use of antacid 0.161
  Yes 71 5 (7.0)  
  No 200 6 (3.0)  
Blood glucose level 0.406
  ≤250mg/dL 168 8 (4.8)  
  ＞250mg/dL 10 1 (10.0)  
Absolute neutrophil count 0.017
  ≤500/μL 165 12 (7.2)  
  ＞500/μL 84 0 (0)  
Platelet count 0.460
  ≤20,000/μL 47 3 (6.4)  
  ＞20,000/μL 222 8 (4.5)  
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