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Lim, Ha, Tchah, Jeon, Ryoo, Son, Cho, Sun, Kim, Ahn, and Cho: Epidemiology of Staphylococcus aureus Bacteremia in Children at a Single Center from 2002 to 2016
Original Article

Pediatr Infect Vaccine 2019;26(1):11-21.

Published online: 20 April 2019

DOI: https://doi.org/10.14776/piv.2019.26.1.11

Epidemiology of Staphylococcus aureus Bacteremia in Children at a Single Center from 2002 to 2016

Seonhee Lim, Seok Gyun Ha, Hann Tchah, In Sang Jeon, Eell Ryoo, Dong Woo Son, Hye Jung Cho, Yong Han Sun, Hyo Jung Kim, Jung Min Ahn, Hye-Kyung Cho

Department of Pediatrics, Gachon University College of Medicine, Gil Medical Center, Incheon, the Republic of Korea

Correspondence to Hye-Kyung Cho Department of Pediatrics, Gachon University College of Medicine, Gil Medical Center, 21 Namdongdae-ro, 774-beon-gil, Incheon 21565, the Republic of Korea. E-mail: hkcho@gilhospital.com

Received 13 September 2018       Revised 27 December 2018       Accepted 31 December 2018

Copyright © 2019 The Korean Society of Pediatric Infectious Diseases

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

Purpose

We aimed to investigate the epidemiological characteristics of Staphylococcus aureus bacteremia in Korean children.

Methods

We retrospectively collected and analyzed data from the medical records of the patients with S. aureus bacteremia ≤18 years of age in Gil Medical Center from 2002 to 2016.

Results

A total of 212 SAB cases were detected. The annual incidence of SAB from 2002 to 2016 ranged from 0.77 to 1.95 per 1,000 patients hospitalized. The neonate group (<28 days of age) and the pediatric group (28–18 years of age) were 51.4% (n=109) and 48.6% (n=103), respectively. According to the origin of infection, there were 93 cases (43.9%) of community-associated (CA)-SAB and 119 cases (56.1%) of healthcare-associated (HA)-SAB. The rates of HA-SAB among the neonate group and among the pediatric group were 64.2% and 47.6%, respectively (P=0.015). There was no difference in complications between CA-SAB and HA-SAB, but mortality was higher in HA-SAB. The proportion of methicillin-resistance S. aureus (MRSA) was the highest in neonates (88.1%), decreased with age, and was 36.4%–37.5% among children aged ≥5 years. The MRSA proportion was 72.2%, showing no consistent trend over the period.

Conclusions

The annual incidence of SAB and the proportion of MRSA in SAB remained constant in the recent 15 years in children. Judicious decision of antimicrobial agents for treatment considering the patient's age and the origin of infection is necessary.

Keywords: Staphylococcus aureus, Bacteremia, Methicillin-resistant Staphylococcus aureus, Infant, Child

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Fig. 1.
Schematic diagram to classify Staphylococcus aureus bacteremia cases included in the study. Abbreviations: CA, community associated; CO-HA, community onset-healthcare associated; HO-HA, hospital onset-healthcare associated.
piv-26-11f1.tif
Fig. 2.
(A) The annual incidence of SAB and distribution of MSSA and MRSA among the SAB cases, (B) The annual MRSA proportion among the total SAB, CA-SAB, and HA-SAB cases. Abbreviation: SAB, Staphylococcus aureus bacteremia; MSSA, methicillin-sensitive S. aureus; MRSA, methicillin-resistant S. aureus; CA-SAB, community-associated S. aureus bacteremia; HA-SAB, healthcare-associated S. aureus bacteremia; CA-MRSA, community-associated methicillin-resistant S. aureus; HA-MRSA, healthcare-associated methicillin-resistant S. aureus.
piv-26-11f2.tif
Fig. 3.
(A) Distribution of methicillin-resistance according to the age groups among CA-SAB. ORs in <28 days of age, 5–9 years of age, and 10–18 years of age are 8.64 (95% CI, 3.09–24.15; P=0.000), 0.09 (95% CI, 0.01–0.73; P=0.009), and 0.08 (95% CI, 0.02–0.37; P=0.000), respectively. (B) Distribution of methicillin-resistance according to the age groups among HA-SAB. ORs in <28 days group and 10–18 years group are 3.25 (95% CI, 1.19–8.89; P=0.018) and 0.21 (95% CI, 0.07–0.64; P=0.009), respectively. Abbreviations: CA-SAB, community-associated Staphylococcus aureus bacteremia; HA-SAB, healthcare-associated S. aureus bacteremia; CA-MRSA, community-associated methicillin-resistant S. aureus; CA-MSSA, community-associated methicillin-sensitive S. aureus; OR, odds ratio; CI, confidence interval. ∗P<0.05 by χ2 test.
piv-26-11f3.tif
Table 1.
Baseline characteristics of SAB
Characteristics Sex, male Neonate group (n=109) 59 (54.1) Pediatric group (n=103) 65 (63.1) P-value 0.187
Comorbid conditions 58 (53.2)∗ 28 (27.2)† 0.000
Central venous catheter 43 (39.4) 24 (23.3) 0.011
CA-SAB 39 (35.8) 54 (52.4) 0.015
HA-SAB 70 (64.2) 49 (47.6) 0.015
  CO-HA 3 (2.8) 11 (10.7) 0.020
  HO-HA 67 (61.5) 38 (36.9) 0.000
MRSA 96 (88.1) 57 (55.3) 0.000
Primary clinical manifestation 18 (16.5) 32 (31.1) 0.012
  Bone and joint infections 2 (14.3) 13 (48.1) 0.002
  Skin and soft tissue infections 6 (42.9)‡ 6 (22.2) 0.920
  Septic thrombophlebitis 6 (42.9)‡ 0 0.016
  Pneumonia 1 (7.1) 4 (14.8) 0.156
  Endocarditis 0 2 (7.4)§ 0.145
  Urinary tract infections 1 (7.1) 2 (7.4)§ 0.530
  Peritonitis with urachal abscess 0 1 (3.7) 0.305

Values are presented as number (%).

Abbreviations: SAB, Staphylococcus aureus bacteremia; CA, community associated; HA, healthcare associated; CO-HA, community onset-healthcare associated; HO-HA, hospital onset-healthcare associated; MRSA, methicillin-resistant S. aureus.

∗ Fifty-four premature, 3 congenital malformations, 1 maple syrup urine disease;

† 8 malignancy, 8 trauma, 5 neurologic diseases, 4 cardiac disorders, 2 autoimmune diseases, 1 chronic kidney disease;

‡ Two had skin and soft tissue infection combined with two septic thrombophlebitis;

§ One had endocarditis combined with urinary tract infection.

Table 2.
Complications and mortality of Staphylococcus aureus bacteremia according to the origin of infection
Outcomes CA (n=93) HA (n=119) P-value
    CO-HA (n=14) HO-HA (n=105)  
Complication 3 (3.2) 1 (7.1) 5 (4.8) 0.534∗
  Metastatic bone and joint infection 3 (100.0) 1 (100.0) 3 (60.0) 0.542∗
  Endocarditis 0 0 2 (40.0) –
  Septic shock 0 0 12 (11.4) –
Mortality 1 (1.1) 1 (7.1) 15 (14.3) 0.003

Values are presented as number (%).

Abbreviations: CA, community associated; HA, healthcare associated; CO-HA, community onset-healthcare associated; HO-HA, hospital onset-healthcare associated.

∗ Fisher's exact test (except all∗ χ2).

Table 3.
Antimicrobial resistance and multidrug resistance of MRSA according to infection origin
Antimicrobial agents Total MRSA (n=153) CA-MRSA (n=54) HA-MRSA P-value
CO-HA MRSA (n=9) HO-HA MRSA (n=90)
Erythromycin 92 (60.1) 39 (72.2) 5 (55.6) 48 (53.3) 0.078
Clindamycin 47 (30.7) 16 (29.6) 4 (44.4) 27 (30.0) 0.654
  Inducible resistance∗ 26 (28.9)∗ 13 (54.2)∗ 0 13 (21.7)∗ 0.124
Gentamicin 36 (23.5) 14 (25.9) 5 (55.6) 17 (18.9) 0.041
Ciprofloxacin 17 (11.1) 2 (3.7) 2 (22.2) 13 (14.4) 0.077
Tetracycline 52 (34.0) 22 (40.7) 4 (44.4) 26 (28.9) 0.275
TMP-SMX 4 (2.6) 0 0 4 (4.4) 0.450†
Vancomycin 0 0 0 0 –
MDR 27 (17.6) 9 (16.7) 3 (33.3) 15 (16.7) 0.445

Values are presented as number (%).

Abbreviations: MRSA, methicillin-resistant Staphylococcus aureus; CA, community associated; HA, healthcare associated; CO-HA, community onset-healthcare associated; HO-HA, hospital onset-healthcare associated; TMP-SMX, trimethoprim-sulfamethoxazole; MDR, multidrug resistance

∗ Inducible resistance to clindamycin has been tested since 2008, and the fraction (%) is indicated as inducible resistant strains among the strains detected since 2008. The numbers of total MRSA, CA-MRSA, CO-HA-MRSA, HO-HA-MRSA detected since 2008 are 90, 24, 6, and 60, respectively.

† Fisher's exact test (except† are all χ2).

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