Bacterial bloodstream infections and antimicrobial susceptibility pattern in pediatric hematology/oncology patients after anticancer chemotherapy

Figures & data

Table 1 Demographic, clinical and laboratory features of pediatric oncology patients with bacteremia (year 2004–2011)

Parameters	ALL n (%)	AML n (%)	Lymphoma n (%)	Solid tumors n (%)	Brain tumors n (%)	Total n (%)	P-value
Total number of cancer patients	66	9	39	56	15	185
Total number of cancer patients with bacteremia	33 (50)	5 (56)	12 (31)	14 (25)	6 (40)	70 (38)	0.0383
Sex
Male	15 (45)	1 (20)	7 (58)	7 (50)	4 (67)	34 (49)	0.555
Female	18 (55)	4 (80)	5 (42)	7 (50)	2 (33)	36 (51)
Age at diagnosis
<4 years	12 (36)	4 (80)	3 (25)	5 (36)	2 (33)	26 (37)	0.314
≥4 years	21 (64)	1 (20)	9 (75)	9 (64)	4 (67)	44 (63)
Age at diagnosis (year) (mean ± SD)	6.5±3.8	2.1±2.3	7.0±4.6	6.4±4.5	8.1±4.9	6.4±4.2	0.130
Number of episodes among cancer patients with bacteremia	58	11	18	17	7	111
ANC (cells/μL)
<500	26 (44.8)	7 (63.6)	4 (22.2)	3 (17.6)	3 (42.9)	43 (38.7)	0.059
≥500	32 (55.2)	4 (36.4)	14 (77.8)	14 (82.4)	4 (57.1)	68 (61.3)
CRP (mg/L)*
<5	4 (9.3)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)	4 (4.7)	0.380
≥5	39 (90.7)	11(100)	17 (100)	11 (100)	4 (100)	82 (95.3)
AMC (cells/μL)
<500	51 (87.9)	8 (72.7)	11 (61.1)	12 (70.6)	6 (85.7)	88 (79.3)	0.111
≥500	7 (12.1)	3 (27.3)	7 (38.9)	5 (29.4)	1 (14.1)	23 (20.7)
Temperature (°C)
<38.3	11 (19.0)	2 (18.2)	6 (33.3)	7 (41.2)	2 (28.6)	28 (25.2)	0.035
≥38.3	47 (81.0)	9 (81.8)	12 (66.7)	10 (58.8)	5 (71.4)	83 (74.8)
Duration of fever† (temp ≥38.3)
≤24 hours	29 (64.4)	6 (66.7)	12 (92.3)	11 (78.6)	3 (50.0)	61 (70.1)	0.246
>24 hours	16 (35.6)	3 (33.3)	1 (7.7)	3 (21.4)	3 (50.0)	26 (29.9)
Duration of neutropenia (days)†
≤7 days	12 (24.5)	2 (25)	2 (25)	6 (54.5)	0 (0)	22 (27.5)	0.054
>7days	37 (75.5)	6 (75)	6 (75)	5 (45.5)	4 (100)	58 (72.5)

Notes:

* In some patients CRP values were not evaluated and measured;

† duration of fever and duration of neutropenia data were found to be missing for some patients.

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myelocytic leukemia; AMC, absolute monocyte count; ANC, absolute neutrophil count; CRP, C-reactive protein; SD, standard deviation.

Figure 1 Box plot: distribution of CRP values among different types of cancer.

Note: *Extreme outliers.

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; CRP, C-reactive protein.

Table 2 Pattern of bacteria isolated from blood stream infections in pediatric oncology patients

Organism	Number of episodes				MDR n (%)
	Total	Leukemia	Lymphoma	Solid tumor
Gram-positive bacteria
Staphylococcus epidermidis	26	16	3	7	9 (33)
Staphylococcus haemolyticus	7	3	2	2	4 (57)
Staphylococcus hominis	9	6	3	0	7 (78)
Staphylococcus chromogenes	2	2	0	0	0
Staphylococcus warneri	2	2	0	0	0
Staphylococcus Capitis subspecies ureolyticus	1	1	0	0	0
Staphylococcus. aureus	2	1	1	0	0
Enterococcus faecium	1	1	0	0	0
Enterococcus gallinarum	1	0	0	1	1 (100)
Micrococcus luteus	1	0	0	1	0
Micrococcus lylae	1	1	0	0	0
Kocuria rosea	1	1	0	0	0
Kocuria varians	1	1	0	0	0
Brevibacterium species	2	2	0	0	0
Corynebacterium propinguum	1	0	0	1	0
Streptococcus species	5	3	0	2	0
Lactococcus species	1	1	0	0	0
Total	64	41	9	14	21 (32.8)
Gram-negative bacteria
Pseudomonas aeruginosa	10	7	2	1	0
Acinetobacter baumannii	6	3	2	1	0
Escherichia coli	7	5	1	1	4 (57)
Stenotrophomonas maltophilia	2	0	1	1	2 (100)
Citrobacter youngae	1	1	0	0	0
Ochrobactrum anthropi	1	1	0	0	0
Pseudomonas putida	1	1	0	0	0
Chryseobacterium indologenes	1	1	0	0	1 (100)
Enterobacter cloacae	5	3	0	2	2 (21)
Salmonella species	3	1	1	1	0
Klebsiella pneumoniae	14	9	2	3	3 (21)
Pantoea agglomerans	1	1	0	0	0
Total	52	33	9	10	12 (23)
Total G−ve and G+ve MDR	116	74	18	24	33 (28.4)

Abbreviations: (G+ve), Gram-positive; (G−ve), Gram-negative; MDR, multidrug resistant.

Figure 2 Pattern of Gram-positive and Gram-negative bacteria in pediatric cancer patients (2004–2011).

Abbreviations: (G+ve), Gram-positive; (G−ve), Gram-negative.

Table 3 Susceptibility pattern of bloodstream bacteria

Antibiotics	Gram-positive bacteria (n =64)
	Staphylococcus epidermidis (n=26) n (% susceptible)	Staphylococcus haemolyticus (n=7) n (% susceptible)	Staphylococcus hominis (n=9) n (% susceptible)	Other G+ve bacteria (n=22) n (% susceptible)
Clindamycin	17 (53)	6 (85)	5 (60)	8 (88)
Oxacillin	23 (8)	7 (0.00)	9 (22)	8 (88)
Erythromycin	26 (100)	7 (12)	7 (28)	9 (78)
Gentamicin	26 (73)	7 (37)	9 (77)	15 (87)
Linezolid	15 (100)	4 (100)	7 (100)	5 (100)
Vancomycin	26 (96)	7 (100)	9 (100)	18 (94)
Teicoplanin	20 (95)	7 (87)	8 (100)	9 (100)
Streptogramins	14 (100)	4 (100)	6 (100)	3 (100)
Cefazolin	16 (0.00)	7 (0.00)	4 (25)	6 (33)
TMX-SMX	23 (16)	7 (20)	8 (25)	7 (57)
Antibiotic	Gram-negative isolates (n =52)
	Pseudomonas aeruginosa (n=10) n (% susceptible)	Acinetobacter baumannii (n=6) n (% susceptible)	Escherichia coli (n=7) n (% susceptible)	Klebsiella pneumonia (n=14) n (% susceptible)	Other G-ve bacteria (n=15) n (% susceptible)
Cefepime	7 (100)	5 (100)	7 (33)	12 (83)	13 (77)
Gentamicin	7 (100)	6 (100)	7 (55)	12 (75)	11 (64)
Piperacillin/tazobactam	8 (100)	5 (100)	7 (100)	9 (78)	12 (92)
Amikacin	8 (100)	6 (100)	7 (100)	13 (100)	14 (86)
Ceftriaxone	ND	3 (33)	7 (29)	10 (80)	9 (44)
Ciprofloxacin	7 (100)	6 (100)	7 (78)	11 (82)	12 (83)
Meropenem	8 (100)	5 (100)	7 (100)	12 (100)	13 (69)
Imipenem	4 (100)	2 (100)	7 (100)	10 (100)	14 (79)
TMX-SMX	ND	6 (100)	7 (11)	12 (42)	11 (82)
Ceftazidime	7 (100)	6 (100)	8 (50)	13 (77)	13 (77)

Abbreviations: ND, not done; TMX-SMX, trimethoprim sulfamethoxazole.

Figure 3 Causes of mortality in pediatric cancer patients.

Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia.

Table 4 Bacteria isolated from blood stream infections in pediatric neutropenic hematology/oncology patients

Organism	Number of neutropenic episodes
	Total*	Leukemia	Lymphoma	Solid tumor
Gram-positive bacteria
Staphylococcus chromogenes	2	2	0	0
Staphylococcus epidermis	10	7	0	3
Staphylococcus haemolyticus	3	2	0	1
Staphylococcus hominis	3	2	1	0
Staphylococcus warneri	1	1	0	0
Streptococcus viridans group	1	1	0	0
Corynebacterium propinguum	1	0	0	1
Brevibacterium species	2	2	0	0
Lactococcus species	1	1	0	0
Gram-negative bacteria
Acinetobacter baumannii	2	3	0	0
Acinetobacter species	3	0	1	0
Enterobacter cloacae	1	2	0	0
Escherichia coli**	2	2	0	1
Klebsiella pneumoniae	10	5	0	1
Pseudomonas aeruginosa	3	5	1	0
Stenotrophomonas maltophilia**	1	0	1	0

Notes:

* Total number of bacteria =46; double infections =3; episodes with neutropenia =43

** two patients died from MDR organisms, one from Escherichia coli, the other from Stenotrophomonas maltophilia infection.

Abbreviation: MDR, multidrug resistant.