Stenotrophomonas maltophilia pseudobacteraemia in a pediatric hospital associated with contaminated citrated tubes: Importance of appropriate blood collection

Objective: In this study, it was aimed to present a cohort study conduct-ed retrospectively in order to examine the unexpected Serratia marc-escens bacteremia prevalence in a children's hospital in Turkiye.Material and Methods: S. marcescens was isolated in the blood cultures of 45 patients at a 20-month period. Demographic features and clinical findings of the 45 patients including age, sex, underlying diseases, white blood cell (WBC), C-reactive protein (CRP), serum albumin level, length of hospital stay and length of pediatric intensive care unit stay, portal of entry, duration of central venous catheter, results of antimicrobial sus-ceptibility testing and 28-day all-cause mortality were examined. Blood-stream infections (BSI) were classified as BSI or catheter-related BSI. Definitions used to characterize antimicrobial resistant bacteria were classified as multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR).Results: Twelve patients (26.9%) had a malignancy. Mean hospitaliza-tion duration was 42.7 +/- 41.4 (3-171) days. Central venous catheters (CVCs), including chemo-ports and Hickman catheters, were present in 43 patients during episodes of BSI. Twenty-four patients had primary BSI while 21 patients had catheter-related BSI. Mean length of CVC pres-ence before catheter-related BSI was 46.02 +/- 50.96 (1-200) days. During bacteremia episodes, 24 catheters (55.8%) were removed. Four patients (8.9%) died during the bacteremia episode. Laboratory findings of thedeceased patients were as follows: mean WBC was 17.200/mm3; mean serum CRP level was 147.2 mg/L; and mean serum albumin level was 2.43 g/dL. Among all cases, 57.8% of the S. marcescens isolates produced ESBL and 40% produced carbapenemase. We classified these isolates as non-MDR (42.2%), MDR (31.1%), XDR (24.4%) and PDR (2.2%). The most common regimes received for XDR isolates were high-dose prolonged meropenem, amikacin, levofloxacin, and tigecycline.Conclusion: It is a great concern that S. marcescens isolates are intrinsi-cally resistant to polymyxins and produce ESBL and carbapenemase. Our mortality rate was reduced by high-dose prolonged-infusion of mero-penem and early catheter removal.

Catheter-related bloodstream infections (CRBSIs) are an important problem in pediatric patients with central venous catheters. This study aimed to determine the incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in pediatric patients. Between January 2010 and November 2015 all hospitalized pediatric hematology, oncology and immunology patients diagnosed with CRBSIs were retrospectively analyzed. Seventy-eight CRBSI episodes were detected in 60 pediatric patients. The incidence of CRBSIs was 4.20/1000 catheter days. The most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Pseudomonas aeruginosa, Klebsiella spp., and Escherichia coli were other commonly isolated microorganisms. ALT was administered in 42 patients. The success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. CRBSIs are an important cause of morbidity and mortality in pediatric patients. ALT is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs, though in some cases catheter removal is necessary. ALT helps to prevent unnecessary catheter removal in pediatric patients.

Urinary tract infections are one of the major health problems in children and the most frequently encountered etiological agents is Escherichia coli. Antibiotic sensivity and resistance of E. coli species yielded from the urinary cultures of patients diagnosed as urinary tract infection between 1992 and 1996 were reviewed retrospectively. Resistance to ampicilline and trimethoprimsulphamethoxazole (TMP-SMX) were 54.1% and 40.8% respectively in 1992. The resistance increased significantly to 76.4% and 64.4% respectively in 1996 (p<0.001). Resistance to other antibiotics were also reviewed. Rates of resistance to different antibiotics in 1992 and 1996 were as follows respectively: cefixim 1.9% and 4.1%, ceftriaxone 2.4% and 1.4 %, amicasin 1.6% and 7%,tobramycine 13.5% and 11.7% (p>0.05). It was concluded that, resistance to antibiotic which are frequently used empirically for urinary tract infections had increased significantly between 1992 and 1996, thus the empirical treatment should be planned with taking into concideration of the resistance state.

Introduction: The aim of this study was to determine the frequency of central line-associated bloodstream infections, risk factors, their relationship with catheter insertion location, and the effect of central line-associated bloodstream infections on mortality and pediatric intensive care unit (PICU) length of stay. Methods: This was a prospective, observational and cohort study, carried out between November 2009 and February 2011. During this period, all the patients who had central-line were monitored for central line-associated bloodstream infection. Results: In the study period, 275 patients were admitted to our PICU. The frequency of invasive device usage was 38.9% (107) for central venous catheter, 38.2% (105) for mechanical ventilation, 53.3% (147) for urinary catheter, and 11.3% (32) for artery line. Central line-associated bloodstream infection was detected in 16 (14.8%) of the patients and 23 central line-associated bloodstream infection attacks were observed. There were 14 central line-associated bloodstream infection attacks in 1.000 central venous catheter usage days. There were 168 patients without central venous catheter and 4 (2.4%) of them had blood stream infection. Thirty-six patients died and the mortality rate was 13%. Five of these patients (13.8%) died due to central line-associated bloodstream infection, 27 (25%) of them had central venous catheter and 9 (6%) of them did not (p=0.001). Conclusion: In conclusion, central line-associated bloodstream infection is one of the serious healthcare-associated infections, and it is an important cause of morbidity and mortality in PICUs.

Herein we report the successful treatment of catheter related blood stream infections due to Leuconostoc mesenteroides with antibiotic lock therapy in addition to systemic treatment. With our case, we have shown that in the presence of catheter related blood stream infections, antibiotic lock therapy can be used as a therapeutic option to get successful results if the catheter cannot be removed or there are still positive cultures despite the systemic antibiotic therapy.

Introduction.The aim of this prospective singlecenter study was to determine the changings in incidence of invasive pneumococcal disease (IPD), serotype distribution and the antimicrobial resistance patterns of S. pneumoniae in children with IPD after the period (1 to 7 years) of vaccination with PCV7 (2008) and PCV13 (2011).Population and methods.The study was conducted on 39 Turkish children with IPD between ages 1 month and 18 years in Ankara, Turkey.Streptococcus pneumoniae was identified using standard laboratory procedures from blood, cerebrospinal fluid (CSF), pleural fluid, and other sterile body fluids and tissues.S. pneumoniae isolates were tested for resistance to penicilin and ceftriaxone using the E-test methodology.Serotypes of the isolates were determined by Quellung reaction.Results.The overall annual incidence rate of IPD decreased significantly from 7.71 (95% CI, 1.99-13.4) to 1.58 (95% CI, 0.6-3.77;RRR= -79.5; p= 0.006) per 100 000 population among ≤5 years of age without underlying disease.During the overall study period, the PCV7-serotypes and PCV13-serotypes represented 27.8% and 63.8% of isolates, respectively.PCV13-serotypes made up 81.8% of cases of IPD in the pre-PCV13 era and decreased to 56% in the 4 years after PCV13.The penicillin and ceftriaxone (for meningitis) resistance rates were 48.5% and 9.1%, respectively.Conclusions.This is the first study about the changing pattern of the incidence of IPD in Turkish children after the implementation of the PCV7 and PCV13 in Turkish national vaccine schedule and a prominent decrease in incidence of IPD has seen after the implementation of PCV13.

In this report, we describe pseudobacteremia of Stenotrophomonas maltophilia in a paediatric hospital. S. maltophilia was isolated from blood cultures of 14 patients with in 2 months. Most of the patients with positive blood culture were given treatment because of underlying diseases, but pseudobacteremia was suspected since majority of these patients have no clinical and laboratory findings of sepsis and consecutive blood cultures were negative. The collected environmental samples were negative. Upon these isolations continued, it was considered that contamination might occur from the citrated coagulation, hemogram or biochemical tubes. Then S. maltophilia with same antibiogram was isolated from the citrated coagulation tubes. Nine of the patients received levofloxacin for average 7 days due to underlying disease. Medical staff were re-educated about blood culture drawing procedure. After the education no further isolates of S. maltophilia have been encountered to date.

Background and aims Bloodstream infections are the major cause of morbidity, increased cost, prolonged hospitalisation and mortality in paediatric haematology and oncology patients. We aimed to identify causative microorganisms and their antimicrobial susceptibilities in paediatric immunocompromised patients. Methods Patients with haematological and/or oncological diseases who admitted to our hospital with fever between January 2010 and November 2015 were included in this study. Patients’ demografic and clinical findings were collected from hospital information systems and microbiology laboratory records retrospectively. Results Totally 71 paediatric patients who had 111 bloodstream infection episodes were included in this study. The median age of patients was 90 (3-247) months. The most underlying disease was acute lymphoblastic leukaemia. While 31 patients had only peripheral blood culture positivity, 80 patients had catheter related blood stream infections. Of 80.2% blood stream infections occurred in neutropenic period. Responsible pathogens were detected as follows: 35.1% gram-positive microorganisms, 60.5% gram-negative bacteria and 4.4% fungi. The most causative gram negative pathogen was Escherichia coli and the most isolated gram positive microorganism was meticillin resistant coagulase negative Staphylococci. Extended spectrum beta lactamase was produced by 60% of Klebsiella spp. and 42.1% of E. coli. In addition carbapenemase producing E. coli and Klebsiella spp. were 15.8% and 26.7% respectively. Enterococcus spp. had 88.9% ampicillin resistance and%33.3 vancomycin resistance. Bloodstream infection related mortality rate was 2.7%. Conclusion Gram negative microorganisms were predominant pathogens in bloodstream infections. Extended spectrum beta lactamase and carbapenem resistance were increasingly important and they limited treatment options. The choice of empiric antimicrobial drug in immunosuppressed patients is life-saving. For all these reasons, the choice of empirical antibiotics should be made according to the clinical condition of the patient and the prevalent microorganisms in the current clinic, as favourable antimicrobial therapy will be able to achieve positive clinical outcomes.

Background Catheter related blood stream infections (CRBSIs) are important problem in paediatric haematology, oncology and immunology patients with central venous catheter. This study aimed to determine incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in paediatric patients. Methods Between January 2010 and November 2015 all hospitalised paediatric haematology, oncology and immunology patients who were diagnosed as CRBSIs, were retrospectively included in this study. Causative microorganisms and their antibiotic susceptibility, success rate of ALT, treatment failure, recurrence, catheter removal, complications and mortality are analysed. Results Seventy eight CRBSIs episodes were detected in 60 paediatric patients. The median age was 106.4±66.6 (86, 3–240) months. Male/female ratio was 1.9/1. The incidence of CRBSIs was 4.20/1000 catheter days. Most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Antibiotic lock therapy was administered in 42 patients. Success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. Relapse was observed in 1 (1.3%) episodes and mortality was detected in 3 (3.8%) episodes. Conclusion Catheter related blood stream infections are important cause of morbidity and mortality in paediatric patients. However, incidence may be decreased with antiseptic procedures and hand hygiene. Antibiotic lock therapy is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs except in some cases catheter removal must be necessary. Antibiotic lock therapy helps to prevent unnecessary catheter removing in paediatric immunocompromised patients.

Peritonitis is a serious problem in children receiving peritoneal dialysis. Campylobacter jejuni is an unusual cause of peritonitis. A 10-year-old boy who had end stage renal failure due to atypical hemolytic uremic syndrome was admitted to our hospital with abdominal pain and fever. Peritoneal dialysis fluid was cloudy and microscopic examination showed abundant leukocytes. Intraperitoneal cefepime treatment was started. Campylobacter jejuni was isolated from peritoneal dialysis fluid culture and oral clarithromycin was added to the treatment. At the end of therapy, peritoneal fluid culture was negative. To our knowledge, C. jejuni peritonitis was not reported in children previously.Conclusion: Although C. jejuni peritonitis is rarely encountered in children, it should be considered as an etiologic factor for peritonitis.

Kerion celsi is generally known as an inflammatory form of tinea capitis which is the result of delayed type hypersensitivity reaction of the body to fungal agents. It causes a painful, inflamed, crusty mass on the scalp and is often associated with purulent drainage and regional lymphadenopathy. Kerion celsi is often reported in children between three to seven years of age and it has a male predominance. This diagnosis should be kept in mind in patients with scalp scaling and alopecia, especially if they have pustular, crusted and nodular lesions and easily breaking hairs on the scalp. If untreated, alopecic scar tissue inevitably develops on the scalp. Differential diagnosis with bacterial pyoderma or abscess is important and may avoid unnecessary and inappropriate surgical drainage. Although causative species show variations between regions, zoophilic dermatophytes such as Microsporum canis, Trichophyton verrucosum and Trichophyton interdigitale complex are usually isolated from cultures. Herein, we report a ten year-old boy who was referred to our clinic because of pyodermic skin lesion and abscess formation which did not respond to antibacterial treatment. He was diagnosed as kerion celsi related to Trichosporon asteroides and successfully treated with systemic fluconazole within eight weeks. To our knowledge this is the first case of kerion celsi in the literature caused by T. asteroides.

Blastoschizomyces capitatus is a rare fungal pathogen that may lead to severe and fatal infections in patients with hematological malignancies.The risk factors for infections with this pathogen are hematological malignancy, cytotoxic chemotherapy, corticosteroid use, intravascular catheter use, and broad spectrum antibiotic use. In this case report, fungemia and pneumoniae due to B. capitatus is reported in a patient who is diagnosed with acute lymphoblastic leukemia and receiving chemotheraphy. Blood cultures became negative after treatment with liposomal amphotericin B. In immunosupressed patients with severe fungal infection, B. capitatus should be kept in mind and should be considered in the choice of treatment. Further studies are required for the determination of antifungal susceptibilities and susceptibility breakpoints for B. capitatus.

Objective: Acute gastroenteritis is an important cause of morbidity and mortality in developing countries. Children under 5 years of age are more commonly affected, while 80% of deaths occur in children under 2 years of age. Escherichia coli, Salmonella spp., and Shigella spp. are the most common causative bacterial pathogens. Since the summer of 2014, a large number of Salmonella and Shigella gastroenteritis cases have occurred in our region, which is considered as a small local outbreak. We aim to report the features and antibiotic susceptibility of microorganism isolates obtained during this epidemic.Material and Methods: Between July and September 2014, patients who were admitted to pediatric clinics and emergency services on account of acute gastroenteritis lasted less than 15 days were included in this retrospective study. Stool microscopy, stool cultures, and blood cultures were performed. Salmonella and Shigella strains were subjected to antimicrobial susceptibility testing.Results: A total of 2425 patients were admitted because of acute gastroenteritis during the study period. Salmonella spp. and Shigella spp. were isolated in 113 children. The mean age of the children was 91.5 +/- 60.3 months (4-213 months). Of the 113 patients, 56% were male and 44% were female. Shigella spp. were found in 77 patients (3.2%), and Salmonella spp. were found in 36 patients (1.5%). Salmonella enteritidis was detected in 29 patients (80.5%), whereas Salmonella typhimurium was detected in 3 patients (8.3%). In addition, Shigella sonnei was identified in 63 patients (81.8%) and Shigella flexneri in 8 patients (10.3%). In contrast to ceftriaxone susceptibility in Salmonella strains, 9.1% of Shigella strains were found to be resistant to ceftriaxone. Ciprofloxacin resistance was found in 5.6% and 1.3% strains of Salmonella and Shigella spp. respectively. Although the ampicillin resistance values of 2 strains were close, trimethoprim-sulfamethoxazole (TMP) resistance was found in 89.6% Shigella strains.Conclusion: Salmonella and Shigella are common bacterial pathogens. Resistance patterns must be known to select the most effective treatment. According to our study, ceftriaxone and ciprofloxacin appear to be the first choice of empirical treatment for acute bacterial gastroenteritis. Additionally, if the resistance states of ampicillin and TMP are known, these drugs can also be used as empirical treatment. (J Pediatr Inf 2015; 9: 102-7)

The aim of this study was to determine serotype distribution and investigate antimicrobial resistance patterns of Streptococcus pneumoniae in healthy Turkish children in the era of community-wide pneumococcal conjugate vaccine (PCV7). The study was conducted on 1,101 healthy children less than 18 years of age. Specimens were collected with nasopharyngeal swabs between April 2011 and June 2011. Penicillin and ceftriaxone susceptibilities were determined by E-test according to the 2008 Clinical Laboratory Standards Institute, and serotypes of the isolates were determined by Quellung reaction. The nasopharyngeal pneumococcal carriage rate was 21.9 % (241/1,101). Using the meningitis criteria of minimum inhibitory concentration values, 73 % of the isolates were resistant to penicillin and 47.7 % of them were resistant to ceftriaxone. Half of all pneumococcal isolates were serotyped as 19F (15.2 %), 6A (15.2 %), 23F (10.3 %), and 6B (9.3 %) and surprisingly, no serotype 19A was isolated. Serotype coverage rates of PCV7 and non-PCV7 were 46.2 and 53.8 %, respectively. The most common penicillin- and ceftriaxone-resistant serotypes were 6A, 6B, 14, 19F, and 23F. Penicillin- and ceftriaxone-resistant isolates were more prevalent in serotypes covered by PCV7 than the non-PCV7 serotypes. Conclusion: After the community-wide PCV7 vaccination, more non-PCV7 serotypes were isolated from the carriers compared to the time before PCV7 was used especially the serotype 6A, and the antimicrobial resistance of pneumococci was significantly increased.

Background: Colistin is active against most multidrug-resistant, aerobic Gram-negative bacteria. Because of the reported nephrotoxicity during the first years of use of colistin, there were concerns of its use in pediatrics where there was limited experience The aim of this study is to document the clinical characteristics and outcomes of use of colistin in pediatric patients at a pediatric intensive care unit in Turkey.Methods: We reviewed the medical and laboratory records of 29 critically ill children who were treated with colistin for 38 courses between January 2011 and December 2011 at the Department of Pediatric Intensive Care Unit in Ankara University Medical School, Turkey.Results: The median age was 17 months (range 3-217 months). Male-tofemale ratio was 1: 1.37. Ventilator-associated pneumonia (21 courses) was the leading diagnosis followed by catheter-related blood stream infection (6 courses), bacteremia (4 courses), ventriculoperitoneal shunt infection, peritonitis and pneumonia (1 course). The most commonly isolated microorganisms were Acinetobacter baumanni, Pseudomonas aeruginosa, Klebsiella pneumoniae, Serratia marcescens, Stenotrophomonas maltophilia, and Enterobacter cloacae. Two colistin formulations were used. Colimycin (Kocak Farma) was used in 21 colistin treatment episodes. The median dosage of colistin in this group was 5.0 mg/kg/d (2.3-5.6 mg/kg/d). Colomycin (Forest Laboratories) was used in 17 colistin treatment episodes. The median dosage of colistin in the second group was 75,000 International Unit/kg/d (50,000-80,000 International Unit/kg/d). Thirty colistin treatment episodes (79%) had a good or partial clinical response and 8 (21%) had a poor clinical response. Of the 8 colistin treatment episodes with poor clinical response, 3 were in the Colimycin group and 5 were in the Colomycin group. Ten patients died. There was no evidence of neurotoxicity in this study. Nephrotoxicity was observed in 1 patient but was not attributed to colistin because the patient had multiorgan failure at the same time.Conclusions: This study in a small cohort of patients suggests that the use of colistin in severe nosocomial infections caused by multidrug-resistant Gram-negative bacteria is well-tolerated and efficacious.