title: Antimicrobial resistance predicts death in Tanzanian children with bloodstream infections: a prospective cohort study.
abstract: BACKGROUND
  Bloodstream infection is a common cause of hospitalization, morbidity and death in children. The impact of antimicrobial resistance and HIV infection on outcome is not firmly established.
  
  
  METHODS
  We assessed the incidence of bloodstream infection and risk factors for fatal outcome in a prospective cohort study of 1828 consecutive admissions of children aged zero to seven years with signs of systemic infection. Blood was obtained for culture, malaria microscopy, HIV antibody test and, when necessary, HIV PCR. We recorded data on clinical features, underlying diseases, antimicrobial drug use and patients' outcome.
  
  
  RESULTS
  The incidence of laboratory-confirmed bloodstream infection was 13.9% (255/1828) of admissions, despite two thirds of the study population having received antimicrobial therapy prior to blood culture. The most frequent isolates were klebsiella, salmonellae, Escherichia coli, enterococci and Staphylococcus aureus. Furthermore, 21.6% had malaria and 16.8% HIV infection. One third (34.9%) of the children with laboratory-confirmed bloodstream infection died. The mortality rate from Gram-negative bloodstream infection (43.5%) was more than double that of malaria (20.2%) and Gram-positive bloodstream infection (16.7%). Significant risk factors for death by logistic regression modeling were inappropriate treatment due to antimicrobial resistance, HIV infection, other underlying infectious diseases, malnutrition and bloodstream infection caused by Enterobacteriaceae, other Gram-negatives and candida.
  
  
  CONCLUSIONS
  Bloodstream infection was less common than malaria, but caused more deaths. The frequent use of antimicrobials prior to blood culture may have hampered the detection of organisms susceptible to commonly used antimicrobials, including pneumococci, and thus the study probably underestimates the incidence of bloodstream infection. The finding that antimicrobial resistance, HIV-infection and malnutrition predict fatal outcome calls for renewed efforts to curb the further emergence of resistance, improve HIV care and nutrition for children.
authors.affiliation: Department of Medicine, Haukeland University Hospital, Bergen, Norway. bjorn.blomberg@med.uib.no
authors.forename: Bjørn
authors.initials: B
authors.lastname: Blomberg
authors.forename: Karim P
authors.initials: KP
authors.lastname: Manji
authors.forename: Willy K
authors.initials: WK
authors.lastname: Urassa
authors.forename: Bushir S
authors.initials: BS
authors.lastname: Tamim
authors.forename: Davis S M
authors.initials: DS
authors.lastname: Mwakagile
authors.forename: Roland
authors.initials: R
authors.lastname: Jureen
authors.forename: Viola
authors.initials: V
authors.lastname: Msangi
authors.forename: Marit G
authors.initials: MG
authors.lastname: Tellevik
authors.forename: Mona
authors.initials: M
authors.lastname: Holberg-Petersen
authors.forename: Stig
authors.initials: S
authors.lastname: Harthug
authors.forename: Samwel Y
authors.initials: SY
authors.lastname: Maselle
authors.forename: Nina
authors.initials: N
authors.lastname: Langeland
mesh_terms: D000818:Animals; D000906:Antibodies / Q000627:therapeutic use; D016470:Bacteremia / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality* / Q000469:parasitology; D002648:Child; D002675:Child, Preschool; D024901:Drug Resistance, Multiple, Bacterial; D004756:Enterobacteriaceae Infections / Q000188:drug therapy / Q000401:mortality*; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy / Q000401:mortality*; D015658:HIV Infections / Q000150:complications*; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000150:complications*; D008297:Male; D008826:Microbial Sensitivity Tests; D009752:Nutritional Status; D011446:Prospective Studies; D013636:Tanzania / Q000453:epidemiology
chemical_list: D000906:Antibodies