title: Clinical and Bacterial Risk Factors for Mortality in Children With Carbapenem-resistant Enterobacteriaceae Bloodstream Infections in India.
abstract: Carbapenem-resistant Enterobacteriaceae (CRE) are an increasing cause of nosocomial infection in hospitalized children worldwide. Few studies have investigated risk factors for mortality in children with CRE bloodstream infection (BSI). Data are particularly scarce in areas where NDM and OXA carbapenemases predominate. Here, we investigate mortality rates, clinical and microbiologic risk factors for mortality in 50 pediatric patients with CRE BSI in India.
  
  
  
  Children younger than 17 years old with meropenem-resistant Klebsiella pneumoniae or Escherichia coli isolated from blood culture in 2014 and 2015 were identified from laboratory records. Clinical records were systematically reviewed for each child to establish mortality at 30 days and clinical details. Bacterial isolates were subjected to meropenem E test and multiplex polymerase chain reaction to determine carbapenemase gene. Data were analyzed to establish clinical and bacterial risk factors for mortality.
  
  
  
  All CRE BSI were hospital-acquired or associated with healthcare. A total of 84% of children had an underlying comorbidity and 46% had a malignancy. K. pneumoniae was the most common bacteria isolated; NDM was the most common carbapenemase gene detected. The mortality rate was 52%. Significant risk factors for mortality included intensive care admission, intubation, inotropic support and respiratory source. Failure to clear bacteremia and a minimum inhibitory concentration > 8 mg/L for the isolate was associated with a statistically significant increase in mortality. Mortality rates were significantly lower when two or more effective drugs were used in combination.
  
  
  
  CRE BSI affects children with multiple comorbidities and repeated admissions to hospital. The mortality rate is high; combination therapy may be beneficial.
authors.affiliation: From the *Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India; †Public Health England, London, United Kingdom; ‡Department of Biostatistics, and §Department of Pediatrics, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: Laura E B
authors.initials: LEB
authors.lastname: Nabarro
authors.forename: Chaitra
authors.initials: C
authors.lastname: Shankar
authors.forename: Agila K
authors.initials: AK
authors.lastname: Pragasam
authors.forename: Georgekutty
authors.initials: G
authors.lastname: Mathew
authors.forename: Visali
authors.initials: V
authors.lastname: Jeyaseelan
authors.forename: Balaji
authors.initials: B
authors.lastname: Veeraraghavan
authors.forename: Valsan P
authors.initials: VP
authors.lastname: Verghese
mesh_terms: D000293:Adolescent; D016470:Bacteremia / Q000453:epidemiology / Q000382:microbiology* / Q000401:mortality*; D015780:Carbapenems / Q000494:pharmacology*; D002648:Child; D002675:Child, Preschool; D004755:Enterobacteriaceae / Q000187:drug effects*; D004756:Enterobacteriaceae Infections / Q000453:epidemiology / Q000382:microbiology* / Q000401:mortality*; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D018440:beta-Lactam Resistance
chemical_list: D015780:Carbapenems