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.
Conclusion: 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.
