He et al. BMC Infectious Diseases (2017) 17:614 DOI 10.1186/s12879-017-2710-4
RESEARCH ARTICLE
Open Access
Antimicrobial resistance in bacterial pathogens among hospitalized children with community acquired lower respiratory tract infections in Dongguan, China (2011– 2016) Xiaoguang He1,2,3†, Mingyu Xie1,2,3†, Siping Li1,2,3, Junqin Ye1,2,3, Qi Peng1,2,3, Qiang Ma1,2,3, Xiaomei Lu1,2,3* and Baimao Zhong1,2,3*
Abstract Background: Bacterial pathogens are a major cause of childhood community acquired lower respiratory tract infections (CA-LRTIs), and few data described the impact of antimicrobial resistance on children with CA-LRTIs. This study aims to investigate the antimicrobial resistance in common bacterial agents among hospitalized children with CA-LRTIs between 2011 and 2016 in Dongguan, China. Methods: Sputum samples were collected from hospitalized children (0–5 years old) with CA-LRTIs in Dongguan Children’s Hospital. Bacterial pathogens were detected using traditional culture methods, and disc diffusion tests were used to determine antibiotic resistance. Results: Among the 2360 samples analyzed, 342 (14.5%) were positive for bacterial infection. The most prevalent pathogen was MSSA (2.3%), followed by MRSA (1.5%), E. coli (1.7%), E. coli ESBLs (1.2%), K. pneumonia ESBLs (1.5%), K. pneumonia (1.4%) and S. pneumonia (1.3%). Of the hospitalized patients with bacteria causing of CA-LRTIs, 90.1% were less than 1-year-old. MSSA and MRSA were more commonly isolated in infants less than 3 months. E. coli, K. pneumonia and K. pneumonia ESBLs were more common bacteria causing CA-LRTIs in infants less than 1 month. Resistance levels to penicillins, fluoroquinolones, macrolides, cephalosporins, carbapenems and vancomycin varied in different bacteria. Conclusions: S. aureus, E coli and K. pneumonia were the common bacterial isolates recovered from chidren with CA-LTRIs during 2011–2015. Age group of under 1 year old was at a high risk of bacterial infections. Many isolates showed antibiotic resistance level was associated with antibiotic usage in clinic. Increasing surveillance of antibiotic resistance is urgently needed and develops better strategies to cure the antibiotic abuse in China.
* Correspondence: [email protected]; [email protected] † Equal contributors 1 Department of Pediatric Respiratory Medicine, Dongguan Children’s Hospital, Xihu Third Road NO. 68, Dongguan, Guangdong 523325, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
He et al. BMC Infectious Diseases (2017) 17:614
Background Community acquired lower respiratory tract infections (CA-LRTIs) continues to be one of the most frequent infectious diseases causes of hospitalization and death worldwide, especially in children less than five years old [1–4]. Although respiratory viruses,such as respiratory syncytial virus, adenovirus and human metapneumovirus are significantly implicated in LRTIs at present, bacterial pathogens remain a major cause of CA-LRTIs in children, particularly in developing areas [5–7]. Among several previous Chinese studies, Qin et al. [8] found Streptococcus pneumoniae and Haemophilus influenzae were the predominant pathogens in Nanjing. Pei et al. [9] reported S. pneumoniae and Escherichia coli were the major bacterial agents in Xinxiang. Peng et al. [10] found S. pneumoniae and Hemophilus parainfluenzae were the main pathogens in Chongqing. The attributable fractions of each of these pathogens varied largely depending on geographical locations. However, limited information about bacterial pathogens trigging CA-LRTIs were reported in Dongguan, Southern China. Antibiotic resistance is considered to be a worldwide problem, and unwise use of antibiotics has been recognized as a key contributor to the increasing rates of resistance [11]. Therefore, clinical practice typically uses empirical antibiotic selection to target the most likely pathogens based on antibiotic sensitivity data [12]. The antibiotic resistance associated with CA-LRTIs varies significantly depends on geographical locations and investigated populations [13, 14]. Therefore, it is not adequate to simply copy the existing guidelines from other countries, which may be inappropriate and lead to serious problems in clinical practice. For example, the incidence of aminoglycosides and quinolones resistant-MRSA is relatively high in the USA [15] and Thailand [16]. Penicillin-resistant S. pneumoniae is also relatively high in USA [17] and Southeast Asia [18]. Moreover, most studies have described patterns in the resistance of bacterial pathogens among adults with respiratory tract infections, these patterns may occur differently in adults and children [14, 19]. Dongguan is an industrial city in southern China, which has more than 10 million of people. Limited information regarding antimicrobial resistance patterns in Dongguan is available, and it is necessary to clarify the epidemiology and antibiotic resistance in this local area. The objectives of our study were to identify antimicrobial resistance in microorganisms in children diagnosed with CA-LRTIs in Dongguan, China; to provide guidance to local clinical pediatricians regarding the choice of appropriate antibiotic therapy and decrease the incidence of antimicrobial resistance.
Page 2 of 9
Methods Study population
This retrospective study was conducted at the Department of Pediatric Infectious Disease in Dongguan Children’s Hospital, which is a tertiary care center with over 300 beds, including Department of Pediatric Intensive Care Unit, Department of Neonatal Intensive Care Unit, Department of Pediatric Surgery, Department of Pediatric Orthopaedic and several key departments of common pediatric internal medicine, the daily outpatient visits are more than 1000. During the period from March 2011 to June 2016, the hospitalized patients less than 18 years old displaying symptoms of CA-LRTIs were enrolled in this study if they met three inclusion criteria: 1) one or more respiratory symptoms, including cough, expectoration, dyspnea, pleuritic pain, or/and fever; 2) radiographic findings indicating evidence of pneumonia/bronchitis, such as a chest X-ray or computed tomography (CT) scan interpreted by an attending radiologist as showing pulmonary consolidation, opacity, or infiltrate; and 3) children suffering lower respiratory tract infections before admission. The exclusion criteria are: 1) Immunodeficiency disease; and 2) known Mycoplasma pneumoniae or Chlamydia pneumoniae infections, in that Mycoplasma pneumoniae antibodies were detected using Passive Particle Agglutination (SERODIA®-MYCO II, Japan), and lgG/M antibody to Chlamydia pneumoniae was detected using Colloidal (China) in our hospital. Microbiological methods
All the pediatric patients involved were asked to supply single sputum samples from lower respiratory tract for 1-2 ml before initiation of antibiotic therapy. Regrettably, blood samples were not obtained in the retrospective study. As obtaining meaningful sputum specimens were extremely difficult in babies, the clinical specimens in our research from lower respiratory tract were collected using sterility sputum aspirating tubes by trained personnel following standard operating procedures. All samples had been transported to the laboratory for processing and analysis under the conditions of ≤2 h and 4 °C. Each specimen must be in accordance with the microscopic quality criteria: squamous epithelial cells (SEC)25, or SEC/WBC
RESEARCH ARTICLE
Open Access
Antimicrobial resistance in bacterial pathogens among hospitalized children with community acquired lower respiratory tract infections in Dongguan, China (2011– 2016) Xiaoguang He1,2,3†, Mingyu Xie1,2,3†, Siping Li1,2,3, Junqin Ye1,2,3, Qi Peng1,2,3, Qiang Ma1,2,3, Xiaomei Lu1,2,3* and Baimao Zhong1,2,3*
Abstract Background: Bacterial pathogens are a major cause of childhood community acquired lower respiratory tract infections (CA-LRTIs), and few data described the impact of antimicrobial resistance on children with CA-LRTIs. This study aims to investigate the antimicrobial resistance in common bacterial agents among hospitalized children with CA-LRTIs between 2011 and 2016 in Dongguan, China. Methods: Sputum samples were collected from hospitalized children (0–5 years old) with CA-LRTIs in Dongguan Children’s Hospital. Bacterial pathogens were detected using traditional culture methods, and disc diffusion tests were used to determine antibiotic resistance. Results: Among the 2360 samples analyzed, 342 (14.5%) were positive for bacterial infection. The most prevalent pathogen was MSSA (2.3%), followed by MRSA (1.5%), E. coli (1.7%), E. coli ESBLs (1.2%), K. pneumonia ESBLs (1.5%), K. pneumonia (1.4%) and S. pneumonia (1.3%). Of the hospitalized patients with bacteria causing of CA-LRTIs, 90.1% were less than 1-year-old. MSSA and MRSA were more commonly isolated in infants less than 3 months. E. coli, K. pneumonia and K. pneumonia ESBLs were more common bacteria causing CA-LRTIs in infants less than 1 month. Resistance levels to penicillins, fluoroquinolones, macrolides, cephalosporins, carbapenems and vancomycin varied in different bacteria. Conclusions: S. aureus, E coli and K. pneumonia were the common bacterial isolates recovered from chidren with CA-LTRIs during 2011–2015. Age group of under 1 year old was at a high risk of bacterial infections. Many isolates showed antibiotic resistance level was associated with antibiotic usage in clinic. Increasing surveillance of antibiotic resistance is urgently needed and develops better strategies to cure the antibiotic abuse in China.
* Correspondence: [email protected]; [email protected] † Equal contributors 1 Department of Pediatric Respiratory Medicine, Dongguan Children’s Hospital, Xihu Third Road NO. 68, Dongguan, Guangdong 523325, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
He et al. BMC Infectious Diseases (2017) 17:614
Background Community acquired lower respiratory tract infections (CA-LRTIs) continues to be one of the most frequent infectious diseases causes of hospitalization and death worldwide, especially in children less than five years old [1–4]. Although respiratory viruses,such as respiratory syncytial virus, adenovirus and human metapneumovirus are significantly implicated in LRTIs at present, bacterial pathogens remain a major cause of CA-LRTIs in children, particularly in developing areas [5–7]. Among several previous Chinese studies, Qin et al. [8] found Streptococcus pneumoniae and Haemophilus influenzae were the predominant pathogens in Nanjing. Pei et al. [9] reported S. pneumoniae and Escherichia coli were the major bacterial agents in Xinxiang. Peng et al. [10] found S. pneumoniae and Hemophilus parainfluenzae were the main pathogens in Chongqing. The attributable fractions of each of these pathogens varied largely depending on geographical locations. However, limited information about bacterial pathogens trigging CA-LRTIs were reported in Dongguan, Southern China. Antibiotic resistance is considered to be a worldwide problem, and unwise use of antibiotics has been recognized as a key contributor to the increasing rates of resistance [11]. Therefore, clinical practice typically uses empirical antibiotic selection to target the most likely pathogens based on antibiotic sensitivity data [12]. The antibiotic resistance associated with CA-LRTIs varies significantly depends on geographical locations and investigated populations [13, 14]. Therefore, it is not adequate to simply copy the existing guidelines from other countries, which may be inappropriate and lead to serious problems in clinical practice. For example, the incidence of aminoglycosides and quinolones resistant-MRSA is relatively high in the USA [15] and Thailand [16]. Penicillin-resistant S. pneumoniae is also relatively high in USA [17] and Southeast Asia [18]. Moreover, most studies have described patterns in the resistance of bacterial pathogens among adults with respiratory tract infections, these patterns may occur differently in adults and children [14, 19]. Dongguan is an industrial city in southern China, which has more than 10 million of people. Limited information regarding antimicrobial resistance patterns in Dongguan is available, and it is necessary to clarify the epidemiology and antibiotic resistance in this local area. The objectives of our study were to identify antimicrobial resistance in microorganisms in children diagnosed with CA-LRTIs in Dongguan, China; to provide guidance to local clinical pediatricians regarding the choice of appropriate antibiotic therapy and decrease the incidence of antimicrobial resistance.
Page 2 of 9
Methods Study population
This retrospective study was conducted at the Department of Pediatric Infectious Disease in Dongguan Children’s Hospital, which is a tertiary care center with over 300 beds, including Department of Pediatric Intensive Care Unit, Department of Neonatal Intensive Care Unit, Department of Pediatric Surgery, Department of Pediatric Orthopaedic and several key departments of common pediatric internal medicine, the daily outpatient visits are more than 1000. During the period from March 2011 to June 2016, the hospitalized patients less than 18 years old displaying symptoms of CA-LRTIs were enrolled in this study if they met three inclusion criteria: 1) one or more respiratory symptoms, including cough, expectoration, dyspnea, pleuritic pain, or/and fever; 2) radiographic findings indicating evidence of pneumonia/bronchitis, such as a chest X-ray or computed tomography (CT) scan interpreted by an attending radiologist as showing pulmonary consolidation, opacity, or infiltrate; and 3) children suffering lower respiratory tract infections before admission. The exclusion criteria are: 1) Immunodeficiency disease; and 2) known Mycoplasma pneumoniae or Chlamydia pneumoniae infections, in that Mycoplasma pneumoniae antibodies were detected using Passive Particle Agglutination (SERODIA®-MYCO II, Japan), and lgG/M antibody to Chlamydia pneumoniae was detected using Colloidal (China) in our hospital. Microbiological methods
All the pediatric patients involved were asked to supply single sputum samples from lower respiratory tract for 1-2 ml before initiation of antibiotic therapy. Regrettably, blood samples were not obtained in the retrospective study. As obtaining meaningful sputum specimens were extremely difficult in babies, the clinical specimens in our research from lower respiratory tract were collected using sterility sputum aspirating tubes by trained personnel following standard operating procedures. All samples had been transported to the laboratory for processing and analysis under the conditions of ≤2 h and 4 °C. Each specimen must be in accordance with the microscopic quality criteria: squamous epithelial cells (SEC)25, or SEC/WBC
