Carbapenem-resistant Enterobacterales infection at a South African paediatric hospital.

BACKGROUND

Carbapenem-resistant Enterobacterales (CRE) cause significant morbidity and mortality. The global dissemination of CRE is a public health concern, and its impact on children is increasingly being recognised in low-and middle-income countries (LMIC). Studies describing paediatric CRE infections in LMIC are limited. Therefore, this study describes the incidence risk, clinical and microbiological characteristics, treatment, and outcome of children with CRE infections at Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa.

METHODS

A retrospective description was completed on CRE infections diagnosed between January 2016 and December 2021. Clinical and laboratory data were extracted from hospital records and the National Health Laboratory Service database.

RESULTS

The overall incidence risk was 8.4/10,000 admissions. Of 85 infections with sufficient clinical and/or antibiotic information, the median age at CRE diagnosis was 3.9 months (interquartile range 0.8-44.4) and (68/85, 85%) were healthcare-associated. Sites of CRE infection included bloodstream (33/85, 39%), urinary tract (19/85, 22%) and respiratory tract (18/85, 21%). Klebsiella species (58/85, 68%) of which Klebsiella pneumoniae (57/58) predominated, and Serratia marcescens (19/85, 22%) were most isolated. Carbapenemase genes were detected in 63 of 72 isolates tested and included blaOXA-48 (46/63, 73%) and blaNDM (17/63, 27%). The isolates were most susceptible to amikacin (67/85, 79%) and tigecycline (66/85, 78%). Mortality within 30 days of diagnosis occurred in (28/85, 33%). On multivariable analysis, any organ dysfunction (risk ratio (RR) 3.2, 95% confidence interval (CI) 1.1-9.3), cardiovascular dysfunction or shock (RR 1.8, 95% CI 1.1-3.0), and ceftazidime-avibactam and/or colistin-based therapy (RR 1.9, 95% CI 1.1-3.2) were significantly associated with mortality within 30 days of CRE infection diagnosis.

CONCLUSION

This study adds to the limited number of paediatric CRE studies from Africa. The predominant pathogen causing CRE infection was blaOXA-48-producing K. pneumoniae. In our setting where ceftazidime-avibactam and colistin are used as last-resort agents, the finding of receipt of these agents and organ dysfunction as independent risk factors for mortality suggest that severity of disease and delayed initiation of definitive antibiotic therapy may be impacting mortality. These observations warrant further investigation in larger prospective hospital-based paediatric studies.