Effect of Bacteraemia and HIV infection on treatment outcome in children with severe acute malnutrition admitted to the University Teaching Hospital Malnutrition Ward, Lusaka, Zambia

Abstract

Background:Severe malnutrition remains a major cause of mortality in children less than 5 years at the University Teaching Hospital, with rates ranging between 30-40 % among patients admitted in the malnutrition ward. The effects of bacteraemia and HIV infection on outcome to treatment remain unknown. Objective:To establish the magnitude of bacteraemia and HIV infection in children with severe acute malnutrition (SAM) admitted to the Zambian University Teaching Hospital (UTH) malnutrition ward, describe the types of bacteria and antimicrobial sensitivity, and effect on treatment outcome. Method: Children admitted to the malnutrition ward at the UTH from August to December of 2009 were included in the study after acquiring informed consent. Data on nutritional status, social demographic factors and admission medical conditions were collected. In addition blood sample was collected from every child. Identification of positive culture yielding pathogenic bacterial strains were done using BACTEC machine, and completed with morphologic and biochemical tests. Antibiotic susceptibility tests were performed using Kirby-Bauer susceptibility testing method. Results: Data were collected from 441 children aged six to 59 months old, 55.3% (244/441) of whom were boys. Median age of the cohort was 17 months (inter quartile range, IQR 12-22). 68.9% (295/428) had edema at admission; 57.4% (247/430) had weight for height Z score < -3SD at admission. The majority, 67.3% (261/388) of the children presented with diarrhea. 38.9 % (162/420) tested HIV-positive; 21.4% (91/425) of the children had one or more bacteria isolated from their blood samples; 40.5% (174/430) of the children died. The predominant organisms isolated were Coagulase negative Staphylococcus (20.7%), E. coli (15.5%), Staphylococcus aureus (15.5%), Salmonella (12.1%,), Pseudomonas (8.6%), Diphteriods (6.9%) and Klebsiella pneumonia (6.9%). Crystalline Penicillin had 85.7% (12/14) resistance; ranging from 66.7% to S.Aureus to 100% to E.coli and klebsiella. Gentamycine had 23.6% (5/19) resistance; ranging from 0% to E.coli to 100% to Klebsiella; Ciprofloxacin had 27.9% (13/43); ranging from 0% to Salmonella, Klebsiella and Psuedomonas to 55.6% to E.Coli. HIV positive children had increased odds of mortality, adjusted 0R= 1.70 (95% CI 1.04-2.83, P=0.04). Children with bacteremia had increased odds of mortality compared to those with no bacteremia, adjusted OR=1.90 (95% CI 1.04-3.40, P=0.04). There was no interaction between bacteremia and HIV infection on outcome (P=0.77). Conclusion: SAM children admitted in UTH suffer from high prevalence of bacteremia on admission. This has increased their odds of death by almost two folds regardless of their admission nutritional status, diarrhea, age, sex, and HIV status. The baseline mortality and HIV prevalence in the malnutrition ward was higher than other similar studies. The drug resistance, to first line antibiotics mainly to penicillin, calls for an in-depth review of drug management.