Clinical and laboratory characteristics of children under five hospitalized with diarrhea and bacteremia
Authors: Shahunja K. M. , Ahmed Tahmeed , Hossain Md. Iqbal , Islam Md. Munirul , Monjory Mahmuda Begum , Shahid Abu Sadat Mohammad Sayeem Bin , Faruque Abu Syed Golam , Chisti Mohammod Jobayer 
Published: December 2020

Background
Diarrhea is one of the leading causes of mortality in children under five globally. When it is associated with bacteremia, mortality is even higher. However, bacteraemia in diarrheal children has gained little attention in spite of its deleterious impact in under-five mortality. So, we aimed to evaluate associated clinical and laboratory factors for death in under-five children hospitalized with both diarrhea and bacteremia.

Methods
In this retrospective cross-sectional study, we used patients’ electronic database of Dhaka Hospital of ‘icddr,b’, and enrolled all under-five children with diarrhea and bacterial growth in their blood samples on admission between June-2014 and May-2017. Clinical and laboratory characteristics were compared between those who died and who survived with a special attention to bacterial pathogens related to deaths and their sensitivity pattern.

Results
In a total of 401 diarrheal children with bacteraemia, 45 (11%) died. Although Salmonella Typhi (34%) was the most predominant isolate followed by Staphylococcus species (16%) and Pseudomonas species (9%), children who died more often had E. coli (OR = 5.69, 95% CI = 2.42–13.39, p = <0.001) and Klebsiella bacteraemia (OR = 4.59, 95% CI = 1.84–11.46, p = 0.001) compared to those who survived. However, none of them was significantly associated with deaths in regression analysis when adjusted with other potential confounders. E. coli was 100% resistant to ampicillin, 41% to gentamicin, and 73% to ceftriaxone and Klebsiella species was 96% resistant to ampicillin, 42% to gentamicin, and 62% to ceftriaxone. Study children who died had significantly higher overall resistance pattern shown in World Health Organization (WHO) recommended one of the first line antibiotics in treating childhood sepsis such as ampicillin (80% vs. 50%, p = 0.001) and in second line antibiotic such as ceftriaxone (49% vs. 22%, p = 0.001) compared to the survivors. In logistic regression analysis, after adjusting for potential confounders, we found that clinical sepsis (aOR 3.79, 95% CI 1.60–8.96, p = 0.002), hypoxemia (aOR 4.20, 95% CI 1.74–10.12, p = 0.001), and hyperkalaemia (aOR 2.69, 95% CI 1.05–6.91, p = 0.039) were found to be independent predictors of deaths and receipt of sensitive antibiotic (aOR 0.42, 95% CI 0.18–0.99, p = 0.048) was revealed as the independent protective factor for deaths in this population.

Conclusion and significance
The results of our data suggest that diarrheal children with bacteremia who died more often had gram negative bacteremia compared to those who survived and these pathogens are highly resistant to WHO recommended first line and second line antibiotics. The results further emphasize the critical importance of early identification of important clinical problems such as clinical sepsis, hypoxemia and hyperkalaemia in diarrheal children and treat them with potential sensitive antibiotic(s) in order to reduce bacteremia related mortality in children with diarrhea, especially in resource limited settings.