High Proportion of Mucosal Barrier Injury- Laboratory Confirmed Bloodstream Infection Among Paediatric Oncology Patients in a Cancer Centre in Eastern India
Authors: Mukherjee Satyam , Bhattacharya Sanjay , Goel Gaurav , Dey Maitrayee Sarkar , Bhattacharyya Arpita 
Published: November 2023

Abstract

Introduction
Blood stream Infections (BSI) is associated with increased morbidity, mortality, health care costs and healthcare resource utilization. The 2022 version of CDC/NHSN criteria for mucosal barrier injury-associated laboratory-confirmed bloodstream infection (MBI-LCBI-1) included isolation of any intestinal organism from blood culture in a patient with absolute neutrophil count &lt;500/mm3. Children with malignancy have a high risk for infections due to neutropenia, immunosuppressive therapy, individual immune and nutritional status, chemotherapy infusion, radiotherapy, impaired mucosal barrier, and presence of different types of indwelling catheters. CLABSI is defined as an LCBI where an eligible BSI organism is identified, and an eligible central line is present on the LCBI date of event or the day before. Device Utilisation Ratio (DUR) is a ratio comparing the number of device days to the number of patient days for the included time period.

Methods
A retrospective analysis of all BSI-s in the paediatric unit of a tertiary oncology hospital in a low-middle income country (LMIC) for 43 months (April 2019-October 2022) was performed. The primary objective was to assess the burden of MBI-LCBI-1 in children with cancer. The secondary objective was to assess the CLABSI rate and compare it to the DUR. MBI-LCBI-1, CLABSI and DUR were determined using the standard CDC/NHSN criteria.
The adapted CDC/NHSN bloodstream infection case report form included microbiological (type of pathogen) and clinical (signs, symptoms, and underlying conditions such as neutropenia) information. Neutropenia (absolute neutrophil count &lt;500 cells/mm3) was the underlying condition in the MBI-LCBI cases.
Blood cultures were done using BACT-ALERT system and antibiotic susceptibility testing performed using VITEK2 system (Biomerieux).

Results
A total of 47 positive blood cultures were obtained from 46 patients during the study period. Thirty-three cases of MBI-LCBI-1 (33/47= 70%) from 28 patients (median age 14 years; range 4-20 years) and 3 cases of CLABSI (3/47= 6.3%) from 3 patients (median age 7 years; range 3-9 years) were detected giving a CLABSI rate of 0.60 per 1000 central line days. Total Patient days and central line days was 15,002 and 14,764 respectively. The device utilization ratio of central line was 0.98.
There were 48 isolates from 47 cases of BSI. Forty-three (90%) were Gram negative bacilli (GNB), 2 (4%) Gram positive cocci (GPC) and 3 (6%) Candida species. Klebsiella pneumoniae (28%) was the commonest GNB. Amongst the multi-drug resistant organisms (MDRO) associated with MBI-LCBI-1, carbapenem-resistant enterobacterales (CRE) was detected in 14/43 (32.5%), carbapenem-resistant Acinetobacter baumanii complex (CRAb) in 1/43 (2.3%), carbapenem-resistant Pseudomonas aeruginosa (CRPseu) in 2/43 (4.7%). Candida auris was detected in 1/3 Candida isolates. Six out of 46 patients with BSI died within 30 days of BSI (all-cause mortality). Four of these patients had CRE, 1 had CRAb and 1 had Candida auris. There were no isolates of Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE).

Conclusion
All patients who died had MDRO isolates. Strict adherence to standard and contact precautions, with high level of awareness is necessary for lowering the incidence of BSI. Low incidence of CLABSI is a good indicator of good infection control practices.