Turkish Journal of Hematology Volume: 33 - Issue: 3

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BRIEF REPORT DOI: 10.4274/tjh.2015.0368 Turk J Hematol 2016;33:244-247 Results of Four-Year Rectal Vancomycin-Resistant Enterococci Surveillance in a Pediatric Hematology-Oncology Ward: From Colonization to Infection Bir Pediatrik Hematoloji-Onkoloji Ünitesinde Vankomisine Dirençli Enterokok Kolonizasyon ve Enfeksiyonu: Dört Yıllık Sürveyans Sonuçları Hacer Aktürk 1 , Murat Sütçü 1 , Ayper Somer 1 , Serap Karaman 2 , Manolya Acar 1 , Ayşegül Ünüvar 2 , Sema Anak 2 , Zeynep Karakaş 2 , Aslı Özdemir 3 , Kutay Sarsar 4 , Derya Aydın 4 , Nuran Salman 1 1İstanbul University İstanbul Faculty of Medicine, Department of Pediatric Infectious Diseases, İstanbul, Turkey 2İstanbul University İstanbul Faculty of Medicine, Department of Pediatric Hematology and Oncology, İstanbul, Turkey 3İstanbul University İstanbul Faculty of Medicine, Infection Control Committee, İstanbul, Turkey 4İstanbul University İstanbul Faculty of Medicine, Department of Clinical Microbiology, İstanbul, Turkey Abstract Objective: To investigate the clinical impact of vancomycinresistant enterococci (VRE) colonization in patients with hematologic malignancies and associated risk factors. Materials and Methods: Patients colonized and infected with VRE were identified from an institutional surveillance database between January 2010 and December 2013. A retrospective case-control study was performed to identify the risk factors associated with development of VRE infection in VRE-colonized patients. Results: Fecal VRE colonization was documented in 72 of 229 children (31.4%). Seven VRE-colonized patients developed subsequent systemic VRE infection (9.7%). Types of VRE infections included bacteremia (n=5), urinary tract infection (n=1), and meningitis (n=1). Enterococcus faecium was isolated in all VRE infections. Multivariate analysis revealed severe neutropenia and previous bacteremia with another pathogen as independent risk factors for VRE infection development in colonized patients [odds ratio (OR): 35.4, confidence interval (CI): 1.7-72.3, p=0.02 and OR: 20.6, CI: 1.3-48.6, p=0.03, respectively]. No deaths attributable to VRE occurred. Conclusion: VRE colonization has important consequences in pediatric cancer patients. Keywords: Colonization, Infection, Pediatric malignancy, Vancomycinresistant enterococci Öz Amaç: Hematolojik malignitesi olan pediatrik hastalarda vankomisine dirençli enterokok (VDE) kolonizasyonunun Öz klinik öneminin araştırılması ve eşlik eden risk faktörlerinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntemler: Ocak 2010-Aralık 2013 tarihleri arasında yapılan VDE sürveyans kayıtlarından faydalanılarak VRE ile kolonize ve/veya enfekte olmuş hastalar belirlenmiştir. VDE ile kolonize hastalarda VRE enfeksiyonu gelişimi ile ilişkili risk faktörlerini belirlemek amacıyla retrospektif olgu-kontrol çalışması yapılmıştır. Bulgular: Çalışma süresince yatırılan 229 hastanın 72’sinde (%31,4) rektal VRE kolonizasyonu saptanmıştır. VRE kolonize hastaların yedisinde (%9,7) kolonizasyon sonrası sistemik VRE enfeksiyonu gelişmiştir. Beş hastada bakteriyemi (n=5), bir hastada idrar yolu enfeksiyonu (n=1) ve bir hastada menenjit (n=1) gözlenmiştir. Tüm enfeksiyonlarda ilgili klinik örneklerde Enterococcus faecium üretilmiştir. Multivaryant analiz sonucunda, ciddi nötropeni ve başka bir patojene bağlı bakteriyemi öyküsü VDE kolonize hastalarda VDE enfeksiyonu gelişimi için risk faktörleri olarak bulunmuştur [odds ratio (OR): 35,4; güven aralığı (GA): 1,7-72,3; p=0,02 ve OR: 20,6; GA: 1,3-48,6; p=0,03; sırasıyla]. VDE enfeksiyonuna bağlı mortalite saptanmamıştır. Sonuç: Pediatrik kanser hastalarında VDE kolonizasyonunun önemli klinik sonuçları olduğu gözlenmiştir. Anahtar Sözcükler: Kolonizasyon, Enfeksiyon, Pediatrik malignite, Vankomisine dirençli enterokok Address for Correspondence/Yazışma Adresi: Serap KARAMAN, M.D., İstanbul University İstanbul Faculty of Medicine, Department of Pediatric Hematology and Oncology, İstanbul, Turkey Phone : +90 212 414 20 00 E-mail : drkaramans@yahoo.com Received/Geliş tarihi: November 04, 2015 Accepted/Kabul tarihi: February 29, 2016 244
Turk J Hematol 2016;33:244-247 Aktürk H, et al: Vancomycin-Resistant Enterococci Infections in Pediatric Malignancies Introduction Children with cancer are at high risk of developing systemic infections by the microorganisms that colonize their own intestinal system [1,2]. Vancomycin-resistant enterococci (VRE) are health care-associated opportunistic pathogens. Limited data exist on the incidence of subsequent VRE infection development among VRE-colonized pediatric cancer patients and associated risk factors, which were investigated in this study. Materials and Methods All patients admitted to the pediatric hematology/oncology ward were sampled within 48-72 h after admission and weekly thereafter as part of institutional rectal VRE surveillance. An infection control nurse assigned by the Hospital Infection Control Committee (HICC) prospectively tracked the results of rectal surveillance and all health care-associated infections occurring in the hematology/oncology ward. VRE-colonized and VRE-infected patients were identified from the HICC surveillance database retrospectively. Detailed clinical and laboratory features of these patients were collected from their medical records. The overall rate of VRE colonization and the subsequent infection occurrence throughout the study period were determined. To identify the risk factors associated with VRE infection occurrence in a colonized patient, a retrospective case-control study was performed. Patients were defined as VREcolonized (VRE-C) when the culture of the rectal swab yielded VRE in the absence of any clinical specimens positive for VRE [3]. Systemic VRE infection (VRE-I) was defined as isolation of VRE from a clinical specimen together with signs and symptoms of infection. Statistical analysis was performed with SPSS 21.0 for Windows. Parameters were compared between groups with the chi-square test, Fisher exact test, or Mann-Whitney U test. Variables with a p-value of ≤0.1 in univariate analysis were fitted to perform logistic regression analysis to identify independent risk factors associated with VRE infection occurrence. Results A total of 229 children were admitted to the hematology/ oncology ward. Fecal VRE-C was documented in 72 of these patients (31.4%). Excluding eight patients who were transferred from the pediatric intensive care unit, 89% of the patients were colonized during their stay in the hematology/oncology ward. Species determination could be performed in 32 VRE-colonized patients: Enterococcus faecium was isolated in 28 patients, Enterococcus gallinarum in 2 patients, and nontypeable Enterococcus in 2 patients. VRE-I was detected in 7 patients, all of whom were previously colonized with VRE. The overall rate of VRE-I developing in patients with VRE-C was 9.7%. VRE bacteremia was detected in five patients (6.9%). Other VRE infections were urinary Table 1. Demographic and clinical characteristics of vancomycin-resistant enterococci-colonized patients who developed systemic vancomycin-resistant enterococci infection and those who did not. VRE-Colonized Patients Who Did Not Develop VRE Infection (n=65) VRE-Colonized Patients Who Developed VRE Infection (n=7) Age, months; mean ± SD 77.7±6.1 45.2±12.9 0.16 Sex, n (%) Male Female Underlying malignancy, n (%) ALL AML Solid tumor Duration of time between admission and determination of VRE colonization, days; mean ± SD 38 (58.5) 27 (41.5) 33 (50.8) 15 (23.1) 17 (26.2) 2 (28.6) 5 (71.4) 2 (28.6) 3 (42.9) 2 (28.6) p 0.13 0.67 27.8±3.9 25.5±7.5 0.85 Severe neutropenia (
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