Nosocomial and community acquired infections in malnourished Jamaican children - abstract

ABSTRACT

Infection is a contributing or initiating factor in children with inadequate food intake who develop malnutrition, and malnutrition by virtue of immunosuppression leads to further episodes of infection. In this prospective study, 206 community acquired and 73 nosocomial infections occurring in 50 hospitalised severely malnourished children were investigated. This represented an average of 5.6 episodes of infection per child. Predominant community acquired infections in the 50 children included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent), and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen and Klebsiella sp. were recovered from the majority of urines. Coagulase Negative Staphylococcus was the most frequent aetiological agent of bacteraemia, 12 of the 13 episodes were associated with fever +/- leucocytosis and in six episodes this organism was recovered from two or more blood culture sets. The lack of clinical signs and symptoms, and the atypical presentation in some of the infected malnourished children were attributed to impairment of the acute inflammatory response. Nasal, throat and axillary swabs taken on admission revealed significant colonisation with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Two of the four deaths were attributed to infection. The role of Cryptosporidium, an enteric pathogen which is prevalent in immunocompromised hosts, was further investigated. Cryptosporidium was isolated from the stools of 19.5 percent (15/77) malnourished children compared to 2.4 percent (10/436) well-nourished children, who were more likely to present with fever, vomiting, prolonged diarrhoea and dehydration. Community acquired non-bacterial respiratory tract infections were further investigated from paired sera in 83 moderately malnourished children. In 60 percent of the children with a history of respiratory tract disease and 25 percent of those without reported disease, a specific non-bacterial infection was diagnosed. Multiple aetiological agents were identified in 6 of the 42 chidren with respiratory disease. The most common micro-organisms observed were Para-influenza 1,2 or 3 (in 15 children), Influenza H1N1, H2N3 or "B" in 12, Adenovirus in 10, Respiratory Syncitial Virus in 7 and Mycoplasma Pneumoniae in 6 children. These three studies report a high prevalence of common and unusual infections, especially Cryptosporidium enteritis and Coagulase Negative Staphylococcus bacteraemia, occurring in these immunocompromised children. Diagnosis of infection requires a high index of suspicion and a comprehensive screening system (AU)