ORIGINAL

Niger J Paed 2015; 42 (2): 93 –97

Onubogu UC

Anochie IC

Akani NA

Prevalence of bacteraemia in febrile,

under-five children in the children’s

outpatient clinic of University of

Port Harcourt Teaching Hospital,

Port Harcourt, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v42i2.4

Accepted: 19th November 2014

Abstract: Background: Bacterae-

mia is the presence of viable bac-

teria in the circulating blood. The

most common manifestation of

bacteraemia is fever. Untreated

bacteraemia can progress in 10%

of children to focal infection and

sepsis which can be fatal. Knowl-

edge of the organisms implicated

in causing bacteraemia would

help in the right choice of antibi-

otics while awaiting blood culture

results.

Objective: This study determined

the prevalence and aetiology of

bacteraemia among febrile non

neonatal, under–five children seen

in the Children’s Clinic of the

University of Port Harcourt

Teaching Hospital.

Result: A total of 362 children

(M:F 1.1:1) were studied. Bacte-

raemia was found in 32 (8.8%)

children. The prevalence rate of

bacteraemia was highest in chil-

dren aged 1-12months (12.1%)

and higher in males 13(10.2%)

compared to females 19(7.4%).

Staphylococcus aureus was the

commonest (56.3%) organism

isolated.

Conclusion: The prevalence of

bacteraemia in febrile post-

neonatal under-five children in the

Children’s Outpatient Clinic of

University of Port Harcourt Teach-

ing Hospital was 8.8% with

Staphylococcus aureus being the

commonest organism implicated.

It is recommended that antibiotics

active against Staphylococcus

aureus should be among the drugs

that need to be

Onubogu UC⁽

)

Department of Paediatrics,

Braithwaite Memorial Specialist

Hospital, Port Harcourt,

Rivers State, Nigeria.

Email: utchayonubogu@yahoo.co.uk

Anochie IC, Akani NA

Department of Paediatrics

University of Port Harcourt Teaching

Hospital, Port Harcourt.

Method: Febrile Children, aged

2

9 days to < 60 months, who pre-

sented in the outpatient clinic and

whose parents gave consent were

recruited from September 2010 to

January 2011. Information on

their weight, bio-data, and blood

culture results were collected and

analysed.

commenced in this group of chil-

dren while blood culture result is

being awaited.

Key words: Fever, blood culture,

bacteremia, under-five children,

Introduction

if untreated it can progress to focal infection in 10% of

1,9

children and to sepsis, which can be fatal . Ispahani

1

0

Bacteraemia is the presence of viable bacteria in the

circulating blood . Bacteraemia can present with fever

et al , found mortality directly related to bacteraemia to

1

11

be 19.5 %. Berkley et al reported a threefold increase

as the only symptom, it can also present with focal in-

fections (such as meningitis, osteomyelitis, endocarditis,

epiglottitis, cellulitis, pneumonia, septic arthritis, etc) or

in mortality among children with severe malaria and

bacteraemia compared with those without coexisting

bacteraemia(33.3% vs 10.4%). An early diagnosis of

bacteraemia in a febrile child is crucial in reducing

childhood mortality. Knowledge of the organisms impli-

cated in causing bacteraemia would also help in the right

choice of antibiotic while awaiting blood culture results.

This will help in effective management of febrile chil-

dren and decrease childhood morbidity and mortality.

2

,3

as a systemic infection causing sepsis . The most com-

2,4

mon manifestation of bacteraemia is fever . Fever is

also one of the most common presenting symptoms in

the emergency room, accounting for 20% of paediatric

emergency room visits as reported by Nelson et al in

5

Boston . In the United States of America, bacteremia

6

,7

occurred in <2% of febrile children . In Nigeria, bacte-

raemia was found in 38.2% of febrile infants in

8

Ibadan. Bacteraemia is of clinical significance because

9

4

1

4,15

Objectives

catalase) . Bacteraemia was considered positive if

blood culture yielded growth of any organism within

seven days incubation period, except all isolates of

likely contaminants (coagulase n₆e_.₁g₇ative Staphylococ-

The aim of this study was to determine the prevalence

and aetiology of bacteraemia among febrile post-

neonatal, under–five children seen in the Children’s

Clinic of the University of Port Harcourt Teaching Hos-

pital (UPTH). The specific objectives were to determine

the percentage of febrile children aged 29 days to < 60

months with bacteraemia and identify the organisms

implicated in bacteraemia.

1

cus, epidermidis, and Bacillus sp) . It was considered

negative if no growth was detected during the 7-day

incubation period. Data was collected and analysed us-

ing Epi info version 3.5.1. Statistical analysis was also

done using chi-square test and Fisher’s exact test for

variables that are ≤ five. Statistical significance of 95%

confidence interval was set at p < 0.05.

Ethics

Ethical clearance for the study was obtained from the

Ethics Committee of the UPTH. A signed or thumb

printed written informed consent was obtained from

parents/guardians of each child, after adequate explana-

tion.

Result

A total of 438 children aged 29days to <60 months pre-

sented to children outpatient clinic with fever over the

3

months period. Seventy four (16.9%) children who had

taken antibiotics within three days of presenting in the

clinic and two children whose parents did not give con-

sent were excluded while 362 febrile children were re-

cruited for the study.

Method

This was a prospective study done in the Children’s Out

There were 186 (51.4%) males and 176 (48.6%) females

(M:F ratio, 1.1: 1), the age range was 1 to <60 months

(mean 21± 16 months, mode 24 months). Bacteria was

cultured from blood samples of 32(8.8%) febrile chil-

dren. The prevalence of bacteraemia was highest in chil-

dren between the ages of 1-12months (12.1%) and de-

creased with increasing age, although, the difference

was not statistically significant (Table 1).

-patient Clinic of UPTH from September 2010 to Janu-

ary 2011. UPTH is a tertiary health institution located in

Port Harcourt, a cosmopolitian city in the southern part

of Nigeria. It serves as a referral centre for patients

within a₂nd outside its locality. The sample size was cal-

1

13

culated using a bacteremia prevalence rate of 38.2% .

Children aged 29 days to <60 months, with axillary tem-

perature ≥37.5°C and those whose parents or guardian

gave informed-consent were consecutively recruited till

the calculated sample size of 362 was reached. Those

that had taken antibiotics within three days of presenting

to the clinic were excluded. Their parents or guardians

were interviewed and blood culture was done for all the

patients under sterile condition. The blood culture bot-

tles were in pairs, each containing thioglycollate for

anaerobic organisms and tryptone soy broth for aerobic

organisms, respectively. 2mls of venous blood was in-

jected into each of the two blood culture bottles and kept

Table 1: Prevalence of bacteraemia according to age groups

Age-groups Positive--blood Negative--blood Total No

(Months)

Culture No (%) Culture No (%)

(%)

1

-12

17(12.1)

11(9.6)

3(5.3)

0(0)

1(3.1)

32(8.8)

123(87.9)

104(90.4)

54(94.7)

18(100)

31(96.9)

330(91.2)

140(100)

115(100)

57(100)

18(100)

32(100)

362(100)

>12-24

>24-36

>36-48

>48-<60

Total

2

0

(

χ = 5.9,df = 4,p = 0.205)

in an incubator (Triup inter Corp U.K) set at 37 C. By

2

4 hours after incubation the bottles were examined for

The commonest organism isolated from the blood

cultures was Staphylococcus aureus in 18(56.3%)

children while Proteus mirabilis and Streptococcus spp

were isolated in 1(3.1%) child each (Fig.1).

signs of bacterial growth which₄_,₁i₅nclude turbidity, hae-

1

molysis, gas bubbles and clots . A sterile wire loop

was used to get some broth from the blood culture bot-

tles. The broth was then inoculated on Chocolate agar

(

5% heated human blood) and MacConkey plates by

Fig 1: Organisms isolated from blood culture

streaking the plates horizontally in one direction (i.e.

subculture). Many single horizontal streaks were made

to cover the plates. Each time the loop was used to in-

oculate plates it was sterilised by heating over a Bunsen

burner till it was red hot and was then allowed to cool

before repeating the inoculation of the plate. The choco-

2

late agar plate was incubated in a CO enriched environ-

ment (candle light in extinction). Both chocolate and

0

MacConkey plates were incubated at 37 C and exam-

ined the following day for presence of colonies. All

bottles were subcultured daily up to seven days. The

Colonies on the plates were identified by morphology,

gram stain and biochemical tests (coagulase, oxidase,

9

5

2

4

The prevalence rate of bacteraemia was higher in males

3(10.2%) compared to females 19(7.4%). However, the

ing incidence₇ of bacteraemia , the methodology used by

Alpern et al excluded children with chronic disease,

those with focal infection and all children that required

admission within 24 hours of presenting to the hospital.

As a₂r₅e_,₂s₆ult, children that were at higher risk of bacterae-

1

observed gender difference among children with bacte-

raemia was not statistically significant (p=0.343). All

the isolates were more in males than females except

Pseudomonas aerugenosa which was more in females

than in males. There was however no statistically

significant difference in the organism pattern according

to gender (p>0.05), Table 2.

mia

were excluded from the study, possibly ac-

counting for the lower prevalence rate in their study.

The present study did not exclude children based on the

severity of their illness.

Table 2: Organisms Isolated according to gender

The higher prevalence of bacteraemia found among in-

fants (12₂₁.₂1₇%_,₂₈) in the present₂₈study. compares to previous

Organisms isolated

Gender

Total

Pvalues

Female (%)

Male(%)

11(57.9)

studies

. Enwere et al in Gambia reported a high

Staphylococcus

aureus

Pseudomonas

aerugenosa

8(42.1)

3(60)

19(100)

5(100)

0.55

0.47

incidence of invasive bacterial disease which was high-

est in the first one year of life and thereafter decreased

with increasing age in both children vaccinated with

pneumococcal₂v₇accine and unvaccinated children. Simi-

larly, Berkley in Kenya reported a minimal annual

incidence of community acquired bacteraemia of 1457

cases per100₁,000 children among infants. Also, Mere-

2(40)

Escherichia coli

1(33.3)

0(0)

2(66.7)

1(100)

19(59.4)

3(100)

1(100)

1 (100)

32(100)

0.52

0.51

Klebsiella

Proteus spp

Streptococcus spp

Total

0(0)

2

mikwu et al in Calabar found the prevalence rate of

13(40.6)

bacteraemia among children hospitalized with features

of sepsis to be 49.1% among neonates and 20.5%

among those aged 2 to 5 years and 2.9% among those

aged 11 to 15 years. Young ag₉e_,₃₀has been documented as

2

Discussion

a risk factor for bacteraemia . The reason for higher

prevalence of bacteraemia in younger children which we

found in our study could be due to the immaturity of the

immune system which caus₁e_,₃s₂poor humoral a₃n₃d cell

The prevalence of bacteraemia among febrile, non-

neonatal under-five children was 8.8%. This is similar to

the₈8.2% prevalence rate reported by Rattanaphone et

3

mediated immune response . Lee and Harper how-

1

al in Vietnam and comparable to 7.8% reported by

ever, found a lower risk of occult pneumococcal bacte-

raemia in children aged 3 to 6 months when compared to

older children aged 6 to 36 months, they attributed the

low rate of nasal colonization by streptococcus pneumo-

nia in the younger age group less than 6 months of age

as a possible explanation for their findings.

1

Berkley et al in Kenya. While both studies were done

in developing countries with similar demographic data₁₈,

the prevalence of 8.2% found by Rattanaphone et al

was among hospitalized infants. The present study had a

predominantly infant population 140(38.7%), which

could also account for the similarity₁in prevalence rates

1

between the studies. Berkley et al had a prevalence

All the organisms isolated in this study have been impli-

cated as causes of bacterial infection in children

rate of 7.8% and though the age distribution of their

study population was not stated, they had a mean age

of 31 months which is within the age range of the pre-

sent study. Besides the age of their study population,

both studies were done in malaria endemic areas, and

that can account for the similarity seen in the prevalence

rate in both studies. Malaria may predispose to bacterae-

mia because plasmodium falciparum impairs

7

,11,18,22,23

. This study showed a preponderance of gram

positive organisms (59%) compared to gram negative

7

,11,18,21,24

.

organisms as reported in previous studies

Staphylococcus aureus was the commonest organism

isolated in the present study, confirming the increasing

role of this pathogen in child₁h₁o_,₁o₂_,d₁₈_,b₂₁a_,₂c₄terial infection as

documented by other studies

. The presence of

T-lymphocyte proliferative responses and causes a

poor personal hygiene, overcrowding and recurrent skin

abrasions could explain the high frequency of staphylo-

coccal infection found in our study, as they have been

documented as some₃o₄_,f₃₅the risk factors for staphylococ-

cus aureus infection . While the earlier two factors

could be due to the poor socioeconomic demography in

Nigeria, the latter factor could be due could be caused

by frequent mosquito bites (which is common in the

area) that bridge the skin epithelium, increasing staphy-

lococcal infection, which is a skin commensal. Other

organisms isolated in this study were Pseudomonas

1

9,20

.

reduction in the number of circulating T-cells

Higher prevalence rates of bacteraemia were r₁eported in

2

other Nigerian studies by Meremikwu et al (48.9%),

l8

22

Ayoo₃la et al (38%), Onipede et al (27%) and Prada

2

et al (16%). While these studies were done among hos-

pitalized children, the present study was done in an out-

patient clinic where the severity of illness of most of the

patients was less, which might explain the lower preva-

lence of bacteraemia in our study.

(

15.6%), Escherichia coli (12.5%), and Klebsiella spp

A lower prevalence rate of 1.9% was found by Alpern et

al in Philadelphia USA. Besides the fact that the study

was done in a developed economy with better sanitation

and health facilities which would contribute to decreas-

(9₈.4%). This was similar to₁r₈esults found by Ayoola et

al and Rottanaphone et al among febrile Nigerian

children and hospitalized Vietnamese children respec-

tively, where the common organisms were

7

9

6

Staphylococcus aureus, Escherichia coli and Klebsiella

spp

6.1% and 6.4% compared to 5.5% and 6.3% in females,

respectively. The cause of the gender disparity in favour

of the males could be due to over representation of

males in the general study population. The gender dis-

parity could also be attributed to the presence of andro-

gen hormones in males, which has been found to have

an immunosuppressive₄e₀_,f₄f₁e_,₄c₂t on humoral and cell medi-

Although, Pseudomonas aerugenosa has been found to

1

1,21,24

,

cause bacterae₄mia in previous studies in Nigeria

2

18

South Africa and Vietnam , it has contributed to less

than 6% of the causative organisms in these studies.

The reason for the relatively high prevalence of pseudo-

monas isola₁t₁e_,d₁₈_,i₂n₁_,₂t₄his study (15.6%) compared to previ-

ated immune response

. This effect of androgens

has been postulated to predispose males to higher risk of

infection than their female counterparts, although this

effect has been documented in adults and there are lim-

ous studies

could not be readily explained, as

none of the children from which it was isolated from had

any known underlying illness and none was severely

malnourished. These factors would have decreased their

host immunity a₆nd predisposed the children to pseudo-

4

3

ited studies done in children. Isaacman et al , however

found females to be at increased risk for bacteraemia

compared to males in a retrospective review of febrile

children aged 3-36 mo₃nths in an emergency room in

3

monasinfection .

4

Virginia,. The authors acknowledged that the reason

The presence of Streptococcus spp as a causative organ-

ism of bacteraemia in our study is similar to₈_,₂f₁i_,₂n₂d_,₂i₈ngs in

for the higher of risk bacteraemia among females could

not be explained.

1

8

11

24

Asia , Kenya , South Africa , Nigeria

, and

during pre- pneumococcal conjugate vaccine (PCV) era

3

7

in the USA . This is because these studies were done

where PCV vaccine was not administered routinely. The

absence of Salmonella spp among the isolated organ-₈

isms is similar to other Nigerian studies by Ayoola et al

Conclusion

In conclusion, the prevalence of bacteraemia in febrile

post-neonatal under-five children in the Children’s

Outpatient Clinic of University of Port Harcourt Teach-

ing Hospital is 8.8%. Staphylococcus aureus is the

commonest organism implicated. We recommend there-

fore, that antibiotics active against Staphylococcus

aureus should be among the drugs that need to be com-

menced in febrile under-five children at risk for bacte-

raemia while blood culture result is being awaited.

3

8

and₁_,₂J₄ohnson et al , and differs from other African studi-

1

es

where Salmonella spp has been reported to con-

tribute significantly to bacteraemia. The fact that salmo-

nella inf₉ection is more prevalent in children aged 5 to

3

1

1years could account for lack of salmonella isolate in

the present study which involved only children under 5

years old.

A higher male prevalence for bacteraemia was found in

our study.₂T₄ his observation is similar to the finding₂s₇ by

Berkowitz in South Africa and Berkley et al in

Kenya who reported a higher prevalence in males of

Conflict of Interest: None

Funding: None

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