Tuğba Erat

Underlying Diseases and Causative Microorganisms of Recurrent Pneumonia in Children: A 13-Year Study in a University Hospital

Abstract Pneumonia is a significant cause of death for children, particularly those in developing countries. The records of children who were hospitalized because of pneumonia between January 2003 and December 2015 were retrospectively reviewed, and patients who met the recurrent pneumonia criteria were included in this study. During this 13-year period, 1395 patients were hospitalized with pneumonia; of these, 129 (9.2%) met the criteria for recurrent pneumonia. Underlying diseases were detected in 95 (73.6%) patients, with aspiration syndrome (21.7%) being the most common. Rhinovirus (30.5%), adenovirus (17.2%) and respiratory syncytial virus (13.9%) were the most frequent infectious agents. These results demonstrate that underlying diseases can cause recurrent pneumonia in children. Viruses are also commonly seen in recurrent pneumonia. Appropriate treatments should be chosen based on an analysis of the underlying disease, the patient’s clinical condition and the laboratory and radiological data.

P266 An outbreak of stenotrophomonas maltophilia pseudobacteremia in a paediatric hospital associated with contaminated citrated tube

In this report, we describe pseudobacteremia of Stenotrophomonas maltophilia in a paediatric hospital. S. maltophilia was isolated from blood cultures of 14 patients with in 2 months. Most of the patients with positive blood culture were given treatment because of underlying diseases, but pseudobacteremia was suspected since majority of these patients have no clinical and laboratory findings of sepsis and consecutive blood cultures were negative. The collected environmental samples were negative. Upon these isolations continued, it was considered that contamination might occur from the citrated coagulation, hemogram or biochemical tubes. Then S. maltophilia with same antibiogram was isolated from the citrated coagulation tubes. Nine of the patients received levofloxacin for average 7 days due to underlying disease. Medical staff were re-educated about blood culture drawing procedure. After the education no further isolates of S. maltophilia have been encountered to date.

P271 Underlying disease and causative microorganisms of recurrent pneumonia in children: 13-year study in a university hospital

Background and aims Pneumonia is the most important cause of death in children in many countries. The use of inappropriate antibiotics in the treatment of pneumonia is associated with multi drug resistant microorganisms that lead to increased morbidity and mortality. Therefore, the causative microorganism should be detected for avoidence of unnecessary antibiotic usage. Underlying diseases are predisposing factors for recurrent pneumonia. The choice of pneumonia treatment should be based on causative microorganisms and underlying diseases. In this study we aimed to evaluate the frequency of recurrent pneumonia and underlying disease in hospitalised children, to identify the distribution of causative microorganisms and to compare our data with previous studies. Methods Between January 2003 and December 2015 children hospitalised due to pneumonia were retrospectively owerviewed. The patients who met criteria for recurrent pneumonia were included in this study. Demographic, clinical, laboratory and imaging results were collacted from the data system. Results During 13 years, 129 (9.2%) hospitalised children met criteria of recurrent pneumonia. Underlying diseases were detected in 95 (73.6%) patients. Rhinovirus, adenovirus and respiratory synstial virus were the most frequent causative agents. Conclusion The majority of patients who were hospitalised due to recurrent pneumonia had an underlying disease. The most common cause was aspiration syndrome and viruses were leading causative agents for recurrent pneumonia. As a result; It should kept in mind that viruses can be commonly seen in recurrent pneumonia. Appropriate treatment choice should be made according to the underlying disease, clinical condition, laboratory and radiological data of the patient.

P270 Clinical characteristics of childhood hydatid disease: a single tertiary centre experience from turkey

Background and aims Hydatid disease is a parasitic infection and it is a major health problem in some areas. We aimed to evaluate the demographic and clinical findings of patients with hydatid disease in our hospital and to compare our results with previous studies. Methods Between January 2009 and December 2015, patients who were diagnosed as hydatid disease in our hospital, were included retrospectively in this study. Demographic characteristics, clinical findings, laboratory and imaging results, treatment modalities and complications were collected. Results Twenty-eight patients were involved in our study. Patients often admitted to hospital with chest pain, cough, fever, abdominal pain, nausea and vomiting. The median age of patients’ was 134 (55-197) months. Twenty (71.4%) patients were male. The most common physical finding was decreased breath sounds. Most frequently affected organs were liver (71.4%) and lungs (57.1%). In addition cysts were detected atypical locations such as heart (n=2), brain (n=2), spleen (n=2), pancreas (n=1), kidney (n=1) and pelvis (n=1). Medical treatment was given in all patients with hydatid disease. Treatment modalities were as follows: 60.7% (17/28) surgical treatment, 14.3% (4/28) interventional radiologic drainage, 21.4% (6/28) only medical treatment and 3.6% (1/28) interventional radiology drainage and surgery treatment together. Post operative complications were bile leakage, cholangitis, pneumothorax and fistula. No mortality occurred, but recurrence was seen in 1 (3.6%) patient. Conclusions Hydatid disease is an important problem in our country. In patients with hydatid disease, there might be multiple organ involvement at the same time. Therefore, advanced imaging methods such as abdominal ultrasonography, echocardiography, and brain magnetic resonance should be used for the detection of localised atypical cysts for all patients. Clinical findings and location of the cysts may help deciding the choice of treatment. Long term outcomes are satisfactory with adequate treatment.

P268 Bloodstream infections in paediatric immunocompromised patients, responsible pathogens, antibiotic susceptibility patterns and treatment outcomes: experience of single centre in turkey

Background and aims Bloodstream infections are the major cause of morbidity, increased cost, prolonged hospitalisation and mortality in paediatric haematology and oncology patients. We aimed to identify causative microorganisms and their antimicrobial susceptibilities in paediatric immunocompromised patients. Methods Patients with haematological and/or oncological diseases who admitted to our hospital with fever between January 2010 and November 2015 were included in this study. Patients’ demografic and clinical findings were collected from hospital information systems and microbiology laboratory records retrospectively. Results Totally 71 paediatric patients who had 111 bloodstream infection episodes were included in this study. The median age of patients was 90 (3-247) months. The most underlying disease was acute lymphoblastic leukaemia. While 31 patients had only peripheral blood culture positivity, 80 patients had catheter related blood stream infections. Of 80.2% blood stream infections occurred in neutropenic period. Responsible pathogens were detected as follows: 35.1% gram-positive microorganisms, 60.5% gram-negative bacteria and 4.4% fungi. The most causative gram negative pathogen was Escherichia coli and the most isolated gram positive microorganism was meticillin resistant coagulase negative Staphylococci. Extended spectrum beta lactamase was produced by 60% of Klebsiella spp. and 42.1% of E. coli. In addition carbapenemase producing E. coli and Klebsiella spp. were 15.8% and 26.7% respectively. Enterococcus spp. had 88.9% ampicillin resistance and%33.3 vancomycin resistance. Bloodstream infection related mortality rate was 2.7%. Conclusion Gram negative microorganisms were predominant pathogens in bloodstream infections. Extended spectrum beta lactamase and carbapenem resistance were increasingly important and they limited treatment options. The choice of empiric antimicrobial drug in immunosuppressed patients is life-saving. For all these reasons, the choice of empirical antibiotics should be made according to the clinical condition of the patient and the prevalent microorganisms in the current clinic, as favourable antimicrobial therapy will be able to achieve positive clinical outcomes.

P269 Responsible pathogens of paediatric implantable long term catheter related blood stream infections and effectiveness of antibiotic lock therapy

Background Catheter related blood stream infections (CRBSIs) are important problem in paediatric haematology, oncology and immunology patients with central venous catheter. This study aimed to determine incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in paediatric patients. Methods Between January 2010 and November 2015 all hospitalised paediatric haematology, oncology and immunology patients who were diagnosed as CRBSIs, were retrospectively included in this study. Causative microorganisms and their antibiotic susceptibility, success rate of ALT, treatment failure, recurrence, catheter removal, complications and mortality are analysed. Results Seventy eight CRBSIs episodes were detected in 60 paediatric patients. The median age was 106.4±66.6 (86, 3–240) months. Male/female ratio was 1.9/1. The incidence of CRBSIs was 4.20/1000 catheter days. Most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Antibiotic lock therapy was administered in 42 patients. Success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. Relapse was observed in 1 (1.3%) episodes and mortality was detected in 3 (3.8%) episodes. Conclusion Catheter related blood stream infections are important cause of morbidity and mortality in paediatric patients. However, incidence may be decreased with antiseptic procedures and hand hygiene. Antibiotic lock therapy is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs except in some cases catheter removal must be necessary. Antibiotic lock therapy helps to prevent unnecessary catheter removing in paediatric immunocompromised patients.

P278 First day fever: diagnosis? hyperimmunoglobulinemia d syndrome

An 18-week-old girl, second child of non-consanguineous parents presented to our hospital due to nasal discharge, fever. On physical examination,her vital signs included a temperature of 39.2°C. Other findings were hyperemic oropharynx, right cervical 1*1 cm lymphadenopathy and macular rash with more markedly in the flexor surface of the forearm which has become prominent in the febrile period and than disappeared. A white whole blood count of 61.280/mm³(88% neutrophils, 9% lymphocytes, 2%monocyte) and ESR rate was 52 mm/h and CRP was 143.8 mg/L. Biochemical and urine analysis,.chest x-ray was normal. Medical history of the patient revealed that she had been admitted to neonatal service in an out centre upon fever developed at the postnatal 20th hour. Her physical examination was normal. White blood cell count of 23.160/mm³ and a CRP level of 31.6 mg/L. Patient who had normal chest x-ray and urinalysis had been put on iv vancomycin and meropenem. Cultures remained were negatif. Her fever had dropped at the 4th day and leukocytosis had regressed in the non-febrile period (14060/mm³). Patient whose fever had raised again to 39°C at the 8th day had a normal physical examination and developed leukocytosis (22.390/mm³), CRP (306 mg/L) Because the patient whose fever lasted 3 days had become febrile again at the 15th day of life, Cerebrospinal fluid was normal,ciprofloxacin iv had been added to the treatment and her fever had dropped after 3 days. The patient’s discharged was planned at the 22nd day. Following non-febrile period of 40 days, patient had fever after vaccination when she was 60-day-old which had been attributed to vaccination since she had no any other symptom. In follow-up performed at the 75, 90, 106 and 120th days, patient had no any symptom except fevers lasting 3 day. The patient presented to our hospital when she was 130-day-old. Her family stated that, these rashes occurred during the last fever episodes and they attributed them to fever and in addition they reported that her vomiting was increasing in febrile periods. Upon fever episodes seen once in 15 days lasting 3 days accompanied by rash, vomiting, lymphadenopathy, elevated acute phase reactants and increased urinary mevalonic acid excretion, genetic analysis was ordered. Patient’s MVK gene analysis I268T was found heterozygote and her diagnosis is hyperimmunoglobulinemia D syndrome.

P263 Nosocomial pneumonia caused by legionella pneumophila in a paediatric hematopoietic stem cell transplantation recipient for thalassemia major

A nosocomial pneumonia caused by Legionella pneumophilaserogroup 2oc–14oc curred in a 7-year-old patient following allogeneic hematopoietic stem cell transplantation for thalassemia major. The patient was diagnosed as nosocomial Legionella pneumonia by a polymerase chain reaction (PCR) from bronchoalveolar lavage and a culture of L. pneumophilaserogroup 2–14 from patient’s room faucet water. Legionella was eradicated from our hospital’s water distribution system by superheating and chemical eradication methods (hyper-chlorination and hydrogen peroxide). We did not detect any case after this event. Early recognition of contamination of hospital water system with Leigonella proves the importance of prevention new cases.

P272 The importance of directly observed therapy in perinatal tuberculosis

9.5 month-old boy presented with a one-month history of cough and lymphadenopathy. The mother was diagnosed with pulmonary tuberculosis when the baby was 1,5 months old. Thus, the breastfeeding was stopped and isoniazid prophylactic therapy was recommended to baby. However, the treatment was only applied between 6–9 months old by the family. He was evaluated for pneumonia at first and nonspecific antibiotic therapies were started. After ten-day treatment, the symptoms didn’t get better. He was again evaluated and three serial samples of gastric aspirates that sent for ARB and Tbc PCRes were positive. Chest CT revealed that concerning the whole middle and lower lobes in the right lung at the widespread consolidation area, necrotic areas where the largest reached over 23 × 13 mm was monitored. He was administered a four-drug anti-tuberculous treatment of INH (11.5 mg/kg), rifampicin (15 mg/kg), pyrazinamide (25 mg/kg), etambuthol (18.75 mg/kg). At the first month of treatment all acid fast stains and PCR were negative. Even though ChestCT were the same, findings showed remarkable improvement After 2 months the child was discharged to his home with two-drug- maintence therapy. As well as early diagnosis and treatment, directly observed therapy is crucial in tuberculosis.

P274 An unexpected disease in an infant with pancytopenia and pulmonary abscess: glycogen storage disease type 1b

2.5-month-old boy had presented to another hospital with the complaints of wheezing and groaning. Thoracic CT of the patient revealed a heterogeneous, irregular lesions measured as 53 × 40 mm in size at the right hilar region. In addition; anaemia and neutropenia was detected. The patient had been referred to our hospital. Parents of the patient had cross-cousin marriage. In his physical examination; respiratory sounds were decreased in the middle and lower right lung, hepatomegaly (8 cm) and splenomegaly (8 cm) were detected. The whole blood count revealed a haemoglobin level of 6.1 g/dL, a white blood count of 8800/mm³ (total neutrophil count: 540/mm³), and a platelet count of 171.000/mm³. Blood glucose was 88 mg/dL, aspartate aminotransferase (AST) was mildly elevated (59 IU/mL). CT showed irregular soft tissue mass containing hypodense necrotic areas. Necrotizing pneumonia with abscess development was thought. Staphylococcus aureus was isolated in bronchoalveolar lavage collected with bronchoscopy. At the 4th day of treatment, pancytopenia was increased. Neutrophil functions, lymphocyte count and activity were normal and no chronic granulomatous disease gene and HAX-1 gene mutation was detected. Since neutropenia continued, GCSF was initiated. Hypertriglyceridemia (661 mg/dL) was found in lipid panel which was examined because of glycogen storage disease suspected due to parental consanguinity, neonatal hypoglycemia, hepatosplenomegaly and the apperance of the patient phenotypically as a doll face. Lactic acid level was found to be high (37 mg/dL), and uric acid value was at the upper limit (7 mg/dL). Compensated metabolic acidosis was observed in the blood gas. Hypoglycemia (32 mg/dL) was detected towards morning in the patient whom blood glucose was monitored. Homozygote c.1042_1043 delCT mutation was detected in the SLC37A4 gene of the patient which was considered to GSD 1b. When presenting our case, we aimed to make a contribution to early diagnosis and treatment by emphasising that GSD 1b disease should be considered in differential diagnosis even there is no symptomatic hypoglycemia in patients and particularly in often-fed infants presented with severe infection picture accompanied by hepatosplenomegaly and neutropenia and/or pancytopenia.