Bacterial pathogens and resistance causing community acquired paediatric bloodstream infections in low- and middle-income countries: a systematic review and meta-analysis

Abstract

<jats:title>Abstract</jats:title><jats:sec> <jats:title>Background</jats:title> <jats:p>Despite a high mortality rate in childhood, there is limited evidence on the causes and outcomes of paediatric bloodstream infections from low- and middle-income countries (LMICs). We conducted a systematic review and meta-analysis to characterize the bacterial causes of paediatric bloodstream infections in LMICs and their resistance profile.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>We searched Pubmed and Embase databases between January 1st 1990 and October 30th 2019, combining MeSH and free-text terms for “sepsis” and “low-middle-income countries” in children. Two reviewers screened articles and performed data extraction to identify studies investigating children (1 month-18 years), with at least one blood culture. The main outcomes of interests were the rate of positive blood cultures, the distribution of bacterial pathogens, the resistance patterns and the case-fatality rate. The proportions obtained from each study were pooled using the Freeman-Tukey double arcsine transformation, and a random-effect meta-analysis model was used.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>We identified 2403 eligible studies, 17 were included in the final review including 52,915 children (11 in Africa and 6 in Asia). The overall percentage of positive blood culture was 19.1% [95% CI: 12.0–27.5%]; 15.5% [8.4–24.4%] in Africa and 28.0% [13.2–45.8%] in Asia. A total of 4836 bacterial isolates were included in the studies; 2974 were Gram-negative (63.9% [52.2–74.9]) and 1858 were Gram-positive (35.8% [24.9–47.5]). In Asia, <jats:italic>Salmonella</jats:italic> typhi (26.2%) was the most commonly isolated pathogen, followed by <jats:italic>Staphylococcus aureus</jats:italic> (7.7%) whereas in Africa, <jats:italic>S. aureus</jats:italic> (17.8%) and <jats:italic>Streptococcus pneumoniae</jats:italic> (16.8%) were predominant followed by <jats:italic>Escherichia coli</jats:italic> (10.7%). <jats:italic>S. aureus</jats:italic> was more likely resistant to methicillin in Africa (29.5% vs. 7.9%), whereas <jats:italic>E. coli</jats:italic> was more frequently resistant to third-generation cephalosporins (31.2% vs. 21.2%), amikacin (29.6% vs. 0%) and ciprofloxacin (36.7% vs. 0%) in Asia. The overall estimate for case-fatality rate among 8 studies was 12.7% [6.6–20.2%]. Underlying conditions, such as malnutrition or HIV infection were assessed as a factor associated with bacteraemia in 4 studies each.</jats:p> </jats:sec><jats:sec> <jats:title>Conclusions</jats:title> <jats:p>We observed a marked variation in pathogen distribution and their resistance profiles between Asia and Africa. Very limited data is available on underlying risk factors for bacteraemia, patterns of treatment of multidrug-resistant infections and predictors of adverse outcomes.</jats:p> </jats:sec>