bacterial and viral infections associated with thalassemia...
TRANSCRIPT
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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009
Bacterial and Viral Infections associated with
Thalassemia Patients in Hillah City
Abstract :-
This study was performed from March to July 2008. A total of
100 blood samples obtained from patients with febrile in different age
who presented to the Babylon Maternity and Children Hospital
(Thalassemia Wards) and Al-Hillah Teaching Hospital with
temperature >38°C were evaluated by residents and pediatric
emergency medicine attending.Bacterial infections represented by
Staphylococcus aureus (43 patients), Streptococcus pneumoniae (33
patients), Escherichia coli (31 patients), Salmonella typhi (28
patients), Bacillus spp. (25 patients), Haemophilus influenzae (20
patients), Klebsiella pneumoniae (13 patients) and Pseudomonas
aeruginosa (11 patients), while the viral infections with Hepatitis
were; Hepatitis C (26 patients) and Hepatitis B (25 patients).
Sex distribution founded to be not significant and distribution
according to residence were revealed higher in rural area than in
Urban. Our investigation showed that from the 100 febrile patients
with bacteremia and thalassemia, 91 had CRP >24 mg/L, 94 had
ESR >35 mm/hour, and 89 had WBC >15 000/mL.
Staphylococcus aureus shows sensitivity for Amikacin,
Nitrofurantoin, Norfloxacin and Ofloxacin, while Streptococcus
pneumoniae sensitive to Amikacin, Amoxicillin, Cefodizime,
Chloromphenicol, Clarithromycin, Gentamycin, Kanamycin,
Lincomycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin,
Oxytetracyclin, Penicillin and Rifampin, Bacillus spp. Reveals
Ali H. Al-Marzoqi
*
*Ammal R. Shemmran *Zeana Sh. Al-Hindi
Mohammad K. Al-Nafee'
Babylon Hospital of Maternity
Zahraa M. Al-Taee
Babylon University\College of
Science
Babylon University\College of Science for women*
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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009
sensitivity with Amikacin, Chloromphenicol, Gentamycin,
Kanamycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Piperacillin,
Tetracycline, Tobramycin and Vancomycin. While Haemophilus
influenzae showed sensitivity to Ceftizoxime ، Ofloxacin ،
Tetracycline.
E. coli isolates shows sensitivity with Amikacin, Chloromphenicol,
Nitrofurantoin, Ofloxacin, Norfloxacin, while Pseudomonas
aeruginosa shows sensitivity with Norfloxacin, Ofloxacin,
Piperacillin, Tobramycin, Proteus species shows sensitivity with
Amikacin, Amoxicillin , Cefodizime, Cefoxitin, Cephalexin,
Gentamycin, , Norfloxacin, Piperacillin, Tobramycin and Klebsiella
pneumoniae isolates shows sensitivity with Amikacin, Norfloxacin,
Piperacillin, Tobramycin.
Introduction :-
Thalassemia is one of the major health concerns in World. The rate of
carriage of β- thalassemia is >1.1% [14, 18]. With receipt of regular
blood transfusions and iron-chelating therapy, the prognosis of the
disease improves [6]. Unfortunately, the prevalence of severe
complications due to iron overload is still high. Excluding heart
failure, infection is the predominant cause of death; it is directly
responsible for 12%–46% of patient deaths [4, 12]. Early recognition
with prompt treatment and prevention of predisposing factors are
essential in the treatment of patients with thalassemia and infection.
With the implementation of different means of treatment, including
blood transfusion, administration of deferoxamine, and hematopoietic
and cord blood stem cell transplantation [17], the probability of 20-
year-survival for patients with thalassemia major in Hong Kong has
reached 90% [6], a figure comparable to the rate in such Western
countries as Italy. Despite all of these treatment successes, infection
has remained an important cause of death [16]. This study aimed to
revealed the causative agent causing bacteremia comparing with the
non thalassemic patients and using physiological parameters to detect
the infection like C-reactive protein, total WBCs, ESR and
antimicrobial sensitivity.
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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009
Material and Methods :-
This study was performed from March to July 2008. hundred blood
sample obtained from patients with febrile (50 patients as Control
without Thalassemia and 50 patients with Thalassemia) in different
age who presented to the Babylon Maternity and Children Hospital
(Thalassemia Wards) and Al-Hillah Teaching Hospital with
temperature >38°C were evaluated by residents and pediatric
emergency medicine attending. Those patients, after careful history
and physical examination, had clinically undetectable source for the
fever were enrolled in the study.Demographic information, like age
and sex, temperature, duration of fever, Total WBC, erythrocyte
sedimentation rate (ESR) and semi-quantitative CRP concentration
were obtained. All patients received a blood culture.
C-reactive protein test done by using latex kit from HUMATEX CRP
(Germany) for qualitative and semi-quantitative determination.
Hepatitis type B and C were diagnosis with Chromatography Kit
from AKON and ELISA kit From BioKit (Spain). In this study we
used 20 different antibiotics to estimate the sensitivity of febrile
causative agents, using disk diffusion agar using Muller Hinton agar.
For hemocytometer WBC counts, blood specimens were examined
microscopically on a Neubauer chamber (Neubauer hemocytometer)
by the same technician.Bacterial isolates were identified to the level
of species using cultural characteristics and conversional biochemical
test [3 and 19].
Results and Discussion :-
There are two type of infections recorded in this research, bacterial
and viral. Bacterial infections represented by Staphylococcus aureus
(43 patients), Streptococcus pneumoniae (33 patients), Escherichia
coli (31 patients), Salmonella typhi (28 patients), Bacillus spp. (25
patients), Haemophilus influenzae (20 patients), Klebsiella
pneumoniae (13 patients) and Pseudomonas aeruginosa (11 patients),
while the viral infections with Hepatitis were; Hepatitis C (26
patients) and Hepatitis B (25 patients) (Table 1). The increased
frequency and changing etiology of bacteremia may be a result of
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varying patient population [15].This result was in accordance with
other studies, where the percentages of Gram-positive and Gram-
negative organisms isolated from bacteremic children were 68% and
29% respectively [2]. Chapman and Faix (2003) stated that Gram-
positive organisms and Gram-negative organisms accounted for
causes bacteremic infections, another study pointed out that the
etiology may even vary at different times within the same place [2,
22]. This study revealed that the infection with bacteria and virus
were higher in thalassemia group than the control (Table 1).
Hepatitis cases recorded, Hepatitis (B and C) infection may happen
through blood transfusion [23]. Iranian study found that (19.3%)
patients were Hepatitis C positive while 11 (1.5%) were Hepatitis B
positive and no one was HIV positive [21]. Australian study found
that the infection with Hepatitis C was higher the others and the
epidemic of HCV infection continues to escalate in Australia,
predominantly through transmission related to injecting drug use
[11]. Other study found that the wave of increased HCV-related
morbidity and mortality that we are now facing is the result of an
unprecedented increase in the spread of HCV during the 20th century.
Two 20th century events appear to be responsible for this increase;
the widespread availability of injectable therapies and the illicit use
of injectable drugs [1]. Hepatitis B virus (HBV) may occasionally be
transmitted through transfusion of blood units that are hepatitis B
surface antigen (HBsAg) negative but HBV DNA positive [26].
In the present study, iron overload was noted in the infection group. It
is clear that any organisms, such as Y. enterocolitica, Klebsiella
species, E. coli, Streptococcus pneumonia, P. aeruginosa and Listeria
monocytogenes, have been shown to increase in virulence in the
presence of excess iron in vitro [8, 25].
Table1: Percentage of etiological agents causes
bacteremia in febrile patients [Control group and
Thalassemia group] with mixed infections.
Causative agents Control group Thalassemia Total
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(50 patients) group
(50 patients)
No. % No. %
Bacterial Causes
Staphylococcus aureus
18
(41.9)
25
(58.1)
43
Escherichia coli 11 (35.5) 20 ( 64.5) 31
Streptococcus
pneumoniae 15 (45.5) 18 (54.5)
33
Bacillus spp. 10 (40) 15 (60) 25
Haemophilus
influenzae 7 (35) 13 (65)
20
Salmonella typhi 18 (64.3) 10 (35.7) 28
Klebsiella pneumoniae 4 (30.8) 9 (69.2) 13
Pseudomonas
aeruginosa 3 (27.3) 8 (72.7)
11
Viral Causes
Hepatitis C
7
(26.9)
19
(73.1)
26
Hepatitis B 2 (8) 23 (92) 25
Sex distribution in this study (Table 2) founded to be not significant
and this result nearly agreed with Chung [25] and Shih [24].
Distribution according to residence were revealed higher in rural area
than in Urban, Difference between rural and urban patients related to
the bad socioeconomic status, malnutrition and lack of medical
facilities [27].
Table 2: Distribution and percentage of Etiological
causes of bacteremia in febrile patients [Control group
and Thalassemia group] according to sex.
Type of causes
\ Sex
Control group
(50 patients)
Thalassemia group
(50 patients) Total
Male
%
Female
%
Male
%
Female
%
Bacterial causes 22 (22) 23 (23) 28 (28) 22 (22) 100
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Viral causes 5 (9.8) 4 (7.8) 26 (51) 16 (31.4) 51
Table 3: Distribution and Percentage of Etiological
causes of bacteremia in febrile patients [Control group
and Thalassemia group] according to residence.
Type of causes
\ Sex
Control group
(50 patients)
Thalassemia group
(50 patients) Total
Rural
%
Urban
%
Rural
%
Urban
%
Bacterial causes 29 (29) 21 (21) 33 (33) 17 (17 ) 100
Viral causes 3 (5.9) 6 (11.8) 30
(58.8)
12
(23.5) 51
CRP >20 mg/L, ESR >30 mm/hour, and WBC >15 000/mL are key
findings in various studies on febrile infants [7].The diagnostic value
of these parameters for predicting serious bacterial infection in febrile
patients, however, is conflicting.Our investigation showed (Table 4)
that from the 100 febrile patients with bacteremia and thalassemia, 91
had CRP >24 mg/L, 94 had ESR >35 mm/hour, and 89 had WBC
>15 000/mL. Our results corroborate the findings Bircan [5] and
Cuello [9] .
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Table 4: The Results of Diagnostic Test in Presence of a
Positive Blood Culture.
Diagnostic Test
Control group
(50 patients)
Thalassemia
group
(50 patients) Total
No. of
positive %
No. of
positive %
CRP > 24 mg/L 43 86 48 96 91
ESR > 35 mm/h 44 88 50 100 94
Peripheral WBC > 15
000/mL 45 90 44 88
89
This study shows the distribution and antibiotic susceptibility pattern
of microbial species isolated from infants with bacteremia (Tables 5,
6 and 7).These organisms cause a variety of infections including
bacteremia [20]. Antibiotic resistance is a major clinical problem in
treating infections caused by these microorganisms. The resistance to
the antimicrobials has increased over the years.Resistance rates vary
from country to country [13]. These results are nearly consistent with
the previous data of other community- based studies [10].In tables (5,
6, 7) Staphylococcus aureus shows sensitivity for Amikacin,
Nitrofurantoin, Norfloxacin and Ofloxacin, while Streptococcus
pneumoniae sensitive to Amikacin, Amoxicillin, Cefodizime,
Chloromphenicol, Clarithromycin, Gentamycin, Kanamycin,
Lincomycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin,
Oxytetracyclin, Penicillin and Rifampim, Bacillus spp.
Reveals sensitivity with Amikacin, Chloromphenicol, Gentamycin,
Kanamycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Piperacillin,
Tetracycline, Tobramycin and Vancomycin. While Haemophilus
influenzae showed sensitivity to Ceftizoxime ، Ofloxacin ،
Tetracycline.E. coli isolates shows sensitivity with Amikacin,
Chloromphenicol, Nitrofurantoin, Ofloxacin, and Norfloxacin.
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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009
While Pseudomonas aeruginosa shows sensitivity with Norfloxacin,
Ofloxacin, Piperacillin, Tobramycin, Proteus species shows
sensitivity with Amikacin, Amoxicillin , Cefodizime, Cefoxitin,
Cephalexin, Gentamycin, Norfloxacin, Piperacillin, Tobramycin and
Klebsiella pneumoniae isolates shows sensitivity with Amikacin,
Norfloxacin, Piperacillin, Tobramycin.
Table 5: Antimicrobial potency and spectrum for 13
selected antimicrobial agents tested against most
frequently occurring bacteremia pathogens.
Microorgani
sm
Antimicrobial agent / % sensitive strains
A
K
A
X
AM
C
AZ
M B
P
Y
CD
Z
FO
X
ZO
X
C
L C CLR
D
A
Staphylococ
cus aureus 90 - 1 1
1
5 10 50 - 10 10 10 10 -
Streptococc
us
pneumoniae
88 90 - 10 - - 100 - 20 15 75 75 15
Bacillus
spp.
10
0 - - - - - - - - - 90 15 10
Escherichia
coli 88 20 5 - 5 - - 5 10 20 90 - 5
Haemophilu
s influenzae - 5 45 50 - - 50 25 75 50 45 65 -
Salmonella
typhi 20 90 85 5 5 10 80 50 75 50 80 10 5
Pseudomona
s
aeruginosa
40 10 20 - 1
0 - 10 - 15 60 15 - -
Klebsiella
pneumoniae 90 - - 25 - 10 - 5 10 5 - 10 -
AK \Amikacin, AX \Amoxicillin, AMC \Amoxicillin + Clavulanic
acid, AZM\Azithromycin, , B \Bacitracin, PY \Carbenicillin, CDZ
\Cefodizime, FOX \Cefoxitin, ZOX \Ceftizoxime, CL \Cephalexin, C
\Chloromphenicol, CLR \Clarithromycin, DA \Clindamycin
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Table 6: Antimicrobial potency and spectrum for 13
selected antimicrobial agents tested against most
frequently occurring bacteremia pathogens.
Microorganism
Antimicrobial agent / % sensitive strains
E CN K L ME F NOR OFX OX T P PRL RA
Staphylococcus
aureus 20 10 10 10 10 90 95 - 90 50 50 - -
Streptococcus
pneumoniae 45 90 80 95 10 90 100 95 85 95 90 10 75
Bacillus spp. 50 70 85 30 - 100 100 90 20 20 10 85 -
Escherichia
coli 10 - 10 10 5 70 100 90 5 - 5 - 10
Haemophilus
influenzae - 10 - 25 5 - - 70 - 10 - - 45
Salmonella
typhi 5 40 45 15 15 70 85 20 10 5 50 75 -
Pseudomonas
aeruginosa 30 25 20 5 - 20 95 70 10 40 - 90 -
Klebsiella
pneumoniae 10 - - 10 - 10 100 - 10 - 15 100 10
E \Erythromycin, CN\Gentamycin, K\Kanamycin, L\Lincomycin,
ME\Methicillin, F\Nitrofurantoin, NOR\Norfloxacin, OFX
\Ofloxacin, OX\Oxacillin, T\Oxytetracyclin, P\Penicillin G, PRL
\Piperacillin, RA\Rifampim.
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Table 7: Antimicrobial potency and spectrum for 8
selected antimicrobial agents tested against most
frequently occurring bacteremia pathogens.
Microorganism Antimicrobial agent / % sensitive strains
RF SP S TE TOB TMP SXT VA
Staphylococcus
aureus 10 - 15 - - - 45 20
Streptococcus
pneumoniae 65 90 - 55 75 55 10 65
Bacillus spp. 20 20 10 65 75 10 30 75
Escherichia coli - 10 10 50 70 - 10 5
Haemophilus
influenzae 5 - - 70 - 5 10 -
Salmonella typhi 80 - 60 10 45 65 70 80
Pseudomonas
aeruginosa 30 - 30 20 100 10 30 -
Klebsiella
pneumoniae - - 10 - 100 - - 10
RF \Rifamycin, SP\Spiramycin, S\Streptomycin, TE\Tetracycline,
TOB\Tobramycin, TMP\Trimethoprim, SXT\Trimethoprim +
Sulphamethaxazole, VA\Vancomycin
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ي فاالصابات البكتيريه والفيروسيه المرافقه لمرضى الثالسيميا
مدينة الحله
-: الخالصة
100. تم جمع 2008الى تموز/ 2008انجزت هذه الدراسه في الفتره مابين اذار/
عينة دم من مرضى مصابين بالحمى تم ادخالهم الى مستشفى بابل للووالده واالطفال
م . االصابات 39ºدهة الثاالسيميا( ومستشفى الحله التعليمي ممن تتجاوز حرارتهم )ر
StreptococcusحالهStaphylococcus aureus (43 ،)البكتيريه كانت متمثله
pneumoniae (33 ،)حالهEscherichia coli (31 ،)حالهSalmonella typhi (28
حالهHaemophilus influenzae (20 ،)حالهBacillus spp (25 ،)حاله(،
Klebsiella pneumoniae (13 و )حالهPseudomonas aeruginosa (11 ،)حاله
حالهHepatitis B (25 .)حاله( و 26) Hepatitis Cبينما كانت االصابات الفيروسيه
اليوجد هناك تاثير في توزيع االصابات حسب الجنس ، بينما كانت نسب االصابه في
عينه تجرثم دموي 100من مما هي عليه في المدينه. في هذه الدراسه وجد ان الريف اعلى
ملم/ساعه( و ESR >35 عينه ) 94، (ملغم/لتر CRP>24 عينه ) 91وثالسيميا ،كانت
Staphylococcus aureus/مل(.اظهرت بكتريا الـ WBCs >15000عينه ) 89
و Amikacin, Nitrofurantoin Norfloxacinحساسيه تجاه المضادات
Ofloxacin بينما لبكتريا الـStreptococcus pneumoniae فكانت نسب المضادات
,Amikacin, Amoxicillin, Cefodizime, Chloromphenicolاعلى وشملت
Clarithromycin Gentamycin, Kanamycin, Lincomycin,
Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin, Oxytetracyclin,
Penicillin and Rifampin اما لبكتريا Bacillus spp. فكانت المضادات
,Amikacin, Chloromphenicol, Gentamycin, Kanamycinالتاليه
Nitrofurantoin Norfloxacin, Ofloxacin, Piperacillin, Tetracycline,
Tobramycin and Vancomycin .
*علي حسين المرزوكي
*امال راغب شمران
*زينه شاكر الهندي
بايولوجي جامعة بابل/كلية العلوم للبنات *
زهراء محمد الطائي
بايولوجي جامعة بابل/كلية العلوم محمد كاظم النافعي
بايولوجي مستشفى بابل للوالده
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Haemophilus influenzaeاما بكتريا الـ فقد اظهرت حساسيه تجاه Ceftizoxime ،
Ofloxacin ، Tetracycline اظهرت سالالت الـ . Escherichia coli حساسيه تجاه
,Amikacin Chloromphenicol, Nitrofurantoinالمضادات الحياتيه التاليه :
Ofloxacin, Norfloxacin ، بينما بكتريا Pseudomonas aeruginosa كانت
ساسه تجاه ح Norfloxacin, Ofloxacin, Piperacillin, Tobramycin بكتريا ،
Proteus species كانت حساسه للمضادات Amikacin, Amoxicillin ,
Cefodizime, Cefoxitin Cephalexin, Gentamycin, , Norfloxacin,
Piperacillin, Tobramycin و Klebsiella pneumoniae كانت حساسه تجاه
Amikacin, Norfloxacin, Piperacillin, Tobramycin.