Pediatric Surgical Patients with Sepsis at a National Referral Hospital in Uganda: Predominant Organisms and Antibiotic Resistance Patterns

Authors:
Julia Harrison, Brian Kasagga, Grace Nambatya, Janet Maseka, Michael Semanda, Nasser Kakembo, Jennifer Rickard

Body of Abstract:
Background

Sepsis remains a leading cause of morbidity and mortality among children in low- and middle-income countries (LMICs), yet its burden in pediatric surgical patients is poorly characterized. Additionally, there is limited data describing causative organisms or antibiotic resistance patterns in pediatric surgical patients in LMICs.

Methods

This analysis is part of a larger prospective observational study evaluating the etiology, diagnosis, management, and outcomes of sepsis among children on a pediatric surgery ward in Uganda. Patients with clinical criteria for sepsis are eligible for blood culture collection. A single sample is routinely obtained and processed using the BD BACTEC system in Peds Plus Aerobic bottles. In addition to culture data, demographic information, clinical diagnoses, antibiotic use, operative details, and patient outcomes are recorded.

Results

Of 82 patients enrolled to date, 42 blood culture results were available. Pathologies leading to sepsis were predominantly intra-abdominal (67%), followed by urinary tract (10%), pulmonary (7%), and skin/soft tissue infection (6%), with 10% of patients having an unknown source. The median age at culture collection was 11 days (IQR 6-21). 27 of 42 cultures (64%) were positive and all isolated bacteria were multidrug resistant. Klebsiella pneumoniae accounted for 12/27 (44%) positive cultures, followed by Staphylococcus species (5/27, 18.5%), and Candida species (5/27, 18.5%). All patients were on antibiotics, while none were on antifungals, at the time of culture collection. Based on culture results, 1 of 27 (3.7%) patients was adequately covered by antimicrobials, 20/27 (74.1%) were not adequately covered, and adequate coverage was unable to be determined in 6/27 (22.2%) patients. Klebsiella pneumoniae isolates showed high rates of resistance across 10 of 11 tested antibiotic classes (figure 1), while most (10/12 isolates, 83%) retained sensitivity to carbapenems. In-hospital mortality among all enrolled was 58%. Mortality among those with positive cultures was 60%, with 73% mortality among those with Klebsiella bacteremia.

Conclusions

These findings demonstrate a substantial burden of culture-positive sepsis among pediatric surgical patients in Uganda. There was a predominance of intra-abdominal, followed by urinary tract pathology and most patients were extremely young at presentation. All isolated bacteria demonstrated multidrug resistance and almost all isolated bacteria were resistant to empirically used antibiotics. Empiric antifungal coverage, while not currently in practice, appears to be needed. Klebsiella pneumoniae was the leading pathogen isolated and exhibited extensive multidrug resistance. The high overall mortality highlights the severity of sepsis in this population and underscores the urgent need for strengthened infection prevention, earlier recognition of sepsis, local antibiograms, and improved access to effective antibiotics and antifungals.