ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10081-1464 |
Study the Prevalence of Bacterial Infection in Under-five Malnourished Children
1–3Department of Pediatrics, Pt Jawahar Lal Nehru Memorial Medical College, Raipur, Chhattisgarh, India
Corresponding Author: Praveen Kumar Selvagandhi, Department of Pediatrics, Pt Jawahar Lal Nehru Memorial Medical College, Raipur, Chhattisgarh, India, Phone: +91 7708495233, e-mail: praveenmedino@gmail.com
Received: 04 November 2024; Accepted: 22 December 2024; Published on: 20 March 2025
ABSTRACT
Background: Malnutrition means both undernutrition and overnutrition. Under-five children who are malnourished are at increased risk of bacterial infection and sepsis, which contribute to morbidity and mortality.
Methods: We conducted a cross-sectional survey among 155 under-five malnourished children through a consecutive sampling method in the Department of Pediatrics at Pt JNM Medical College, Raipur, Chhattisgarh, India, after obtaining informed consent from their respective parents.
Results: The prevalence of bacterial infection in my study was 11.6%. Prevalence was higher in children with severe acute malnutrition (14.4%) compared to children with moderate acute malnutrition. The most common organism isolated was methicillin-resistant Staphylococcus aureus.
Conclusion: A significant proportion of under-five malnourished children were complicated by serious bacterial infections, the majority in the form of respiratory illness, like bronchopneumonia. There is a need for intervention to improve the nutritional status of under-five malnourished children.
Keywords: Antibiotic resistance, Infections, Undernutrition
How to cite this article: Selvagandhi PK, Dhruw S, Phuljhele S. Study the Prevalence of Bacterial Infection in Under-five Malnourished Children. Pediatr Inf Dis 2025;7(2):50–53.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Malnutrition refers to the cellular imbalance between the supply of nutrients and energy [World Health Organization (WHO)].1 Malnutrition is contributed to by both macronutrient and micronutrient deficiency.1 The terms malnutrition and protein-energy malnutrition are the same.1,2 Malnourished children have a higher risk of morbidity and mortality.3,4 Protein-energy malnutrition is associated with 35% of under-five child deaths.4
In the first 6 months of life, almost 20–30% of children were already malnourished due to low birth weight.5,6 The incidence of undernutrition and stunting was mainly seen after 4–6 months of age.6,1 Septicemia, up to 25%, was found to be reported in previous studies from India.7,8 The lack of a proper surveillance system fails to identify the pattern of antimicrobial resistance among childhood bloodstream infections across the country.9
It is difficult to diagnose bacteremia in low-income and middle-income countries because of poor laboratory diagnosis.9,10 Obvious signs of fever are usually not present in malnourished children.11,13 The WHO recommends the use of empirical broad-spectrum antibiotics for all admitted severely malnourished children to reduce mortality.14,16 Nowadays, the emergence of antimicrobial resistance is increasing because of unauthorized usage of antibiotics, and there is a challenge in the future due to the limited availability of antibiotics.17,19
METHODS
Study Design
Cross-sectional descriptive study.
1. Anthropometry of under-five children was calculated, and malnourished children were identified.
2. According to the WHO classification of undernutrition, the malnourished children were classified into moderate acute malnutrition and severe acute malnutrition based on the following criteria:
Moderate Acute Malnutrition
Weight-for-length/height or BMI-for-age ≤ −2 and ≥ −3 SD of the median, or mid-upper arm circumference ≥115 and <125 mm.
Severe Acute Malnutrition
Weight-for-length/height or BMI-for-age < −3 SD of the median, or mid-upper arm circumference <115 mm, or bilateral pitting edema.
3. Blood investigations like CBC, blood culture, and urine cultures were sent.
Sampling
Sampling method: Consecutive sampling.
The sample size for my study was 155 based on a previous prevalence study on bacterial infection. I have calculated the study sample size from the below mentioned formula:
4pq/d2, p = 10.8%, q = 89.2, d = 5
A study was done by Msafiri et al.7 regarding bacterial infection in febrile under-five children at Makole Health Centre, Dodoma City, Tanzania, in which they found that the prevalence of bacteremia was 10.8%.
Ethical Consideration
The study was approved by an expedited review by the Institutional Ethics Committee of Pt JNM Medical College, Raipur, Chhattisgarh, India. Informed and written consent was obtained from all participants’ parents.
Statistical Analysis
-
Obtained data were entered into a Microsoft Excel sheet and analyzed with SPSS version 20.
-
Obtained data were displayed in pie chart.
Inclusion Criteria
All malnourished children from ages 6 months to 5 years admitted to the pediatric department of Pt JNM Medical College, Raipur, Chhattisgarh, India.
Exclusion Criteria
All malnourished children received unknown antibiotics before admission.
RESULTS
In my study, 155 malnourished children were included. Characteristics of children who participated in the study are summarized in Table 1. Male children represented more than female children. Over 63.3% of the study population were males and 36.7% of the study population were females.
| Characteristic | N (%) |
|---|---|
| Male | 98 (63.3) |
| Female | 57 (36.7) |
Table 1 shows that, among the study population, malnourished males under-five were more than females.
Table 2 shows that, among the study population, most of the cases belonged to the age-group of 6 months to 1 year, followed by 1–3 years and 3–5 years.
| Characteristic | N (%) |
|---|---|
| 6 months to 1 year | 71 (45.8) |
| 1–3 years | 57 (36.8) |
| 3–5 years | 27 (17.4) |
Illness of Study Population
Out of 155 malnourished children, 34 (22%) of them had bronchopneumonia, followed by other illnesses like bronchiolitis, lobar pneumonia, empyema thoracis, urinary tract infection, septic arthritis, dimorphic anemia, iron deficiency anemia, congenital heart disease, acute gastroenteritis, dysentery, sickle cell anemia, thalassemia, sickle beta thalassemia, cerebral palsy, hydrocephalus, febrile seizure, enteric fever, dengue fever, extrahepatic biliary atresia, and unknown poisoning.
Table 3 shows that, among the study population, severely underweight children were more than underweight children.
| S no. | Degree of undernutrition | % (N) |
|---|---|---|
| 1. | Underweight (very low weight) | 42.6% (66) |
| 2. | Severely underweight | 57.4% (89) |
Table 4 shows that, among the study population, stunting/short stature was more than severe stunting.
| S no. | Stature | % (N) |
|---|---|---|
| 1. | Stunting/short stature | 10.9% (17) |
| 2. | Severe stunting | 4.5% (7) |
Malnutrition
Out of 155 malnourished children, 97 (62.6%) had severe acute malnutrition and 58 (37.4%) had moderate acute malnutrition, as shown in Figure 1.
Fig. 1: SAM vs MAM
Prevalence of Bacterial Infection
The prevalence of bacterial infection, about 11.6% (18), was found in 155 under-five malnourished children, as shown in Figure 2. The prevalence was higher in children with severe acute malnutrition (14.4%) compared to moderate acute malnutrition (7.4%).
Fig. 2: Prevalence of bacterial infection
Severe Acute Malnutrition vs Moderate Acute Malnutrition
The culture positivity rate was higher in children with severe acute malnutrition (14.4%, n = 97) compared to children with moderate acute malnutrition (6.89%, n = 58), as shown in Figures 3 and 4.
Fig. 3: Culture positivity in SAM
Fig. 4: Culture positivity in MAM
Table 5 shows that, among the culture-positive children with severe acute malnutrition, the majority were affected by bronchopneumonia, followed by urinary tract infection, local site infection, and lobar pneumonia.
| Bronchopneumonia | 8 |
| Urinary tract infection | 3 |
| Local site infection | 2 |
| Lobar pneumonia | 1 |
Table 6 shows that, among severe acute malnutrition patients, the most common organism isolated was methicillin-resistant Staphylococcus aureus.
| Methicillin-resistant S. aureus | 7 |
| S. aureus | 4 |
| K. pneumonia | 1 |
| P. aeruginosa | 1 |
| P. mirabilis | 1 |
Table 7 shows the disease pattern in culture-positive moderate acute malnutrition patients.
| Urinary tract infection | 1 |
| Local site infection | 1 |
| Sickle cell anemia (SS) with VOC | 1 |
| Neuroblastoma with pancytopenia | 1 |
Table 8 shows that, among culture-positive moderate acute malnutrition patients, the most common organism isolated was S. aureus.
| S. aureus | 2 |
| Methicillin-resistant S. aureus | 1 |
| E. coli | 1 |
Bacteremia is a major cause of nonmalarial febrile illnesses in children, which has high mortality occurring in the first 48 hours of hospitalization.7 The prevalence of bacterial infection among hospitalized children was found to be 8.3%, ranging from 3.3 to 19.9%, with the lowest reported in Kenya at a prevalence of 3.3%.7 The prevalence of bacterial infection in febrile children admitted to Bugando Medical Centre in Tanzania was 6.6%.7 The United Kingdom reported a very low level of bacteremia, at 1.42 per 1,000 children.7 In the present study, among 155 children, the prevalence of bacterial infection was about 11.6% (18).
Antibiotic Sensitivity Pattern
Methicillin-Resistant Staphylococcus aureus
Out of 155 malnourished children, 5.16% (8) of patients were culture positive for MRSA (7 in SAM and 1 in MAM). All 8 patients were sensitive to linezolid and vancomycin. Three patients were resistant to azithromycin, and two patients were resistant to azithromycin, gentamycin, and ceftriaxone. About 25% of MRSA strains were resistant to ceftriaxone.
Staphylococcus aureus
Out of 155 malnourished children, 3.8% (6) of patients were culture positive for S. aureus (four in SAM and two in MAM). All six patients were sensitive to ceftriaxone and vancomycin. Two patients were resistant to azithromycin and gentamycin.
Klebsiella pneumonia
Out of 155 malnourished children, 0.64% (1) of patients with SAM were culture positive for K. pneumoniae. The patient had a urinary tract infection and was sensitive to meropenem, gentamycin, amikacin, ceftriaxone, ciprofloxacin, cefoperazone/sulbactam, piperacillin/tazobactam, nitrofurantoin, and amoxyclav. The patient was resistant to ampicillin, cefixime, and cotrimoxazole.
Proteus mirabilis
Out of 155 malnourished children, 0.64% (1) of patients with a local site infection were culture positive for P. mirabilis and were sensitive only to piperacillin/tazobactam and tigecycline.
Pseudomonas aeruginosa
Out of 155 malnourished children, 0.64% (1) of patients with a local site infection were culture positive for P. aeruginosa and were sensitive to piperacillin/tazobactam, ciprofloxacin, and tigecycline. The patient was resistant to ceftriaxone, meropenem, amikacin, gentamycin, ciprofloxacin, and cefixime.
Escherichia coli
Out of 155 malnourished children, 0.64% (1) of patients with a urinary tract infection were culture positive for E. coli and were sensitive to ampicillin, amoxyclav, meropenem, gentamycin, and piperacillin/tazobactam. The patient was resistant to ceftriaxone and ciprofloxacin.
The antibiotics mainly used in malnourished children are sulfonamides, beta-lactam, and aminoglycoside antibiotics.20 Some programs use antibiotics like ceftriaxone or cefotaxime as second-line management.21,22 Children with SAM are administered antibiotics both in inpatient and outpatient settings, despite the severity of illness.22 Previous retrospective clinical studies have shown an increasing level of antibiotic resistance in geographical areas with a widespread of malnourished patients.23,25
In a similar study, among patients with gram-positive sepsis, there was a high level of resistance to penicillin in both the CONS and Staphylococcus groups. Among patients with gram-negative sepsis, E. coli was the most common at 4.6%, followed by Acinetobacter. More than 60% resistance against ciprofloxacin and amikacin was seen in Klebsiella. Organisms like E. coli, Klebsiella, and Enterobacter were resistant to third-generation cephalosporins.26,27
In my study, most of the organisms were sensitive to first-line antibiotics such as ceftriaxone, except P. mirabilis, which is sensitive only to piptaz and tigecycline. All MRSA strains were sensitive to vancomycin and linezolid. About 25% of MRSA strains were resistant to ceftriaxone. 33.3% of Staphylococcus strains were resistant to azithromycin and gentamycin. Klebsiella strains were resistant to ampicillin, cefixime, and cotrimoxazole. P. aeruginosa strains were resistant to ceftriaxone, meropenem, amikacin, gentamycin, ciprofloxacin, and cefixime. E. coli strains were resistant to ceftriaxone and ciprofloxacin.
In a similar study done by Abrha et al., the most common organisms isolated were S. aureus and K. pneumoniae, with sensitivity >80% to gentamycin, ciprofloxacin, and ceftriaxone. These organisms showed an increased level of resistance to commonly used antibiotics, such as co-trimoxazole and amoxicillin.26,27
CONCLUSION
A significant proportion of malnourished children were complicated by serious bacterial infections, the majority in the form of respiratory illness, such as bronchopneumonia. The prevalence of bacterial infection in under-five malnourished children in my study was found to be 11.6%. The most common organism isolated was methicillin-resistant S. aureus (44.4%, 8 out of 18).
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