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Original Investigation |

Epidemiology and Mortality of Staphylococcus aureus Bacteremia in Australian and New Zealand Children ONLINE FIRST

Brendan J. McMullan, BMed (Hons)1,2; Asha Bowen, MBBS, PhD3,4,5,6; Christopher C. Blyth, MB, PhD3,4,6,7; Sebastiaan Van Hal, PhD8; Tony M. Korman, MBBS (Hons)9; Jim Buttery, MBBS10; Lesley Voss, MBChB11; Sally Roberts, MBBS12; Celia Cooper, BMBS13; Steven Y. C. Tong, MBBS (Hons), PhD5,14; John Turnidge, MBBS15,16,17,18
[+] Author Affiliations
1Department of Immunology and Infectious Diseases, Sydney Children’s Hospital, Randwick, New South Wales, Australia
2School of Women’s and Children’s Health, University of New South Wales, New South Wales, Australia
3Department of Infectious Diseases, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia
4Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
5Menzies School of Health Research, Darwin, Northern Territory, Australia
6School of Pediatrics and Child Health, University of Western Australia, Subiaco, Western Australia, Australia
7Department of Microbiology, Princess Margaret Hospital, PathWest Laboratory Medicine, Western Australia, Australia
8Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital Camperdown, Sydney, New South Wales, Australia
9Monash Infectious Diseases, Monash University, Monash Health, Victoria, Australia
10Department of Infection and Immunity, Monash Children’s Hospital, Department of Pediatrics, Monash University, Victoria, Australia
11Department of Pediatric Infectious Disease, Starship Children’s Hospital, Auckland, New Zealand
12Microbiology Department, LabPlus, Auckland Hospital, Auckland, New Zealand
13Department of Microbiology and Infectious Diseases, South Australia Pathology, Women's and Children’s Hospital, North Adelaide, South Australia, Australia
14Royal Darwin Hospital, Darwin, Northern Territory, Australia
15Department of Anatomy and Pathology, University of Adelaide, Adelaide, South Australia, Australia
16Department of Pediatrics, University of Adelaide, Adelaide, South Australia, Australia
17Department of Molecular and Cellular Biology, University of Adelaide, Adelaide, South Australia, Australia
18Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
JAMA Pediatr. Published online August 15, 2016. doi:10.1001/jamapediatrics.2016.1477
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Importance  Staphylococcus aureus bacteremia (SAB) in children causes significant morbidity and mortality, but the epidemiology in children is not well characterized.

Objective  To describe the epidemiology of SAB in children and adolescents younger than 18 years from Australia and New Zealand.

Design, Setting, and Participants  A prospective cohort study, using data from the Australian New Zealand Cooperative on Outcomes in Staphylococcal Sepsis cohort for 1153 children with SAB from birth to less than 18 years in pediatric and general hospitals across Australia and New Zealand, collected between January 1, 2007, and December 31, 2012. Multivariate analysis was performed to identify risk factors for mortality. Incidence calculations were calculated separately for Australasian children younger than 15 years using postcode population denominator data from Australian and New Zealand census data.

Main Outcomes and Measures  Demographic data, hospital length of stay, principal diagnosis, place of SAB onset (community or hospital), antibiotic susceptibility and principal antibiotic treatment, and 7- and 30-day mortality.

Results  Of the 1153 children with SAB, complete outcome data were available for 1073 children (93.1%); of these, males accounted for 684 episodes (63.7%) of SAB. The median age was 57 months (interquartile range, 2 months to 12 years). The annual incidence of SAB for Australian children was 8.3 per 100 000 population and was higher in indigenous children (incident rate ratio, 3.0 [95% CI, 2.4-3.7]), and the incidence for New Zealand children was 14.4 per 100 000 population and was higher in Māori children (incident rate ratio, 5.4 [95% CI, 4.1-7.0]). Community-onset SAB occurred in 761 cases (70.9%), and 142 cases (13.2%) of the infections were methicillin-resistant S aureus (MRSA). Bone or joint infection was most common with 348 cases (32.4%), and endocarditis was uncommon with 30 cases (2.8%). Seven- and 30-day mortality rates were 2.6% (n = 28) and 4.7% (n = 50), respectively. Risk factors for mortality were age younger than 1 year; Māori or Pacific ethnicity; endocarditis, pneumonia, or sepsis; and receiving no treatment or treatment with vancomycin. Mortality was 14.0% (6 of 43) in children with methicillin-susceptible S aureus (MSSA) treated with vancomycin compared with 2.6% (22 of 851) in children treated with alternative agents (OR, 6.1 [95% CI, 1.9-16.7]). MRSA infection was associated with increased length of stay but not mortality.

Conclusions and Relevance  In this large cohort study of the epidemiology of SAB in children, death was uncommon, but the incidence was higher for infants and varied by treatment, ethnicity, and clinical presentation. This study provides important information on the epidemiology of SAB in children and risk factors for mortality.

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Figure 1.
Susceptibility of Children to Staphylococcus aureus Bacteremia by Region

ACT indicates Australian Capital Territory; mrMRSA, multiresistant methicillin-resistant S aureus; MSSA, methicillin-susceptible S aureus; nmMRSA, nonmultiresistant methicillin-resistant S aureus; and NSW, New South Wales.

aIn the Northern Territory, 79 of 99 (79.8%) children were Australian Indigenous compared with fewer than 15% in all other Australian regions studied.

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Figure 2.
Survival by Age

SAB indicates Staphylococcus aureus bacteremia.

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