225 - Antimicrobial Resistant Bacteria among Community Deaths in Children Aged <5 Years in the Child Health and Mortality Prevention Services (CHAMPS) Network

Publication Number: 1214.225

Jim S. Katieno, Kenya Medical Research Institute, Kisumu, Nyanza, Kenya; Anne Emanuels, Emory University School of Medicine, Atlanta, GA, United States; Delfino Vubil, Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Maputo, Mozambique; Sumanth Cherukumilli, University of Maryland School of Medicine, Nottingham, MD, United States; Cynthia G.. Whitney, The Task Force for Global Health, Atlanta, GA, United States; Chris A. Rees, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States

Background: Antimicrobial resistance (AMR) is an emerging global health threat. Bacterial AMR was estimated to be associated with 4.7 million deaths in 2021; one in five AMR-related deaths occurred in children aged < 5 years. Although prior studies have evaluated AMR in nosocomial infections, patterns of AMR in community settings are unclear, particularly in low- and middle-income countries (LMICs).

Objective: To compare the prevalence and patterns of AMR bacteria among infant and child deaths occurring in the community to facility deaths and to describe antecedent healthcare encounters among community deaths with AMR.

Design/Methods: We conducted a descriptive analysis of data collected in a prospective mortality surveillance program across 7 LMICs in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. We included deaths of infants and children aged 1-59 months who underwent postmortem testing and had a bacterial pathogen identified through blood or CSF culture and were subjected to antimicrobial susceptibility testing (AST). Deaths were categorized as a ‘community death’ if they occurred outside of a healthcare facility, including those who arrived at a healthcare facility but died en route. We utilized the WHO Priority Pathogen List to focus on specific bacteria with resistance to commonly used antimicrobials. Descriptive statistics were used to compare AMR to priority pathogens between community deaths and facility deaths.

Results: We examined 509 CHAMPS deaths that underwent AST for priority pathogens; 364 (71.5%) occurred in a healthcare facility and 145 (28.5%) occurred in the community. The median age at death was 294 days (interquartile range 97-631 days) and 54.8% were male (Table 1). Of community deaths, 25.5% had AMR to a priority pathogen compared to 73.6% of healthcare facility deaths (P < 0.001). Of community deaths with AMR, 51.4% had preceding healthcare encounters including hospitalizations or clinic visits (Table 2). The proportion of cases with third-generation cephalosporin resistant Klebsiella pneumoniae, E. Coli, and Enterobacter cloacae was higher among facility deaths than community deaths (P < 0.001). Carbapenem resistant Acinetobacter baumannii was also more common in facility deaths than community deaths (P < 0.001; Table 3).

Conclusion(s): Although AMR was identified in a quarter of community deaths, AMR was less common among community than facility deaths. Previous healthcare encounters were common among community deaths with AMR bacteria identified postmortem. Further studies are warranted to identify potential sources of the community spread of AMR bacteria.

Table 1. Description of deaths included in analysis of AMR-resistance within the Child Health and Mortality Prevention Surveillance (CHAMPS) network
Table 1.pdfN=509 unless stated otherwise.
a Pearson’s χ2 test was used to compare proportions when all expected cell counts were ≥5, whereas Fisher’s exact test was used when at least one expected cell count was <5. The Mann-Whitney-Wilcoxon test was used to compare medians.


Table 2. Clinical exposures prior to death among community deaths (N=145).
Table 2.pdf

Table 3. Bacterial pathogens identified among community deaths with AMR and facility deaths with AMR, and the proportion of resistant organisms among those pathogens.
Table 3.pdfP-values from Fisher’s exact test comparing community vs facility deaths.
3rd generation cephalosporin includes Cefixime, Cefotaxime, Ceftazidime, and Ceftriaxone
Carbapenem includes Doripenem, Ertapenem, Faropenem, Imipenem, and Meropenem.
Fluoroquinolone includes Ciprofloxacin, Levofloxacin, Moxifloxacin, Norfloxacin, and Ofloxacin.
Our dataset did not include methicillin, but we incorporated functional analogues within the same antibiotic class (anti-staphylococcal penicillins), including oxacillin, cloxacillin, and flucloxacillin/floxacillin.
Macrolide includes Azithromycin, Clarithromycin, and Erythromycin.