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94 Common Bacterial Infections in Children

positive, gram-negative, and anaerobic coverage. Usually, a combination the affected area with constitutional symptoms is an important indicator
of third-generation cephalosporin with metronidazole is used. Extensive of a rapidly developing fulminant infection. Local signs, such as redness,
tissue debridement is necessary in most children. Mortality remains high, induration, skin color changes, and pouring of pus, are indicative of seri-
and more than 50% of patients with Type-I NF may die secondary to ous tissue infection.
overwhelming sepsis. Nosocomial Infections
Meleney’s progressive bacterial gangrene is a form of necrotising
fasciitis caused by microaerophilic streptococci, aerobic staphylococci, Nosocomial infections are those caused by a hospital stay but not
bacteroides, and gram-negative organisms. It is usually seen as a related to the patient’s original condition. Infections are considered
complication after abdominal surgery, especially after bowel surgery, nosocomial if they appear after 48 hours in hospital or within 30 days
abdominal abscess drainage, mass abdominal closure under tension, after discharge from hospital. Nosocomial is a Greek word and comes
and surgical drains. The symptoms appear one to two weeks after the from nosos, which means “disease”, and komeo, which means “care”.
initial procedure. The skin around the wound becomes red and tender, Nosocomial infections are now considered one of the major causes of
with a foul-smelling discharge. Wide areas of skin and tissue necrosis morbidity and mortality in patients with prolonged hospitalisation. In
then occur, and the patient may become very sick and toxic. Aggressive developed countries, the incidence of nosocomial infections ranges
resuscitation and use of a combination of broad-spectrum antibiotics are from 7% to 14%; it is higher in developing countries with limited
necessary. Wound debridement should be done as soon as the patient resources. The most common sites of nosocomial infections are the
is stable, and the wounds left open for adequate drainage of infected urinary tract, surgical wounds, cannula sites, and respiratory tract.
material. With the removal of dead and necrotic tissue, the patient’s There are at least five modes of transmission of infections in admitted
condition may improve. Mortality, however, remains high, especially in patients, including direct and indirect contact, droplet infections, as
diabetics, immunocompromised patients, and malnourished children. See well as airborne, vehicle-borne, and vector-borne infections.
Chapter 21 for additional information. Direct contact between patients (hand shaking, sitting together, or
Fournier’s gangrene is a polymicrobial synergistic gangrene. This sharing beds) may transfer bacteria from one patient to another. In these
usually affects the perineal area (Figure 15. 1). It starts as a small itching cases, the patient harboring the bacteria acts as a source and the one
area, which forms a small ulcer, and then widespread tissue necrosis infected is the target. Indirect infection occurs by the use of various
occurs. The condition is initially painful but pain subsides with the loss intermediate substances, such as infected instruments, gloves, syringes,
of skin and subcutaneous tissue. dressings, and so forth. Droplet infections occur by cross infection
when coughing, sneezing, and talking. Vectors (e.g., flies, mosquitoes,
and rodents) may also cause transmission of infection in the admitted
patients. Vehicle-borne infections are secondary to food products, water,
and ward equipment. Hospital staff who are harbouring the infection
are another important source of infection. The incidence of nosocomial
infections rises with the duration of the stay in hospital.
Various factors, such as premature birth, advanced age, immuno-
deficiencies, indwelling catheters, prolonged antibiotic therapy, and
repeated blood product transfusions, predispose patients to nosocomial
infections. The most important factor, however, is the lack of cleanliness
in the wards. Prevention is the mainstay in warding off nosocomial
infections. Prevention may be achieved by avoiding direct contact among
patients and isolating patients with any active infection. Open wounds
Figure 15.1: Fournier’s gangrene. and contaminated utensils are the main cause of cross infections in the
hospitals. All patients with open wounds should be treated with utmost
Cancrum oris and noma vulva are mucocutaneous gangrenes affecting care; any cross contamination may be avoided by using disposable lines,
the mouth and vulva. These occur in severely malnourished children with gloves, and gowns. In case of an outbreak of ward infections, the wards
infectious diseases such as gastroenteritis, measles, and chicken pox. A should be closed immediately and properly fumigated, and all trolleys,
polymicrobial fulminant infection occurs, causing extensive skin and soft beds, and utensils should be fumigated. Any source of infection in the
tissue necrosis. The progression of the inflammatory process is rapid, and ward staff should be identified by nasal swabs and armpit cultures, and
extensive tissue destruction may be noted in a few days. This may cause staff with positive cultures should be treated before returning to work.
serious disfigurement of the face, and extensive surgical procedures may Staphylococci are the commonest organisms that may stay for a long time
be required later to cover the facial defects. The patient should be managed in the naris of carriers. In affected patients, local fuscidin crème should be
by correction of malnutrition, control of infection with broad-spectrum used until the cultures are negative.
antibiotics, and tissue reconstruction. Corrective surgery should be performed It has now been proven without a doubt that the incidence of
only when the patient has fully recovered, to avoid any recurrence. nosocomial infections can be minimised significantly by hand washing
before coming in contact with the patients. Therefore, hand washing
Type-II Necrotising Fasciitis must be ensured in all wards, and hand-washing areas should be present
Children with varicella zoster infection are at a high risk of developing in accessible locations in the wards. Cholorhexadine lotion may help in
GABHS-associated necrotising fasciitis. Children younger than 10 years the prevention of infection if the water supply is scarce. In developing
of age who have chicken pox have a 58-fold risk of developing invasive countries, the use of disposable gloves may not be possible for all
GABHS infections. The infections usually appear 4–6 days after the patients, but must be used for patients with open and infected wounds,
onset of a rash in children with chicken pox and may cause widespread for the safety of the other patients as well as the treating personnel.
tissue necrosis. Mortality is high, and aggressive management is needed
to control infection and save the life of the patient. Mortality in children Abscesses
after NF may be from 10% to 20%. The clinical presentation in GABHS- An abscess is a collection of pus in a cavity surrounded by a pyogenic
associated necrotising fasciitis may start as the flu-like symptoms of membrane. Pus is composed of necrotic leucocytes, tissue cells, and bac-
fever with chills, malaise, and pain, but the patient soon develops signs teria. Abscess formation occurs secondary to bacterial invasion of tissue.
of toxicity, tachypnoea, local tenderness, and erythema. Severe pain in The bacteria multiply rapidly in the tissue and initiate an inflammatory