Elsevier

Journal of Infection

Volume 65, Issue 2, August 2012, Pages 135-141
Journal of Infection

Staphylococcus aureus infections in pediatric patients with diabetes mellitus

https://doi.org/10.1016/j.jinf.2012.04.001Get rights and content

Summary

Objectives

To describe Staphylococcus aureus infections in children with diabetes mellitus (DM).

Methods

Children with DM (cases) and S. aureus infections (2/02-6/10) were identified from a surveillance database. Patient charts were reviewed, and S. aureus isolates were characterized by molecular methods. Cases were compared to age-matched controls without DM but with CA-S. aureus skin and soft tissue infections (SSTI) using conditional logistic regression.

Results

Forty-seven cases were identified; 41 were matched with 123 controls. Four cases had osteomyelitis and 43 had SSTI. Mean age was 14.2 years and 63% of cases had hemoglobin (Hb) A1c levels above 10%. Cases and controls differed by gender (85% vs. 45% female, P < 0.001), BMI% (median 87% vs. 72%, P = 0.04), methicillin-resistant S. aureus (MRSA) infection (49% vs. 68%, P = 0.04), and recurrent infections (22% vs. 4%, P = 0.001). Among cases, 88% of recurrences were caused by MRSA.

Conclusions

The majority of cases had poor glycemic control, more recurrences, fewer primary MRSA infections and were more likely to be female compared to a control group. Improved glycemic control may reduce the risk for infection, and decrease hospitalizations due to S. aureus infections.

Introduction

Diabetes mellitus is increasing among children worldwide. It is estimated that about 65,000 children under 15 years of age develop type 1 diabetes mellitus each year1 and recent studies have shown an increase in the number of children with type 2 diabetes mellitus.2, 3 Type 2 diabetes accounted for 2–4% of new cases of diabetes in children and adolescents before 1992, but may now account for up to 45% of new-onset cases among adolescents.3 The increasing prevalence of type 2 diabetes in children and adolescents has paralleled increasing rates of overweight and obese children and adolescents.2

Among adults, diabetic patients are more susceptible to infections compared to healthy individuals.4, 5 Common sites of infection in diabetic patients include the respiratory tract, urinary tract, and skin and soft tissues.6 The increased prevalence of infection may involve impairment of phagocytic activity of polymorphonuclear leukocytes which is depressed in diabetic patients due to a high serum concentration of glucose.7, 8

In one study, a direct correlation was found between the overall prevalence of infection in adult patients with diabetes and their mean plasma glucose levels,5 and it has been suggested that a tight control of blood sugar levels in diabetic patients may prevent the risks and complications of infections. There are no data investigating the impact of glycemic control on infectious complications in the pediatric population.

Staphyloccocus aureus is known to cause pediatric infections ranging from skin and soft tissue infections to invasive infections such as osteomyelitis, septic arthritis, bacteremia and pneumonia. In the United States, community-acquired methicillin-resistant S. aureus (CA-MRSA) has emerged as a major cause of S. aureus infections in addition to methicillin susceptible S. aureus (MSSA).9 The increase in CA-MRSA infections among both children and adults has been mainly attributed to one particular clone, USA300, which causes the majority of CA-MRSA infections at Texas Children’s Hospital (TCH), Houston, TX, and in many other regions of the United States. USA300 has also been described among MSSA isolates,10, 11 and has been associated with skin and soft tissue infections (SSTI)12, 13 as well as severe invasive disease.14, 15, 16 Features associated with USA300 include the Panton–Valentine leukocidin, a poreforming toxin, a SCCmec cassette type IV conferring the oxacillin resistance, and an arginine catabolic mobile element (ACME).17, 18

While the role of MRSA in adult diabetic foot infections has been well described,19 general studies on S. aureus infections in patients with diabetes mellitus are lacking, especially in the pediatric population. Large studies on MRSA infections frequently identify diabetes as a risk factor, and a recent publication compiling results from three randomized controlled treatment trials for MRSA SSTIs found that patients with diabetes did not respond as well to treatment as did those without diabetes.20

No studies have described in detail the S. aureus infections seen in children and adolescents with diabetes mellitus. We hypothesized that S. aureus infections in children with diabetes mellitus would differ from those of normal children with respect to clinical course, e.g., the infections would be more difficult to treat and there would be more complications. Based on previous studies we expected these differences to be related to the level of glycemic control.

The first objective of this study was to identify the clinical characteristics of pediatric diabetes patients with S. aureus infections at our institution. We compared patients with type 1 vs. type 2 diabetes mellitus and patients grouped according to their level of glycemic control (hemoglobin A1c levels greater or less than 10%). We also characterized the corresponding S. aureus isolates.

Second, we compared the patient characteristics from the study population to a group of age-matched controls, which consisted of previously healthy children with a S. aureus SSTI who sought care at TCH within the study period.

Section snippets

Study design and patients

Patients with S. aureus infections have been prospectively identified and their isolates collected at TCH, Houston, TX, since August 1, 2001.21 The study was approved by the Baylor College of Medicine Institutional Review Board and was exempt from obtaining informed consent.

From the surveillance database, pediatric patients with diabetes, who presented with S. aureus infections to TCH between February 2002 and June 2010, were identified. Patients were excluded if they had cystic fibrosis

Cases

Forty-seven patients with diabetes who had a S. aureus infection from between February 2002 and June 2010 were identified. Nine patients had a total of 16 recurrent infections. Only the first incident of infection was included in the main analysis; recurrences were compared separately.

Thirty-nine (83.0%) patients were female. The mean age at time of infection was 14.2 years (SD = 3.7). The mean BMI percentile was 82.0% (SD = 17.7), 12 (25.5%) patients were classified as overweight and 15

Discussion

In recent years, CA-MRSA infections have become increasingly prevalent among pediatric patients and diabetes has been described as a risk factor for S. aureus infection among both adults and children.25, 26 While no recent studies have investigated S. aureus infections in children and adolescents with type 1 and type 2 diabetes, several studies describe S. aureus nasal colonization, which may predispose to infection.27 The studies differ widely in the percentage of adult and pediatric diabetes

Acknowledgment

The study was presented, in part, as a poster at the Pediatric Academic Society Annual Meeting, Denver, Colorado, April 30–May 3, 2011, Paper #535. This study was supported, in part, by an investigator initiated grant from Pfizer (Kaplan). The funding source had no role in the study design, in the collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr. Kaplan is the local PI for a study initiated by

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    This study was, in part funded by a grant from Pfizer.

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