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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Bacterial and Viral Infections associated with

Thalassemia Patients in Hillah City

Abstract :-

This study was performed from March to July 2008. A total of

100 blood samples obtained from patients with febrile in different age

who presented to the Babylon Maternity and Children Hospital

(Thalassemia Wards) and Al-Hillah Teaching Hospital with

temperature >38°C were evaluated by residents and pediatric

emergency medicine attending.Bacterial infections represented by

Staphylococcus aureus (43 patients), Streptococcus pneumoniae (33

patients), Escherichia coli (31 patients), Salmonella typhi (28

patients), Bacillus spp. (25 patients), Haemophilus influenzae (20

patients), Klebsiella pneumoniae (13 patients) and Pseudomonas

aeruginosa (11 patients), while the viral infections with Hepatitis

were; Hepatitis C (26 patients) and Hepatitis B (25 patients).

Sex distribution founded to be not significant and distribution

according to residence were revealed higher in rural area than in

Urban. Our investigation showed that from the 100 febrile patients

with bacteremia and thalassemia, 91 had CRP >24 mg/L, 94 had

ESR >35 mm/hour, and 89 had WBC >15 000/mL.

Staphylococcus aureus shows sensitivity for Amikacin,

Nitrofurantoin, Norfloxacin and Ofloxacin, while Streptococcus

pneumoniae sensitive to Amikacin, Amoxicillin, Cefodizime,

Chloromphenicol, Clarithromycin, Gentamycin, Kanamycin,

Lincomycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin,

Oxytetracyclin, Penicillin and Rifampin, Bacillus spp. Reveals

Ali H. Al-Marzoqi

*

*Ammal R. Shemmran *Zeana Sh. Al-Hindi

Mohammad K. Al-Nafee'

Babylon Hospital of Maternity

Zahraa M. Al-Taee

Babylon University\College of

Science

Babylon University\College of Science for women*

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

sensitivity with Amikacin, Chloromphenicol, Gentamycin,

Kanamycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Piperacillin,

Tetracycline, Tobramycin and Vancomycin. While Haemophilus

influenzae showed sensitivity to Ceftizoxime ، Ofloxacin ،

Tetracycline.

E. coli isolates shows sensitivity with Amikacin, Chloromphenicol,

Nitrofurantoin, Ofloxacin, Norfloxacin, while Pseudomonas

aeruginosa shows sensitivity with Norfloxacin, Ofloxacin,

Piperacillin, Tobramycin, Proteus species shows sensitivity with

Amikacin, Amoxicillin , Cefodizime, Cefoxitin, Cephalexin,

Gentamycin, , Norfloxacin, Piperacillin, Tobramycin and Klebsiella

pneumoniae isolates shows sensitivity with Amikacin, Norfloxacin,

Piperacillin, Tobramycin.

Introduction :-

Thalassemia is one of the major health concerns in World. The rate of

carriage of β- thalassemia is >1.1% [14, 18]. With receipt of regular

blood transfusions and iron-chelating therapy, the prognosis of the

disease improves [6]. Unfortunately, the prevalence of severe

complications due to iron overload is still high. Excluding heart

failure, infection is the predominant cause of death; it is directly

responsible for 12%–46% of patient deaths [4, 12]. Early recognition

with prompt treatment and prevention of predisposing factors are

essential in the treatment of patients with thalassemia and infection.

With the implementation of different means of treatment, including

blood transfusion, administration of deferoxamine, and hematopoietic

and cord blood stem cell transplantation [17], the probability of 20-

year-survival for patients with thalassemia major in Hong Kong has

reached 90% [6], a figure comparable to the rate in such Western

countries as Italy. Despite all of these treatment successes, infection

has remained an important cause of death [16]. This study aimed to

revealed the causative agent causing bacteremia comparing with the

non thalassemic patients and using physiological parameters to detect

the infection like C-reactive protein, total WBCs, ESR and

antimicrobial sensitivity.

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Material and Methods :-

This study was performed from March to July 2008. hundred blood

sample obtained from patients with febrile (50 patients as Control

without Thalassemia and 50 patients with Thalassemia) in different

age who presented to the Babylon Maternity and Children Hospital

(Thalassemia Wards) and Al-Hillah Teaching Hospital with

temperature >38°C were evaluated by residents and pediatric

emergency medicine attending. Those patients, after careful history

and physical examination, had clinically undetectable source for the

fever were enrolled in the study.Demographic information, like age

and sex, temperature, duration of fever, Total WBC, erythrocyte

sedimentation rate (ESR) and semi-quantitative CRP concentration

were obtained. All patients received a blood culture.

C-reactive protein test done by using latex kit from HUMATEX CRP

(Germany) for qualitative and semi-quantitative determination.

Hepatitis type B and C were diagnosis with Chromatography Kit

from AKON and ELISA kit From BioKit (Spain). In this study we

used 20 different antibiotics to estimate the sensitivity of febrile

causative agents, using disk diffusion agar using Muller Hinton agar.

For hemocytometer WBC counts, blood specimens were examined

microscopically on a Neubauer chamber (Neubauer hemocytometer)

by the same technician.Bacterial isolates were identified to the level

of species using cultural characteristics and conversional biochemical

test [3 and 19].

Results and Discussion :-

There are two type of infections recorded in this research, bacterial

and viral. Bacterial infections represented by Staphylococcus aureus

(43 patients), Streptococcus pneumoniae (33 patients), Escherichia

coli (31 patients), Salmonella typhi (28 patients), Bacillus spp. (25

patients), Haemophilus influenzae (20 patients), Klebsiella

pneumoniae (13 patients) and Pseudomonas aeruginosa (11 patients),

while the viral infections with Hepatitis were; Hepatitis C (26

patients) and Hepatitis B (25 patients) (Table 1). The increased

frequency and changing etiology of bacteremia may be a result of

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

varying patient population [15].This result was in accordance with

other studies, where the percentages of Gram-positive and Gram-

negative organisms isolated from bacteremic children were 68% and

29% respectively [2]. Chapman and Faix (2003) stated that Gram-

positive organisms and Gram-negative organisms accounted for

causes bacteremic infections, another study pointed out that the

etiology may even vary at different times within the same place [2,

22]. This study revealed that the infection with bacteria and virus

were higher in thalassemia group than the control (Table 1).

Hepatitis cases recorded, Hepatitis (B and C) infection may happen

through blood transfusion [23]. Iranian study found that (19.3%)

patients were Hepatitis C positive while 11 (1.5%) were Hepatitis B

positive and no one was HIV positive [21]. Australian study found

that the infection with Hepatitis C was higher the others and the

epidemic of HCV infection continues to escalate in Australia,

predominantly through transmission related to injecting drug use

[11]. Other study found that the wave of increased HCV-related

morbidity and mortality that we are now facing is the result of an

unprecedented increase in the spread of HCV during the 20th century.

Two 20th century events appear to be responsible for this increase;

the widespread availability of injectable therapies and the illicit use

of injectable drugs [1]. Hepatitis B virus (HBV) may occasionally be

transmitted through transfusion of blood units that are hepatitis B

surface antigen (HBsAg) negative but HBV DNA positive [26].

In the present study, iron overload was noted in the infection group. It

is clear that any organisms, such as Y. enterocolitica, Klebsiella

species, E. coli, Streptococcus pneumonia, P. aeruginosa and Listeria

monocytogenes, have been shown to increase in virulence in the

presence of excess iron in vitro [8, 25].

Table1: Percentage of etiological agents causes

bacteremia in febrile patients [Control group and

Thalassemia group] with mixed infections.

Causative agents Control group Thalassemia Total

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

(50 patients) group

(50 patients)

No. % No. %

Bacterial Causes

Staphylococcus aureus

18

(41.9)

25

(58.1)

43

Escherichia coli 11 (35.5) 20 ( 64.5) 31

Streptococcus

pneumoniae 15 (45.5) 18 (54.5)

33

Bacillus spp. 10 (40) 15 (60) 25

Haemophilus

influenzae 7 (35) 13 (65)

20

Salmonella typhi 18 (64.3) 10 (35.7) 28

Klebsiella pneumoniae 4 (30.8) 9 (69.2) 13

Pseudomonas

aeruginosa 3 (27.3) 8 (72.7)

11

Viral Causes

Hepatitis C

7

(26.9)

19

(73.1)

26

Hepatitis B 2 (8) 23 (92) 25

Sex distribution in this study (Table 2) founded to be not significant

and this result nearly agreed with Chung [25] and Shih [24].

Distribution according to residence were revealed higher in rural area

than in Urban, Difference between rural and urban patients related to

the bad socioeconomic status, malnutrition and lack of medical

facilities [27].

Table 2: Distribution and percentage of Etiological

causes of bacteremia in febrile patients [Control group

and Thalassemia group] according to sex.

Type of causes

\ Sex

Control group

(50 patients)

Thalassemia group

(50 patients) Total

Male

%

Female

%

Male

%

Female

%

Bacterial causes 22 (22) 23 (23) 28 (28) 22 (22) 100

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Viral causes 5 (9.8) 4 (7.8) 26 (51) 16 (31.4) 51

Table 3: Distribution and Percentage of Etiological

causes of bacteremia in febrile patients [Control group

and Thalassemia group] according to residence.

Type of causes

\ Sex

Control group

(50 patients)

Thalassemia group

(50 patients) Total

Rural

%

Urban

%

Rural

%

Urban

%

Bacterial causes 29 (29) 21 (21) 33 (33) 17 (17 ) 100

Viral causes 3 (5.9) 6 (11.8) 30

(58.8)

12

(23.5) 51

CRP >20 mg/L, ESR >30 mm/hour, and WBC >15 000/mL are key

findings in various studies on febrile infants [7].The diagnostic value

of these parameters for predicting serious bacterial infection in febrile

patients, however, is conflicting.Our investigation showed (Table 4)

that from the 100 febrile patients with bacteremia and thalassemia, 91

had CRP >24 mg/L, 94 had ESR >35 mm/hour, and 89 had WBC

>15 000/mL. Our results corroborate the findings Bircan [5] and

Cuello [9] .

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Table 4: The Results of Diagnostic Test in Presence of a

Positive Blood Culture.

Diagnostic Test

Control group

(50 patients)

Thalassemia

group

(50 patients) Total

No. of

positive %

No. of

positive %

CRP > 24 mg/L 43 86 48 96 91

ESR > 35 mm/h 44 88 50 100 94

Peripheral WBC > 15

000/mL 45 90 44 88

89

This study shows the distribution and antibiotic susceptibility pattern

of microbial species isolated from infants with bacteremia (Tables 5,

6 and 7).These organisms cause a variety of infections including

bacteremia [20]. Antibiotic resistance is a major clinical problem in

treating infections caused by these microorganisms. The resistance to

the antimicrobials has increased over the years.Resistance rates vary

from country to country [13]. These results are nearly consistent with

the previous data of other community- based studies [10].In tables (5,

6, 7) Staphylococcus aureus shows sensitivity for Amikacin,

Nitrofurantoin, Norfloxacin and Ofloxacin, while Streptococcus

pneumoniae sensitive to Amikacin, Amoxicillin, Cefodizime,

Chloromphenicol, Clarithromycin, Gentamycin, Kanamycin,

Lincomycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin,

Oxytetracyclin, Penicillin and Rifampim, Bacillus spp.

Reveals sensitivity with Amikacin, Chloromphenicol, Gentamycin,

Kanamycin, Nitrofurantoin, Norfloxacin, Ofloxacin, Piperacillin,

Tetracycline, Tobramycin and Vancomycin. While Haemophilus

influenzae showed sensitivity to Ceftizoxime ، Ofloxacin ،

Tetracycline.E. coli isolates shows sensitivity with Amikacin,

Chloromphenicol, Nitrofurantoin, Ofloxacin, and Norfloxacin.

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

While Pseudomonas aeruginosa shows sensitivity with Norfloxacin,

Ofloxacin, Piperacillin, Tobramycin, Proteus species shows

sensitivity with Amikacin, Amoxicillin , Cefodizime, Cefoxitin,

Cephalexin, Gentamycin, Norfloxacin, Piperacillin, Tobramycin and

Klebsiella pneumoniae isolates shows sensitivity with Amikacin,

Norfloxacin, Piperacillin, Tobramycin.

Table 5: Antimicrobial potency and spectrum for 13

selected antimicrobial agents tested against most

frequently occurring bacteremia pathogens.

Microorgani

sm

Antimicrobial agent / % sensitive strains

A

K

A

X

AM

C

AZ

M B

P

Y

CD

Z

FO

X

ZO

X

C

L C CLR

D

A

Staphylococ

cus aureus 90 - 1 1

1

5 10 50 - 10 10 10 10 -

Streptococc

us

pneumoniae

88 90 - 10 - - 100 - 20 15 75 75 15

Bacillus

spp.

10

0 - - - - - - - - - 90 15 10

Escherichia

coli 88 20 5 - 5 - - 5 10 20 90 - 5

Haemophilu

s influenzae - 5 45 50 - - 50 25 75 50 45 65 -

Salmonella

typhi 20 90 85 5 5 10 80 50 75 50 80 10 5

Pseudomona

s

aeruginosa

40 10 20 - 1

0 - 10 - 15 60 15 - -

Klebsiella

pneumoniae 90 - - 25 - 10 - 5 10 5 - 10 -

AK \Amikacin, AX \Amoxicillin, AMC \Amoxicillin + Clavulanic

acid, AZM\Azithromycin, , B \Bacitracin, PY \Carbenicillin, CDZ

\Cefodizime, FOX \Cefoxitin, ZOX \Ceftizoxime, CL \Cephalexin, C

\Chloromphenicol, CLR \Clarithromycin, DA \Clindamycin

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Table 6: Antimicrobial potency and spectrum for 13

selected antimicrobial agents tested against most

frequently occurring bacteremia pathogens.

Microorganism

Antimicrobial agent / % sensitive strains

E CN K L ME F NOR OFX OX T P PRL RA

Staphylococcus

aureus 20 10 10 10 10 90 95 - 90 50 50 - -

Streptococcus

pneumoniae 45 90 80 95 10 90 100 95 85 95 90 10 75

Bacillus spp. 50 70 85 30 - 100 100 90 20 20 10 85 -

Escherichia

coli 10 - 10 10 5 70 100 90 5 - 5 - 10

Haemophilus

influenzae - 10 - 25 5 - - 70 - 10 - - 45

Salmonella

typhi 5 40 45 15 15 70 85 20 10 5 50 75 -

Pseudomonas

aeruginosa 30 25 20 5 - 20 95 70 10 40 - 90 -

Klebsiella

pneumoniae 10 - - 10 - 10 100 - 10 - 15 100 10

E \Erythromycin, CN\Gentamycin, K\Kanamycin, L\Lincomycin,

ME\Methicillin, F\Nitrofurantoin, NOR\Norfloxacin, OFX

\Ofloxacin, OX\Oxacillin, T\Oxytetracyclin, P\Penicillin G, PRL

\Piperacillin, RA\Rifampim.

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Table 7: Antimicrobial potency and spectrum for 8

selected antimicrobial agents tested against most

frequently occurring bacteremia pathogens.

Microorganism Antimicrobial agent / % sensitive strains

RF SP S TE TOB TMP SXT VA

Staphylococcus

aureus 10 - 15 - - - 45 20

Streptococcus

pneumoniae 65 90 - 55 75 55 10 65

Bacillus spp. 20 20 10 65 75 10 30 75

Escherichia coli - 10 10 50 70 - 10 5

Haemophilus

influenzae 5 - - 70 - 5 10 -

Salmonella typhi 80 - 60 10 45 65 70 80

Pseudomonas

aeruginosa 30 - 30 20 100 10 30 -

Klebsiella

pneumoniae - - 10 - 100 - - 10

RF \Rifamycin, SP\Spiramycin, S\Streptomycin, TE\Tetracycline,

TOB\Tobramycin, TMP\Trimethoprim, SXT\Trimethoprim +

Sulphamethaxazole, VA\Vancomycin

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

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ي فاالصابات البكتيريه والفيروسيه المرافقه لمرضى الثالسيميا

مدينة الحله

-: الخالصة

100. تم جمع 2008الى تموز/ 2008انجزت هذه الدراسه في الفتره مابين اذار/

عينة دم من مرضى مصابين بالحمى تم ادخالهم الى مستشفى بابل للووالده واالطفال

م . االصابات 39ºدهة الثاالسيميا( ومستشفى الحله التعليمي ممن تتجاوز حرارتهم )ر

StreptococcusحالهStaphylococcus aureus (43 ،)البكتيريه كانت متمثله

pneumoniae (33 ،)حالهEscherichia coli (31 ،)حالهSalmonella typhi (28

حالهHaemophilus influenzae (20 ،)حالهBacillus spp (25 ،)حاله(،

Klebsiella pneumoniae (13 و )حالهPseudomonas aeruginosa (11 ،)حاله

حالهHepatitis B (25 .)حاله( و 26) Hepatitis Cبينما كانت االصابات الفيروسيه

اليوجد هناك تاثير في توزيع االصابات حسب الجنس ، بينما كانت نسب االصابه في

عينه تجرثم دموي 100من مما هي عليه في المدينه. في هذه الدراسه وجد ان الريف اعلى

ملم/ساعه( و ESR >35 عينه ) 94، (ملغم/لتر CRP>24 عينه ) 91وثالسيميا ،كانت

Staphylococcus aureus/مل(.اظهرت بكتريا الـ WBCs >15000عينه ) 89

و Amikacin, Nitrofurantoin Norfloxacinحساسيه تجاه المضادات

Ofloxacin بينما لبكتريا الـStreptococcus pneumoniae فكانت نسب المضادات

,Amikacin, Amoxicillin, Cefodizime, Chloromphenicolاعلى وشملت

Clarithromycin Gentamycin, Kanamycin, Lincomycin,

Nitrofurantoin, Norfloxacin, Ofloxacin, Oxacillin, Oxytetracyclin,

Penicillin and Rifampin اما لبكتريا Bacillus spp. فكانت المضادات

,Amikacin, Chloromphenicol, Gentamycin, Kanamycinالتاليه

Nitrofurantoin Norfloxacin, Ofloxacin, Piperacillin, Tetracycline,

Tobramycin and Vancomycin .

*علي حسين المرزوكي

*امال راغب شمران

*زينه شاكر الهندي

بايولوجي جامعة بابل/كلية العلوم للبنات *

زهراء محمد الطائي

بايولوجي جامعة بابل/كلية العلوم محمد كاظم النافعي

بايولوجي مستشفى بابل للوالده

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AL-Qadisiya Journal For Science Vol.14 No. 3 Year 2009

Haemophilus influenzaeاما بكتريا الـ فقد اظهرت حساسيه تجاه Ceftizoxime ،

Ofloxacin ، Tetracycline اظهرت سالالت الـ . Escherichia coli حساسيه تجاه

,Amikacin Chloromphenicol, Nitrofurantoinالمضادات الحياتيه التاليه :

Ofloxacin, Norfloxacin ، بينما بكتريا Pseudomonas aeruginosa كانت

ساسه تجاه ح Norfloxacin, Ofloxacin, Piperacillin, Tobramycin بكتريا ،

Proteus species كانت حساسه للمضادات Amikacin, Amoxicillin ,

Cefodizime, Cefoxitin Cephalexin, Gentamycin, , Norfloxacin,

Piperacillin, Tobramycin و Klebsiella pneumoniae كانت حساسه تجاه

Amikacin, Norfloxacin, Piperacillin, Tobramycin.