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Critical Care Medicine:
doi: 10.1097/CCM.0b013e318260c7f8
Pediatric Critical Care

Coinfection with Staphylococcus aureus increases risk of severe coagulopathy in critically ill children with influenza A (H1N1) virus infection

Nguyen, Trung MD; Kyle, Ursula G. MS, RD/LD; Jaimon, Nancy BS, RN; Tcharmtchi, M. Hossein MD; Coss-Bu, Jorge A. MD; Lam, Fong MD; Teruya, Jun MD; Loftis, Laura MD

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Abstract

Objectives: H1N1 influenza with coinfections has been implicated to have high morbidity and mortality. We hypothesized that critically ill children with 2009 H1N1 and coinfections are at a higher risk of developing disseminated intravascular coagulation.

Design: The chart review included demographics, length-of-stay, severity of illness score (Pediatric Risk of Mortality III acute physiology score), clinical laboratories, and outcomes at hospital day 90 data. Patients were classified as having methicillin-sensitive or -resistant Staphylococcus aureus, other, or no coinfections.

Setting: Single-center pediatric intensive care unit.

Patients: Sixty-six consecutive patients with 2009 H1N1 and influenza A infection.

Interventions: None.

Main Results: There were 12, 22, and 32 patients with methicillin-sensitive or -resistant Staphylococcus aureus, other, and no coinfections, respectively. Pediatric critical care unit length-of-stay was 11, 10, and 5.5 days (median), and survival at day 90 was 83%, 96%, and 91% in patients with methicillin-sensitive or -resistant Staphylococcus aureus, other, and no coinfections. Patients with methicillin-sensitive or -resistant Staphylococcus aureus coinfections compared to patients with other, and no coinfections had higher Pediatric Risk of Mortality III acute physiology scores (14 [6–25] vs. 7 [2–10], p = .052 and 6 [2.5–10], p = .008; median [interquartile range]), higher D-dimer (16.1 [7.9–19.3] vs. 1.6 [1.1–4], p = .02 and 2.3 [0.8–8.7] µg/mL, p = .05), longer prothrombin time (19.3 [15.4–25.9] vs. 15.3 [14.8–17.1], p = .04 and 16.6 [14.7–20.4] secs, p < .39) at admission, and lower day-7 platelet counts (90K [26–161K] vs. 277K [98–314], p = .03 and 256K [152–339]/mm3, p < .07). Patients with methicillin-sensitive or -resistant Staphylococcus aureus coinfections compared to patients without coinfections were more likely to be sicker with Pediatric Risk of Mortality III acute physiology score >10 vs. <10 (relative risk 2.4; 95% confidence interval 1.2–4.7; p = .035) and have overt disseminated intravascular coagulation (relative risk 4.4; 95% confidence interval 1.3–15.8, p = .025).

Conclusions: During the 2009–2010 H1N1 pandemic, pediatric patients with influenza A and methicillin-sensitive or -resistant Staphylococcus aureus coinfections were sicker and more likely to develop disseminated intravascular coagulation than patients with other or no coinfections.

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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