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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

doi: 10.1097/CCM.0b013e318260c7f8
Pediatric Critical Care

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.

From the Section of Critical Care Medicine (TN, UGK, NJ, MHT, JAC-B, FL, LL), Department of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital; Division of Thrombosis Research, Department of Medicine (TN), Baylor College of Medicine, Houston, TX; and Division of Transfusion Medicine, Blood Bank and Coagulation (JT), Departments of Pathology, Pediatrics, and Medicine, Baylor College of Medicine/Texas Children’s Hospital, Houston, TX.

Supported by National Institute of Health, National Institute of General Medical Sciences, 5K08GM83212; National Heart Lung and Blood Institute (contract #HHSN268200536179C-N01-HR-56179), Department of Health and Human Services.

Drs. Nguyen and Kyle designed and performed the research, analyzed the data, and wrote the article. Ms. Jaimon designed and performed the research. Drs. Tcharmtchi, Coss-Bu, and Loftis designed, analyzed, and wrote the article. Drs. Lam and Teruya analyzed and wrote the article. All authors checked the final version of the manuscript.

The authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: tcnguyen@texaschildrenshospital.org

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