Bacterial Pathogens, Antimicrobial susceptibility Pattern and predictors of Lower Respiratory Tract Infection among Children admitted in health care settings in South Ethiopia

doi:10.21203/rs.3.rs-3638376/v1

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Bacterial Pathogens, Antimicrobial susceptibility Pattern and predictors of Lower Respiratory Tract Infection among Children admitted in health care settings in South Ethiopia

https://doi.org/10.21203/rs.3.rs-3638376/v1

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Background

Lower respiratory tract infection is the most widespread health problem that requires frequent hospitalization. It is the leading cause of childhood death, accounting for 16% of all deaths worldwide. An increase in antibiotic resistant strains of bacterial pathogens among children, mainly in hospitals and in the community, aggravates this problem.

Objective

To assess the prevalence of bacterial pathogens of lower respiratory tract infections, antibiotic susceptibility patterns and associated factors among children attending Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, from October 30, 2022 to April 1, 2023.

Methods

A hospital-based cross-sectional study was conducted on 329 children who visited the outpatient department of Wolaita Sodo University Comprehensive Specialized Hospital. The socio-demographic data was collected using pre-structured questionnaires. Bronchoalveolar lavage samples were collected aseptically and inoculated onto macconkey agar, chocolate agar, and blood agar, then incubated for 24 hours at 37℃. Biochemical testing was performed on colonies from pure cultures for the final identification of the isolates. Antimicrobial susceptibility testing was done using the Kirby-Bauer disk diffusion method. Data was entered into EpiData version 3.1 and exported to SPSS version 23 for analysis. Variables with a P-value of 0.25 in bivariate analysis were taken into multivariable logistic regression analysis to control potential confounding factors. Finally, the p-value < 0.05 was used as a significant association with lower respiratory tract infection.

Result

Out of the 329 bronchoalveolar lavage samples, 38.9% were found to be positive for LRTI with different bacterial isolates. The most predominant bacteria were K. pneumonia, 29.7%, followed by S.aureus, 27.3%, and E. coli, 26.6%. E. coli showed higher resistance 31(91.2%) to amoxicillin/clavulanic acid, and meropenem each 29(85.3%). S. aureus were pan resistant to penicillin and augmentin. Among the isolates of S. aureus, 15(43%) were extrapolated as methicillin-resistant S. aureus). Isolates of CoNS were 100% resistant to penicillin, and tetracycline. All isolates of S. pneumonia were resistant to penicillin and 5(83.7%) isolates were resistant to tetracycline and 4(66.7%) were resistant to vancomycin. Being under five [AOR = 0.32: 95% CI, 0.151, 0.68], having no formal education [AOR = 6: 95% CI, 2.178, 16.548] non-exclusive breast feeding [AOR = 0.43 95% CI, 0.206, 0.894], lack of iron folate intake [AOR = 0.3495% CI, 0.178, 0.642], and cooking area without window [AOR = 2.42 95% CI, 1.091, 5.354], were predictors for lower respiratory tract infections.

Conclusion

The overall prevalence of LRTI was relatively higher. K. pneumonia and S. aureus were the predominant bacteria. Hence, regular monitoring of LRTI etiologies and antimicrobial drug resistance testing is essential to maximize the shelf life of effective drugs. Age < 5 years old, lack of formal education, non-exclusive breastfeeding, iron folate intake, and a cooking area without windows were significantly associated with LRTI. It is advisable to continuously monitor trends in antimicrobial resistance pattern.

Lower respiratory tract infection

Bacteria

Antimicrobial susceptibility

predictors

Wolaita

children

Lower respiratory tract infections (LRTIs) are among the most common infectious diseases affecting children worldwide and they are responsible for causing severe morbidity and mortality both in developed and developing nations [1]. Lower respiratory tract bacterial infection is the most frequently diagnosed disease after viral upper respiratory tract infection in infants and young children and is the number one reason for the prescription of antibiotics in pediatric practices[2].

The most common bacteria that cause LRTIs among children with varying distribution are Streptococcus pneumonia, Haemophilus influenza, Klebsiella pneumonia, E. coli and Staphylococcus aureus which are frequent causes of morbidity and mortality among children all over the world, mainly in developing countries [3–5].

Antibiotics are very commonly prescribed for children presenting with uncomplicated LRTI. The increased prevalence of resistance among S pneumonia and H.influenzae pathogens poses a serious challenge in the successful treatment of respiratory tract infections due to those pathogens. Antimicrobial resistance disease burden was significantly impacted by drug resistance in LRTI like pneumonia, which resulted in more than 400,000 deaths and led to over 1.5 million additional death.[6–7]

The emergence and spread of drug-resistant pathogens that have acquired new resistance mechanisms, leading to antimicrobial resistance, continues to threaten our ability to treat common infections. Especially alarming is the rapid global spread of multi- and pan-resistant bacteria that cause infections that are not treatable with existing antimicrobial medicines such as antibiotics [8].

Serious arrays of evidences depicted factors like fetal growth measures, the number of children in the household, maternal education, maternal age, maternal smoking, and low socioeconomic status. Nonexclusive breastfeeding, air pollution, indoor crowding, and lack of immunization in children under one year of age, smoking, zinc deficiency, the mother’s experience as a caregiver, concomitant diseases (e.g., asthma, diarrhea, heart disease, etc.), daycare attendance, humidity and cold weather, vitamin A deficiency, and outdoor air pollution are parent-related risk factors or susceptibility factors for LRTIs [9–13].

Ethiopia is one of the sub-Saharan countries where significant number of under five years children suffering from LRTIs [14]. According to the 2016 Ethiopia Demographic Health Survey report, prevalence of 7% LRTI among children under 5 was reported [15].

Despite their frequent incidence in clinical settings, diagnosis and treatment are still a challenge for pediatricians due to the wide deviations in their clinical manifestations. Consequently, inappropriate treatment can result in the progression of irreversible complications. Expeditious detection of underlying bacterial pathogens and appropriate treatment with antibiotics can hamper the progression of the disease. For this, thorough knowledge of the etiological profile and associated risk factors is important in determining the effective treatment regimens. Therefore, this study is aimed to assess the prevalence of bacterial pathogens of LRTI, antibiotic susceptibility patterns and associated factors among children attending Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia.

Study setting and design and participants

This institutional based cross-sectional study was conducted at Wolaita Sodo University comprehensive specialized hospital (WSUCSH) from August 1 to Oct 30, 2022 to April 30 2023. The WSUCSH is found in Wolaita Sodo town, southern Ethiopia which is located 329 km south of Addis Ababa, the capital city of Ethiopia. The hospital gives service to Wolaita zone and other adjacent neighboring. It services more than 5 million people around the area. The hospital has around 372 beds for inpatient service, which is on medical, emergency and critical care units, pediatrics, surgical, gynecology, eye unit, and obstetrics. Based on patient flow in the previous three months, 990 children were estimated to visit pediatric OPDs in the study period. The study was conducted on 329 children. The sample size was determined using a single population proportion formula with consideration of the prevalence of LRTI, 26.5% that was taken from a study done in Addis Ababa, Ethiopia [16] with, a 95% confidence interval, 5% marginal error, and 10% non-response rate.

The study participants were recruited using systematic random sampling from children who visit the WSUCSH pediatric outpatient department (POPD) during the study period with clinical features of a LRTI and fulfilled the inclusion criteria were considered as the study population. Children who were critically ill, needed immediate medical attention, or who had received antibiotics within the previous two weeks were excluded

Data collection and laboratory examination

The study utilized a structured questionnaire that was adapted and modified from previous research conducted on similar populations in national and international studies. The questionnaire comprises socio-demographic factors, maternal and child factors, environmental factors, and the outcome variable acute LRTIs.

Specimen collection and culturing

The bronchoalveolar lavage (BAL) specimen was collected aseptically by a trained physician using bronchoscope, a lighted tube. The tube is inserted through the nose into the airways, a saline solution is used to wash and collect a fluid sample, which is then sent to the central microbiology laboratory within 30 minutes to 1 hour. The collected specimens were streaked on MacConkey agar, chocolate agar, and blood agar (Oxoid UK), followed by incubation at 37°C for 24 hours. The pure isolate of pathogen/s was stored in the refrigerator at 4 ± 1°C. The isolates were identified and characterized, based on Gram stain, colonial morphology, and biochemical tests (such as catalase test, coagulase test, bacitracin, TSI, simon’s Citrate Agar, SIM, indole test, and oxidase test from primary cultures for the final identification of the isolates [17].

Antimicrobial susceptibility test

Antimicrobial susceptibility testing was done using the Kirby-Bauer disk diffusion method according to Clinical and Laboratory Standards Institute (CLSI) guidelines on Mueller Hinton agar (Oxoid ltd, UK) prepared with 4mm thickness. A pure colony isolates will be dissolved in 3-4ml normal saline and the turbidity of growth becomes equivalent to 0.5 McFarland.

A sterile cotton swab was then dipped into the suspension and the excess was removed by gentle rotation of the swab against the inner surface of the tube. The swab was used to distribute the bacterial suspension evenly over the entire surface of Mueller Hinton agar and antimicrobial disks [18]. The discs was placed at least 24mm away from each other and 15mm from the edge to avoid the overlapping of the zone of inhibition and pressed down to ensure complete contact with the agar surface. The plates were inverted upside down and incubated aerobically at 37°C for 18 to 24 hours. The diameter of the zone of inhibition around each disc was measured to the nearest whole ml by using a digital caliper. Then, the bacterial isolates were classified as sensitive (S), intermediate (I) or resistance (R) by comparing against the inhibition zone diameter of interpretative standards as indicated in the guideline of CLSI.

Quality control

The questionnaire was pre-tested on 5% and adjustment of the questions was made after the pretest. Two days of orientation was given for data collectors on the objective of the study and the art of interviewing. For laboratory personnel, the orientation was given by senior microbiologists who have the qualifications and experience in related laboratory work. The standard operating procedure was strictly followed and the result was checked by the senior microbiologist. Quality control of culture media was done for the sterility test. Standard reference strain of American type culture collection S. aureus (ATCC-25923) and E. coli (ATCC-25922) was used for both media and antibiotics discs.

Data entry and analysis

The data was entered into EPI data version 3.1 and exported to Statistical Package for Social Sciences version (SPSS) 25 for data analysis. Bivariate logistic regression was used to check variables having an association with LRTIs, and those variables found to have a p-value of < 0.25 were further analyzed using multiple logistic regressions. Odds ratios (ORs) with 95% CIs were computed and a variable with a p-value < 0.05 was considered a significant variable.

Operational Definitions

Multidrug resistance isolates non-susceptibility to at least one drug in three or more antimicrobial categories [19].

Children A child between birth and puberty, or between the developmental period of infancy and puberty < 15 years.

Socio-demographic characteristics

A total of 329 children with respondent rate of 100% enrolled in this study, out of whom 178(54.1%) were male. The majority of the participants (41.6%) were in the age range of 10-14 years or older, and more than half (56.2%) were from urban areas (Table 1).

Table 1 Socio-demographic characteristics of children (n=329) attending WSUCSH, Ethiopia, 2023(n=329).

I. Socio-demographic characteristics
Characteristics	Category	Frequency	Percentage
Sex	Male	178	54.1%
Sex	Female	151	45.9%
Age	0-4 year	69	21.0%
	5-9year	123	37.4%
	10-14year	137	41.6%
Residence	Urban	185	56.2%
Residence	Rural	144	43.8%
Occupation of the mother	Government worker	102	31.0%
	Merchant	100	30.4%
	Farmer	73	22.2%
	Housewife	54	16.4%
Educational status	No formal education	73	22.2%
	primary education	79	24.0%
	Secondary education	127	38.6%
	College and above	50	15.2%

Mother and child related clinical factors

Considerable proportion of the participants were having a history of respiratory tract infection within two weeks, 84(25.5%), whereas only a tiny fraction of them, 25(7.6%), had a history of parental chronic illness. Likewise, 85(25.8%) of the participants mentioned that they had not taken vitamin A supplementation. Twelve (3.2%) children were not immunized, and about 63(19.1%) were completely immunized. On the other hand, 271 (82.4%), were exclusively breastfed in the first six months (table 2).

Table 2. Mother and child related clinical characteristics WSUCSH, Southern, Ethiopia 2023. (n=329)

Characteristics		Category	Frequency		Percentage
Immunization status of child	Immunized		254	77.2%
	Incomplete		63	19.1%
	Nonimmunized		12	3.6%
Breastfeeding in the first six month	Nonexclusive breast feeding		58	17.6%
	Exclusive Breastfeeding		271	82.4%
Vitamin A supplementation	No		85	25.8%
	Yes		244	74.2%
Parental chronic illness	No		304	92.4%
	Yes		25	7.6%
Maternal iron folate intake	No		96	29.2%
	Yes		233	70.8%

Environmental related factors

A considerable proportion of the participants, 190(55.8%), had a family size in the range of 4–6, whereas 20(6.1%) had smokers in the house. When participants asked who was the caretaker for the children, only 42(12.8%) of the participants mentioned their fathers. A total of 195(50.3%) participants responded that they have separate kitchens. Concerning the availability of windows for their cooking area, 143 (43.5%) of them lacked the cooking area window (table 3).

Table 3 Environmental related factors among children attending WSUCSH Southern, Ethiopia, 2023

Characteristics		Category	Frequency		Percentage
Family size	1-3		76	23.4%
	4-6		190	55.8%
	7-9		60	18.2%
	>9		3	0.9%
Smoker in house	No		309	93.9%
	Yes		20	6.1%
Who gave care for a child	Mother		287	87.2%
	Father		42	12.8%
Do you have a separate kitchen?	No		134	40.7%
	Yes		195	59.3%
The cooking area has a window	No		143	43.5%
	Yes		186	56.5%

Types and prevalence of bacterial isolates

The overall prevalence of bacterial LRTI among children is 128/329 (38.9%). The isolated bacteria were S. aureus, Coagulase-negative Staphylococci (CoNS), and S. pneumonia, K. pneumoniae and E. coli. The most predominant bacteria were K. pneumoniae 38/128 (29.7%), followed by S.aureus 35/128 (27.3%), and E. coli 34/128 (26.6%). CoNS (15) were not lesser. Out of the 128 total bacterial isolates, MDR was found in the case of 60(47%) isolates.

Antimicrobial susceptibility patterns of gram-negative bacterial isolates

Isolates of GNB showed a wider range of variations in terms of their susceptibility (11.1% to 66.7%) as well as resistance (27.7 to 89.5%). The GNB isolates showed high resistance to meropenem 64/72(88.8%), tetracycline 63/72(87.5%), and augmentin, 57/72(79.2%). K. pneumoniae, showed 31(81.6%) sensitivity to gentamicin and became resistant 35(92.1%) to meropenem and 34(89.5%) to tetracycline. Sixty three percent (24/38) of K. pneumoniae were found to be MDR. E. coli showed higher resistance 31(91.2%) to augmentin, 29(85.3%) each to meropenem and tetracycline (Table 4). It also found to be 35.5% MDR.

Table 4. Antimicrobial susceptibility patterns of gram-negative bacterial isolates among children attending WSUCSH, Ethiopia, 2023.

Bacteria	Patterns	Antibiotics
Bacteria	Patterns	AUG N (%)	CIP N (%)	CAZ N (%)	GEN N (%)	TET N (%)	SXT N (%)	CHR N (%)	MERO N (%)
K.pneumoniae N= 38	S	10(26.3)	26(68.4)	9 (23.7)	27 (71.1)	3(7.9)	21(55.3)	28(73.7)	3(7.9)
	I	2(5.3)	2(5.3)	1(2.6)	4(10.5)	1(2.6)	3(7.9)	0	0
	R	26(68.4)	10(26.3)	28(73.7)	7(18.4)	34(89.5)	14(36.8)	10(26.3)	35(92.1)
E. coli N= 34	S	2(5.9)	14(41.2)	11(32.4)	17(50)	5(14.7)	13(38.2)	20(58.8)	5(14.7)
	I	1(2.9)	2(5.9)	1(2.9)	3(8.8)	0	2(5.9)	4(11.8)	0
	R	31(91.2)	18(52.9)	22(64.7)	14(41.2)	29(85.3)	19(55.9)	10(29.4)	29(85.3)

Abbreviation: SXT-Trimethoprim-sulfamethoxazole, CAZ-Ceftazidime, TTC-Tetracycline, AMC-Amoxicillin-clavulanate, CN - Gentamycin, CRO - Ciprofloxacin, CIP -Cefepime, Mem – Meropenem, and CHL-chloramphenicol

Antimicrobial susceptibility patterns of Gram-positive bacterial isolates

Similar to that of GNB isolates, a wider range of variations concerning resistance (19.6 to 100%) as well as susceptibility, (0 to 73.2%) were observed in GPB. GPB isolates were pan-resistant to penicillin, augmentin 37(90.3%), tetracycline, 48(85.7%) and cefoxitin 46(82.1%). S. aureus were pan resistant to penicillin and augmentin. Among the isolates of S. aureus, 15(43%) were extrapolated as methicillin-resistant S. aureus (MRSA) and 17/35 (48.6%) were found to be MDR. Isolates of CoNS were 100% resistant to penicillin, and tetracycline, whereas 86.7% were resistant to cefoxitin. On the other hand, isolates of CoNS were susceptible to ciprofloxacin and chloramphenicol each, 10/15(66.7%). All isolates of S. pneumonia were resistant to penicillin and five isolates were resistant to tetracycline and four were resistant to vancomycin, clindamycin and cefoxitin (Table 5).

Table 5. Antimicrobial susceptibility patterns of Gram-positive bacterial isolates among children attending WSUCSH, Southern, Ethiopia, 2023.

Isolates	Patterns	Antibiotic tested
Isolates	Patterns	PEN	AUG	CIP	CEFT	ERY	GEN	TET	VANC	SXT	CHR	CLND
S. aureus N= 35	S	0	0	24(68.6)	6(17.1)	15(42.9)	2262.9	3	1645.7	16 45.7	2674.3	1954.3
	%	0	0	68.6	17.1	42.9	62.9	8.6	45.7	45.7	74.3	54.3
	I	0	0	25.7	0	12.9	38.6	12.9	0	25.7	38.6	411.4
	%	0	0		0				0
	R	35100	35100	925.7	2982.9	1954.3	1028.6	3188.6	1954.3	1748.6	6	1234.3
	%										17.1
S. pneumoniae N=6	S	0	350	466.7	233.3	466.7	350	116.7	233.3	233.3	583.3	233.3
	%	0
	I	0	116.7	0	0	116.7	116.7	0	0	116.7	116.7	0
	%	0		0	0			0	0			0
	R	6100	2	233.3	4	116.7	2	583.7	466.7	350.0	0	466.7
	%		33.3		66.7		33.3				0
CoNS N=15	S	0	ND	960	213.3	320	7	0	860	973.3	1066.7	540.0
	%	0	ND				60.0	0
	I	0	ND	16.7	0	213.3	213.3	0	16.7	213.3	0	16.7
	%	0	ND		0			0			0
	R	15100	ND	533.3	1386.7	1066.7	640	15100	640	426.7	533.3	960
	%		ND

Abbreviation: SXT-Trimethoprim-sulfamethoxazole, CAZ-Ceftazidime, TTC-Tetracycline, AMC-Amoxicillin-clavulanate,CN-Gentamycin, CIP-Ciprofloxacin, Mem – Meropenem, CHL-chloramphenicol and ND-not done.

Multiple drug resistance Prevalence

Out of the 128 total bacterial isolates, MDR was found in the case of 60(47%) isolates.

Table 6. MDR pattern of bacterial pathogens among children attending WSUCSH, Southern, Ethiopia, 2023

Isolates	Number of total Isolates	Number of MDR isolates	MDR percentage
K. pneumoniae	38	24	63%
E. coli	34	12	35.3%
S. aureus	35	17	48.6%
CoNS	15	5	33.3%
S. pneumoniae	6	2	33.3%
Total	128	60	47%

Factors associated with LRTI

In multivariable logistic regression analyses, only five variables were found to be statistically significant (P<0.05). 1Children with the age of less than 9 years had less odds to get LRTI as compared to children with the age of 10-14 years (P<0.05). However, low maternal education increase odds of acquiring LTRI among child as compared to mothers educated of college and above (P<0.0P5). Moreover, children exclusive breast feeding, maternal iron folate in taking and cooking area having window had protective effects for LRTI in children (P<0.05) (Table-6).

Table 7. Factors associated with LRTI among children attending WSUCSH, Southern, Ethiopia from Aug 1 to Oct 30, 2023.

Characteristics	Significant growth of pathogen bacteria		Bivariate analysis		Multivariate analysis
	Yes, N =128	No N=201	P-value	COR (95% CI)	P-value	AOR (95% CI)
	n (%)		P-value	COR (95% CI)	P-value	AOR (95% CI)
Age of child 0-4 year	18 (14.1%)	51(25.4%)	0.003*	0.38 (0.202, 0.715)	0.003**	0.32 (0.151, 0.68)
5-9year	44(34.4%)	79 (39.3%)	0.044*	0.6 (0.364, 0.986)	0.005**	0.42(0.225, 0.77)
10-14year	66 (51.6%)	71(35.3%)	1	1
Residence Urban	65(50.8%)	120(59.7%)	1	1
Rural	63(49.2%)	81(40.3%)	0.112*	0 .7 (0.446, 1.089)	0.273	0.68 (0.343, 1.353)
Mother’s occupation Government worker	38(29.7 %)	64(31.8%)	1	1
Merchant	34(26.6%)	66(32.8%)	0.629	0.87(0.488, 1.544)	0.115	0.57(0.284, 1.147)
Farmer	35(27.3%)	38(18.9%)	0.158*	1.55(0.843, 2.855)	0.776	0.36(0.359, 2.148)
House wife	21(16.4%)	33(16.4%)	0.841	1.07 (0.544, 2.113)	0.840	0.92(0.396, 2.123)
Mother’s education No formal education	42(32.8%)	31(15.4%)	0.000*	5.42(2.354, 12.478)	0.001**	6(2.178, 16.548)
Primary education	34(26.6%)	45(22.4%)	0.008*	3.02(1.326, 6.888)	0.017**	3.25(1.233, 8.539)
Secondary education	42(32.8%)	85(42.3%)	0.089*	1.98(0.901, 4.335)	0.068	2.3(0.941, 5.457)
College and above	10(7.8%)	40(19.9%)	1	1
Immunization status Immunized	104(81.3%)	150(74.6%)	1	1
Incomplete	17(13.3%)	46(22.9%)	0.043*	0.53(0.290, 0.981)	0.170	0.61(0.301, 1.236)
Nonimmunized	7(5.5%)	5(2.5%)	0.241*	2 (0.624, 6.536)	0.470	1.66 (0.421, 6.539)
Exclusive Breastfeeding Yes	113(88.3%)	158(78.6%)	1	1
No	15(11.7%)	43(21.4%)	0.027*	0.49(0.258, 0.921)	0.024**	0.43(0.206, 0.894)
Vitamin A supplementation Yes	97(75.8%)	147(73.1%)	1	1
No	31(24.2%)	54(26.9%)	0.593	0.87(0.522, 1.450)
Parental chronic illness Yes	15(11.7%)	10(5.0%)	0.029*	2.54(1.102, 5.834)	0.065	2.5(0.945, 6.632)
No	113(88.3%)	191(95.0%)	1	1
Maternal iron foliate intake Yes	96(75.0%)	137(68.2%)	1	1
No	32(25.0%)	64(31.8%)	0.184*	0.7(0.434, 1.174)	0.001**	0.34(0.178, 0.642)
Smoker in house Ye	12(9.4%)	8(4.0%)	0.052*	2.5(0.991, 6.286)	0.213	2(0.672, 5.952)
No	116(90.6%)	193(96.0%)	1	1
Who gave care for child? Mother	109(85.2%)	178(88.6%)	1	1
Father	19(14.8%)	23(11.4%)	0.369	1.35 (0.702, 2.591)	-	-
Have separate kitchen
Yes	58(45.3%)	137(68.2%)	1	1
No	70(54.7%)	64(31.8%)	0.000*	2.58 (1.635, 4.082)	0.211	1.6 (0.766, 3.355)
The cooking area has a window
Yes	55(43.0%)	131(65.2%)	1	1
No	73(57.0%)	70(34.8%)	0.000*	2.48 (1.577, 3.914)	0.030**	2.42 (1.091, 5.354)

This study was aimed to detect prevalence of LRTI among children who visit WSUCSH pediatric outpatient department with clinical features of a LRTI. Among the total 128/329 (38.9%) were found to be positive for LRTI pathogen Five species of bacteria such as S. aureus, Coagulase-negative Staphylococci (CoNS), and S. pneumonia, K. pneumoniae and E. coli were responsible organisms for LRTI in the study area The most predominant bacteria isolated were K. pneumoniae, followed by S.aureus and E. coli Out of the 128 total bacterial isolated, MDR was found in the case of 60(47%) isolates. Isolates of GNB showed a wider range of variations in terms of their susceptibility (11.1% to 66.7%) as well as resistance (27.7 to 89.5%). Similarly, a wider range of variations concerning resistance (19.6 to 100%) as well as susceptibility, (0 to 73.2%) were observed in GPB. Age of children, low maternal education status, children with no exclusive breast feeding, no maternal iron foliate intake and cooking area with no window were significantly associated with LRTI in the study area.

In the present study, 38.9% of cases were found to be positive for LRTI among children with a clinical features of LRTI and this is in agreement with the results of an earlier study reported from Italy 39.1% [20]. On the other hand, our findings were lower than the results, 43.3%[21], 52.8%[22], and 64%[23], reported elsewhere. Our findings showed an upward trend compared to the data obtained from a couple of studies performed in central Nigeria 14.5%[24] and two studies previously done in Nepal 21.4%[25] and 24.6%[26]. The variations could be due to the differences in sample size allocation and patient follow/ capacity of hospitals. Besides, different clinical criteria used for diagnosing LRTI, inadequate health care and laboratory facilities, and types of infection-prevention control strategies followed by countries may have also impacted the magnitude of bacterial infection.

In our study, K. pneumoniae 29.7% was the most common isolate among isolated bacteria. This is in agreement with a series of previous studies done in various countries [22-27]. It is a point of concern that K. pneumoniae is the perfect example of human pathogen and is well known for causing LRTI among children. On the other hand, contrasting findings were also reported in different parts of the world where other bacteria like A. baumannii [20], and S. aureus [23] were the predominant ones. The diversity of pathogens in different studies is influenced by the source of infection, type, and severity of infection, sample collection, use of antibiotics for treatment and geographical variations.

In the present study, among isolates of GNB, chloramphenicol was the most effective (nearly 77.2% sensitivity) antibiotic and meropenem was the least effective one (88.8% resistance), rescinding empirical usage of meropenem in the management of LRTIs, which is a matter of grave concern as they are widely used as mainstay drugs and leave clinicians with few choices. K. pneumoniae showed 81.6% sensitivity to gentamicin, indicating that, it is the most effective drug. This result is similar to the values reported in past studies from Nigeria, 79% [26], and Bangladesh 100% [23]. In the case of E. coli, it demonstrated a high level of resistance against meropenem and tetracycline, 58.8%. This is in concordance with the study done in Nepal (meropenem, 56%) [20], but indifference with non-resistance reported elsewhere [20,23]. The variation in antibiotic resistance rate for these bacteria could be due to drug abuse, difference in strains, hospital stay, and drug policy in respective settings.

In our study, GPB isolates were pan resistant to penicillin, augmentin 90.26%, tetracycline 85.7% and cefoxitin 82.14%. S. aureus was the most common isolate among GPB, 27.34%, which is in agreement with a previous study done in Addis Ababa 26.5%[16]. On the other hand, the finding of this study is lower than the study carried out in Nepal 48.3%[28]. This situation shows a huge problem in the management of LRTIs caused by such bacteria pathogens. Analysis of resistance rates for gram positive isolates indicated that all of(100%) the isolates of S. aureus were resistant to each penicillin and augmentin. The increased rate of resistance of both gram negative and gram positive bacteria pathogens to routinely used antibiotics was observed in our study. This situation shows a huge problem in the management of LRTIs caused by such bacteria pathogens.

In multivariable logistic regression analysis, the age of the participant, educational status of the mothers, exclusive breastfeed, maternal iron folate intake, and cooking area without a window were variables statistically significant to bacterial LRTI among children. It showed that children under the age of 10 years are susceptible to LRTI when compared to children above the age of 10 years. This may be the reason those children have an immature immune system and are susceptible to crowded environments at school. The risk of LRTI illness was six times greater for children of mothers with no formal education as compared to children of mothers with college and above level. The findings of this study were supported by earlier studies done [28-30].

The overall prevalence of LRTI was high, that is 38.9%. K. pneumonia and S. aureus were found to be the most prevalent causative agents. The most effective antibiotics against GNB and GPB hat cause LRTI are chloramphenicol, gentamicin, and ciprofloxacin, for the management of LRTI in the study area. However, GNB isolates showed high resistance to meropenem, tetracycline and augmentin, whereas GPB isolates were pan-resistant to penicillin, augmentin , tetracycline, and cefoxitin. The prevalence of MRSA among isolates of S. aureus was found to be 43%. The age of the participant, educational status of the mothers, exclusive breastfeed, maternal iron foliate intake, and cooking area without window were variables statistically significant to bacterial LRTI among children.

Due to the high frequency of LRTI observed in the present study, we recommend the following points to be included in the management of LRTI among children in the study area. It is advisable to continuously monitor trends in antimicrobial resistance patterns. Examination and monitoring for resistant strains at definite time intervals should be done by the hospital infection control committee. Health professionals advise women to take maternal iron folate intake and exclusively breastfeed their children. Supporting and increasing public awareness of child spacing, as well as encouraging and increasing awareness of female education. To help decrease the risk of LRTI, it is recommended cooking environment should have a window in the house.

AOM:-Acute Otitis Media; ARTI:- Acute Respiratory Tract Infection; BAL:- Bronchoalveolar Lavage ;GNB:-Gram-negatives bacteria; GPB:-Gram-positive bacteria; LRTI:-Lower Respiratory Tract Infection; PEOPD:- Pediatric Emergency Out Patient Department; POPD:- Pediatric Out Patient Department ;RTI:-Respiratory Tract Infection; URTI………….Upper Respiratory Tract Infection; WHO …………World Health Organization; WSU………….Wolaita Sodo University; WSUCSH…….Wolaita Sodo University Comprehensive Specialized Hospital

Ethics approval and consent to participate

Ethical consideration:- Ethical clearance was obtained from the institutional review board of the College of Health Sciences and Medicine, Wolaita Sodo University, with project No CHSM/ERC/05/14. Parents of study participants were recruited after they were informed about the objectives and use of the study and after they gave informed assent. For all confirmed positive cases, the clinician responsible for the study subjects provided consent. All the information contained within the study was kept confidential. During the study, the positive study participant for LRTI for any pathogenic bacteria was linked to POPD immediately.

Consent to publish:- Not applicable

Availability of data:- The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. E-mail [email protected]

Competing interest:- All authors declare that they have no competing interest

Funding:-This research is funded by Wolaita Sodo University

Author’s contribution:- SD, FS: Conceived the study, study design, execution, acquisition of data, analysis, and interpretation. SD, TT, SS, and FS: Contributed to the design, drafted or written, or substantially revised or critically reviewed the article. SD, TT, SS and FS: Agreed on the journal to which the article will be submitted. SD, TT, SS and FS: Reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage. All authors agree to take responsibility and be accountable for the contents of the article.

Acknowledgment:- We would like to express our deepest gratitude to the staffs of Wolaita Sodo University Teaching Referral Hospital, data collectors and study participants.

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No competing interests reported.

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Bacterial Pathogens, Antimicrobial susceptibility Pattern and predictors of Lower Respiratory Tract Infection among Children admitted in health care settings in South Ethiopia

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