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Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 231-232

Secondary bacterial infection in dengue fever in children: A reality or illusion?

Department of Pediatric Critical Care and Pulmonology, Sri Balaji Action Medical Institute, New Delhi, India

Date of Submission16-Aug-2020
Date of Acceptance24-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Pradeep Kumar Sharma
Flat No. 48, Pocket-7, Sector-21, Rohini, New Delhi - 110 086
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_130_20

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How to cite this article:
Sharma PK. Secondary bacterial infection in dengue fever in children: A reality or illusion?. J Pediatr Crit Care 2020;7:231-2

How to cite this URL:
Sharma PK. Secondary bacterial infection in dengue fever in children: A reality or illusion?. J Pediatr Crit Care [serial online] 2020 [cited 2021 Jun 25];7:231-2. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/231/295017

Dengue fever is a common tropical infection, and its incidence has grown dramatically worldwide in recent decades. According to the World Health Organization, it causes 390 million viral infections per year, with 96 million infections manifesting clinically (with any severity of disease).[1] As per the National Vector Borne Disease Control Programme until November 2019, India, reported 136,422 cases, with 132 mortality,[2] which were slightly higher than the national average of the last 5 years.

Secondary bacterial infections in a child with dengue have the potential to adversely affect the clinical course of the disease and prolong the hospital stay. The incidence of secondary bacterial infection in dengue seems to be low; however, the pediatric literature is currently sparse in this regard. Cause of bacterial coinfection is not well understood, but some authors suggest that immunological alterations such as leukopenia, the proliferation of lymphocytoid and plasmacytoid cells, lymphocytolysis, lympho-phagocytosis, depletion of lymphocyte and breakdown of digestive epithelial barrier (endothelial damage or intestinal hemorrhage) help pathogens to enter the circulation.[3] Most of the documented infections are bacteremia or urinary tract infection (UTI) caused by enteric Gram-negative rods along with Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae. One case report shows coinfection by Pseudomonas aeruginosa.[3] In an adult study by Lee et al., it was found that 5.5% of the patients with dengue infection had bacteremia.[4] Another adult study conducted among patients with confirmed dengue cases with prolonged fever (>5 days), the incidence of secondary bacterial infection was 25%.[5] There are very few studies on this topic among children. In most of the cases, bacteremia is diagnosed. Although sterile pyuria is common, the incidence of culture-proven UTI is low. Adrizain et al. observed that there is a relatively higher use of antibiotics in private setup compared to teaching hospitals in suspicion of secondary bacterial infection.[6] The author himself, in his study of antibiotics usage, observed that in 203 dengue patients with various grades of severity, only 20 (9.8%) required antibiotics.[7]

In this issue, there is an article by Udayasankar et al. on secondary bacterial infection in dengue fever and associated risk factors, which is a retrospective observational study in children.[8] This is a good effort by the authors as literature is scarce in children. They observed 423 children, among which 83 children had persistent fever. Of these 83 children, 29 (34.9%) were culture positive confirmed sepsis and 7 had positive sepsis screen hence labeled as probable sepsis. They observed 8.5% (36/423) of all dengue patients had secondary bacterial infection, among which 6 had bacteremia and 20 had UTI. The incidence of secondary bacterial infection in all dengue cases and dengue with persistent fever is higher than as reported previously. The author reported a very high incidence of UTI and they could not provide any specific reasons behind this high incidence. Coinfection with bacterial pathogens is more in infancy and in severe dengue cases, which is similar as reported by Pandey, and Hongsiriwon.[3],[9] Causative organisms observed by authors are similar to previous studies. The author observed that a longer duration of fever (>5 days) is associated with a higher incidence of secondary bacterial infection (P = 0.020). This is an important finding, and it may help to diagnose secondary bacterial infection in endemic regions like India.

Currently, we are at crossroads with national guidelines on the management of dengue fever not including antibiotics at any stage and many reports of the injudicious and high rate of antibiotic usage in dengue fever. However, antibiotic usage in a case actually complicated by secondary bacterial infection is crucial to improve outcomes. A balanced approach where unnecessary antibiotic usage as well as appropriate usage in dengue fever is need of hour. A national or state registry or multicenter studies may provide more insight and help in forming future treatment guidelines for dengue fever.

  References Top

Dengue and Severe Dengue. World Health Organization. Available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue. [Last accessed on 2020 Jul 05].  Back to cited text no. 1
Dengue/DHF situation in India. National Vector Borne Disease Control Programme. Available from: https://nvbdcp.gov.in/index4.php?lang=1&level=0&linkid=431&lid=3715. [Last accessed on 2020 Aug 10].  Back to cited text no. 2
Pandey M. Case report secondary infection in immuno-competent children with dengue: Case series. Indian J of Child Health 2014;1:74-7.  Back to cited text no. 3
Lee IK, Liu JW, Yang KD. Clinical characteristics and risk factors for concurrent bacteremia in adults with dengue hemorrhagic fever. Am J Trop Med Hyg 2005;72:221-6.  Back to cited text no. 4
Premaratna R, Dissanayake D, Silva FH, Dassanayake M, de Silva HJ. Secondary bacteraemia in adult patients with prolonged dengue fever. Ceylon Med J 2015;60:10-2.  Back to cited text no. 5
Adrizain R, Setiabudi D, Chairulfatah A. The inappropriate use of antibiotics in hospitalized dengue virus-infected children with presumed concurrent bacterial infection in teaching and private hospitals in Bandung, Indonesia. PLoS Negl Trop Dis 2019;13:e0007438.  Back to cited text no. 6
Sharma PK, Kumar M, Sahani A, Goyal R, Aggarwal GK, Kumar V, et al. Evaluation of antibiotics use in a tertiary care pediatric intensive care and high-dependency unit. J Pediatr Crit Care 2020;7:131-5.  Back to cited text no. 7
  [Full text]  
Udayasankar S, Sivakumar V, Sundaramurthy R. Secondary bacterial infection in dengue fever and associated risk factors – An observational study in children. J Pediatr Crit Care 2020;7:243-8.  Back to cited text no. 8
  [Full text]  
Hongsiriwon S. Dengue hemorrhagic fever in infants. Southeast Asian J Trop Med Public Health 2002;33:49-55.  Back to cited text no. 9


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