THE EFFECTIVENESS OF ANTIBACTERIAL THERAPY IN REDUCING THE FREQUENCY OF INFECTIOUS COMPLICATIONS IN CHILDREN WITH HEART DEFECTS AFTER CARDIAC SURGERY Текст научной статьи по специальности «Клиническая медицина»

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PAPERS IN ENGLISH

CLINICAL MEDICINE

PEDIATRICS

DOI: 10.32743/UniMed.2025.118.1.19107

THE EFFECTIVENESS OF ANTIBACTERIAL THERAPY IN REDUCING THE FREQUENCY OF INFECTIOUS COMPLICATIONS IN CHILDREN WITH HEART DEFECTS

AFTER CARDIAC SURGERY

Tazhibayeva Karlygash

PhD, doctor of medical sciences, associate professor, Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty

Aman Berkinbay

Resident 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, E-mail: [email protected] https://orcid.org/0000-0002-3973-7283,

Inabat Alpysbay

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, E-mail: [email protected] https://orcid.org/0009-0005-9607-83326,

Gulbibi Bakhtash

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, E-mail: [email protected]

Dinara Kobey

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, E-mail: [email protected] https://orcid. org/0009-0000-8436-217X,

Dilnaz Kazhgaliyeva

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, E-mail: kazhgaliyeva.d@mail. ru

Библиографическое описание: THE EFFECTIVENESS OF ANTIBACTERIAL THERAPY IN REDUCING THE FREQUENCY OF INFECTIOUS COMPLICATIONS IN CHILDREN WITH HEART DEFECTS AFTER CARDIAC SURGERY // Universum: медицина и фармакология : электрон. научн. журн. Tazhibayeva K. [и др.]. 2025. 1(118). URL:

https://7universum.com/ru/med/archive/item/19107

№ 1 (118)_январь. 2025 г.

Nursaya Kazhgaliyeva

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, Е-mail: [email protected] https://orcid.org/0009-0005-1360-6460,

Kamar Koshkarbaeva

Intern 2nd year,

Kazakh National Medical University named after S.D. Asfendiyarov NCJSC,

Kazakhstan, Almaty, Е-mail: [email protected]

ЭФФЕКТИВНОСТЬ АНТИБАКТЕРИАЛЬНОЙ ТЕРАПИИ В СНИЖЕНИИ ЧАСТОТЫ ИНФЕКЦИОННЫХ ОСЛОЖНЕНИЙ У ДЕТЕЙ С ПОРОКАМИ СЕРДЦА ПОСЛЕ КАРДИОХИРУРГИЧЕСКИХ ОПЕРАЦИЙ

Тажибаева Царлыгаш Нартбаевна

PhD, доктор медицинских наук, доцент, НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы

Беркинбай Аман Бакытжанович

резидент 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: [email protected] https://orcid. org/0000-0002-3973-7283,

Алпысбай Инабат Болысбекцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: [email protected] https://orcid.org/0009-0005-9607-8332,

Бахташ Гулбиб1 Жандосцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: bahtashg@gmail. com

Квбей Динара ЭдЫцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: [email protected] https://orcid. org/0009-0000-8436-217X,

Цажгалиева Дильназ Нурланцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: kazhgaliyeva.d@mail. ru

A UNiVERSUM:

№1(118)_январь, 2025 г.

Цажгалиева Н^рсая Арматцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: [email protected] https://orcid.org/0009-0005-1360-6460,

Цошцарбаева Цамар Махсетбайцызы

интерн 2 курса,

НАО Казахский Национальный медицинский университет им. С.Д. Асфендиярова,

Республика Казахстан, г. Алматы, Е-mail: k [email protected]

ABSTRACT

Each year, the number of open surgeries for congenital heart defects in our country increases; however, despite the introduction of new technologies, infections and complications remain a significant issue. This contributes to the worsening of disease progression, increased mortality and complication rates, significantly reduces the results of surgical interventions, and raises the economic costs for hospitals.

Among the 62 children in the group, n=13 (20.96%) were identified with complications, the main ones being: postoperative pneumonia — n=5 (8.06%), wound infection — n=4 (6.45%), mediastinitis — n=2 (3.23%), sepsis and infectious endocarditis, pyopneumothorax — n=3 (4.84%). The most common microorganisms identified were: Staphylococcus aureus — 14.51%, Staphylococcus epidermidis — 12.9%, Klebsiella spp. and Pseudomonas aeruginosa — 11.3%, Candida — 8.1%, Escherichia coli, and other infections — 6.45%. Carbapenems and glycopeptides demonstrated the highest efficacy (up to 92% and 90%, respectively).

АННОТАЦИЯ

Каждый год в нашей стране увеличивается количество открытых операций на врожденных пороках сердца, однако, несмотря на внедрение новых технологий, инфекции и осложнения остаются актуальной проблемой. Это способствует ухудшению течения заболевания, повышению уровня смертности и осложнений, значительно снижает результаты хирургических вмешательств и увеличивает экономические затраты для больниц.

Из 62 детей в группе n=13 (20,96%) были выявлены осложнения, основными из которых стали: развитие пневмонии после операции — n=5 (8,06%), гнойное воспаление раны — n=4 (6,45%), медиастинит — n=2 (3,23%), сепсис и инфекционный эндокардит, пиопневмоторакс — n=3 (4,84%). Наибольшее количество случаев было связано с микроорганизмами: Staphylococcus aureus — 14,51%, Staphylococcus epidermidis — 12,9%, Klebsiella spp. и Pseudomonas aeruginosa — 11,3%, Candida — 8,1%, Escherichia coli и другие инфекции — 6,45%. Карбапе-немы и гликопептиды показали наивысшую эффективность (соответственно до 92% и 90%).

Keywords: cardiac surgery, congenital heart defects, children, antibiotics, complications, infection

Ключевые слова: кардиохирургия, врожденные пороки сердца, дети, антибиотики, осложнения, инфекция

Introduction. Congenital heart defects (hereinafter referred to as CHD) rank first in prevalence among other congenital anomalies in children and are considered a leading cause of mortality in this population [1, 2].

According to the American Heart Association (AHA), approximately 25% of newborns, or 2.4 per 1,000 live births, are diagnosed with CHD [3]. Other sources report significantly varying prevalence rates, ranging from 4 to 50 cases per 1,000 live births [3-5]. Among CHDs, atrial septal defect occurs most frequently, with 75 cases per 1,000 live births, followed by patent ductus arteriosus, with 19 cases per 1,000 live births [6, 7].

Healthcare-associated infections (HAIs) negatively impact clinical outcomes in pediatric cardiovascular surgery, including thoracotomy or thoracoscopy. These infections can exacerbate disease progression, increase mortality, and prolong hospital stays [2-4]. Risk factors for HAIs include age <2 months, combined congenital anomalies, postoperative complications, prolonged and

open surgical procedures, blood transfusions, resuscitation efforts, and extended stays in intensive care units (ICUs) and hospital wards [7, 8, 9].

According to the literature, the incidence of HAIs following cardiac surgeries varies from 4.9% to 30.8% and is associated with multiple organ dysfunction and a fourfold increase in postoperative mortality [7-10]. This significant variation in the frequency of infectious complications is multifactorial, depending on the patient's initial status (e.g., age, severity of condition, presence of risk factors), the specifics of the surgical procedure, and the postoperative care. Furthermore, differences in how these complications are accounted for also contribute to the variability [11].

Notably, Staphylococci (S. aureus) predominate in cardiac surgical interventions. Gram-negative microorganisms are encountered less frequently; these include E. coli, Klebsiella pneumoniae, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter spp. (Table 1) [5, 6, 7].

Table 1.

Microbiological Epidemiology Following Transcatheter Implantation

Staphylococci (33-54%) Staphylococcus aureus 63-72%

Coagulase-negative staphylococci 28-37%

Streptococci (26-50%) Viridans streptococci 81%

Other streptococci 19%

HACCEK (Haemophilus, Actinobacillus, Cardiobacterium, Capnocytophaga, Eikenella, Kingella) bacteria) (3-13%)

Currently, there is no consensus on the best strategy for managing postoperative mediastinitis in children [12].

Mediastinitis is a rare but severe infectious complication that occurs after pediatric cardiac surgeries, with an incidence ranging from 0.1% to 5% [17]. Prolonged sternum closure after surgery increases the risk of infections, making empirical antibiotic regimens including vancomycin, third- or fourth-generation cephalosporins, carbapenems, or aminoglycosides effective for this complication [12, 17]. In general, antibiotic therapy for mediastinitis is recommended for 3 to 8 weeks, depending on the severity of the infection and the presence of sternal osteomyelitis [12].

Transcatheter occluder placement for correcting ventricular or atrial septal defects has proven to be a safe and effective alternative to surgical intervention [5, 9, 10]. However, surgical procedures, including transcatheter methods, increase the risk of endothelial damage, which can lead to infective endocarditis [5, 9, 10]. Studies report that the incidence of such complications can reach up to 15.9% or 0.43-0.84 cases per 100 children [13, 14, 15].

In 2023, the Swiss Evaluation Registry for Pediatric Infective Endocarditis (SERPIE) presented prospective data on the outcomes of managing infective endocarditis. According to these data, postoperative infective endocarditis most frequently involves the pulmonary valve (25/69; 35%), mitral valve (10/69; 14%), tricuspid valve (8/69; 12%), and aortic valve (6/69; 9%). Additionally, cases of infective endocarditis were identified on prosthetic valves such as Contegra (Medtronic, Switzerland) - 17%, and Abbott valves (Shelhigh Inc., New Jersey, USA) - 12.3% [9].

Lourtet-Hascoet J. et. al. (2023) reported that approximately two-thirds of cases of infective endocarditis following congenital heart defect surgeries are recorded in male children, which is attributed to the protective effects of estrogens [5].

The most common complications after cardiac surgeries include embolism, perivalvular abscess, bacterial thrombosis, valve stenosis, lung abscess, and the formation of valve fistulas [5, 10, 14].

At present, international guidelines and recommendations from professional healthcare organizations exist for managing postoperative complications in children following cardiac surgery [2, 18]. In Kazakhstan, Protocol №10 of the Ministry of Health, published on September 30, 2015, remains in use for these purposes [19].

Objective of the study: to investigate the frequency of infectious complications after pediatric cardiac surgeries and the results of their correction with antibiotics.

Materials and methods: A retrospective analysis of medical data for n=173 children hospitalized in healthcare facilities in Almaty from January 1, 2019, to August 31, 2024, was conducted to analyze the frequency and nature of infectious complications following pediatric cardiac surgeries in children with congenital heart defects.

Inclusion criteria:

• A total of n=62 children, aged 0-18 years, who underwent surgery for congenital heart defects.

• Complete and accessible medical documentation, including postoperative data.

• Documentation of postoperative infectious complications in medical records.

Exclusion criteria:

• Incomplete medical histories, lack of information about the development of infectious complications after surgery, and children who did not undergo surgical treatment (n=111).

All children included in the study were classified according to the Gundobin classification. Data from laboratory and instrumental examinations, clinical severity grades, functional classes, complications, surgical protocols (including types of interventions, anesthesia usage, and duration of surgery), information on the development of infections during the postoperative period (such as wound infections, pneumonia, sepsis, etc.), treatment regimens, antibiotic dosages, duration of antibiotic use, and treatment outcomes were analyzed.

Statistical methods were applied to assess the validity of the data. The means (M±m) and the accuracy of differences between the arithmetic averages were evaluated using Student's t-test. Differences were considered statistically significant at p<0.05. Data analysis was performed using Microsoft Office Excel.

Results and discussion: In this study, an analysis was conducted on the age and sex characteristics of the children, with the following results (Table 2): The proportion of boys was n=38 (61.29%), and the proportion of girls was n=24 (38.71%). The male group was predominant in terms of age and sex characteristics, representing 61.9% (Table 2) (p<0.01). The average age of the children was 11.31 months ± 5.99 months (p<0.01).

Based on the retrospective anamnesis, an analysis was carried out on the main clinical indicators identified in the children. The following results were obtained: The average birth weight of the children was 3160.95±728.48 grams, and their average height was

50.59±4.73 cm (p<0.01). The children were born at an average gestational age of 37.5±2.60 weeks, and the average pregnancy parity was 2.81±1.43 (Table 2).

Table 2.

Clinical data of the study subjects (x)

Indicators Boys Group (n=38 / 61.29%) Girls Group (n=24 / 38.71%) Confidence Difference

Average Age (x) 11,17 au±6,56 months 11,46±5,42 months p<0,01

Birth Weight (x) 3357,47±605,09 grams 2964,45±851,87 grams

Birth Height (x) 51,66±3,41 cm 49,52±6,05 cm

Gestational Week (x) 36,93±2,84 weeks 38,07±2,36 weeks

Pregnancy Parity (x) 3,07±2,15 2,55±0,71

Considering that congenital heart defects (CHD) have several forms, Tetralogy of Fallot (TOF) and coarctation of the aorta (CoA) are more common in boys (approximately a 1.5:1 ratio), while atrial septal defects (ASD) are more common in girls (1:1.5 ratio) [9, 11, 14]. It is believed that these gender differences may be due to genetic factors (e.g., X-linked), as well as differences in hormonal environments and exposure to teratogens [8, 10].

In the present study, the main forms of CHD and gender differences were analyzed. Accordingly, ASD occurred in 16.13% of girls, CoA in 14.52%, aortic arch anomalies (AAA) in 11.29%, TOF in 6.45%, and ventricular septal defects (VSD) in 8.05%. Among boys, the frequencies were as follows: ASD in 25.8%, CoA in 22.58%, AAA in 14.52%, TOF in 9.67%, and VSD in 8.06% (Table 3).

Table 3.

Classification of Forms of Congenital Heart Defects (%)

CHD Forms Boys Group (n=38 / 61.29%) Girls (n=24 / 38.71%) Total

Atrial Septal Defect (ASD) n=6 (9.7%) n=10 (16.13%) n=16 (25.8%)

Ventricular Septal Defect (VSD) n=9 (14.52%) n=5 (8.05%) n=14 (22.58%)

Patent Ductus Arteriosus (PDA) n=7 (11.29%) n=2 (3.23%) n=9 (14.52%)

Tetralogy of Fallot (TOF) n=4 (6.45%) n=2 (3.23%) n=6 (9.67%)

Pulmonary Artery Stenosis (PAS) n=2 (3.23%) n=1 (1.61%) n=3 (4.84%)

Ebstein's Anomaly (EA) n=1 (1.61%) n=0 (0%) n=1 (1.61%)

Coarctation of the Aorta (CoA) n=3 (4.84%) n=2 (3.23%) n=5 (8.06%)

Transposition of the Great Arteries (TGA) n=1 (1.61%) n=0 (0%) n=1 (1.61%)

Complex Malformations (CM) n=5 (8.05%) n=2 (3.23%) n=7 (11.29%)

Total (n=38 / 61.29%) (n=24 / 38.71%) n=62 (100%)

Next, the study focused on evaluating the indications for hospitalization of children, the frequency of complications, including the main causes and risk factors of infectious complications, and the mortality rate.

In general, these complications can vary in type and severity, ranging from superficial postoperative wound infections to severe systemic infections such as sepsis and endocarditis. Among the risk factors are: the placement of central venous catheters, prolonged mechanical ventilation, incomplete immune system development in newborns and children under one year of age, prolonged surgeries (over 3-4 hours), prolonged use of cardiopulmonary bypass (CPB), blood transfusions, artificial valves, stents, occluders, and other devices that increase the likelihood of bacterial adhesion and infection [8, 13, 17].

The average length of stay in the hospital for the children was 14.34±5.27 days, while the average duration of surgery was 193.65±58.51 minutes, with the use of the CPB machine lasting 138.45±23.08 minutes. Among the 62 children, complications were identified in 13 children, or 20.96%, with the main complications being: development of postoperative pneumonia in 5 children (8.06%), wound suppuration in 4 children (6.45%), mediastinitis in 2 children (3.23%), sepsis and infectious endocarditis, and pyopneumothorax in 3 children (4.84%) (Figure 1).

A mortality rate of 1.61% (1 child, diagnosed with Ebstein's anomaly) was recorded due to multiple organ failure following surgery.

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□ Boys Group (n=38 / 61.29%) ■ Girls (n=24 / 38.71%)

Figure 1. Frequency of occurrence of major complications (%)

Taking into account the frequency of development of infectious complications, an analysis was conducted on the bacteriological studies monitoring the growth of microflora (Figure 2). Clinically significant microflora growth (Candida, Klebsiella, Acinetobacter, Enter-ococcus, Staphylococcus, etc.) was found in n=13 patients, including: Staphylococcus aureus - 14.51%, Staphylococcus epidermidis - 12.9%, Klebsiella spp. and Pseudomonas aeruginosa - 11.3%, Candida - 8.1%, Escherichia coli and other infections - 6.45% (Figure 2).

It should be noted that in many studies, S. aureus has been associated with embolization, septic shock, respiratory distress, kidney failure, skin necrosis, and S. epidermidis, S. Lugdunensis, S. capitis entering the bloodstream through skin lesions. Enterococci, after

TAVI or CIED implantation, and HACCEK (Haemophilus, Actinobacillus, Cardiobacterium, Capnocytophaga, Eikenella, Kingella) have been reported to damage prosthetic heart valves in affected patients [5].

Looking at the literature, studies by Samoylova L.M., Gorbatiykh Yu.N., and other authors have reported that Candida was found in 44%, Staphylococcus in 28%, Klebsiella in 17-19%, K. pneumoniae up to 11.4%, with complications including: sepsis (21.4%), pneumonia (50%), mediastinitis (7.1%), and peritonitis (3.6%) [20].

In studies by Lourtet-Hascoët J, Valdeolmillos, and others, Staphylococci (33-54%), Streptococci (2650%), and HACCEK (3-13%) were identified [5].

Other infections Candida

Pseudomonas aeruginosa Klebsiella Escherichia coli Staphylococcus epidermidis Staphylococcus aureus

_6,45%

8,10%

11,30%

11,30%

6,45%

12,90%

14,51%

Figure 2. Frequency of occurrence of the of bacteriological All children admitted to the hospital were provided with all types of conservative therapy in accordance with the treatment protocols, and treatment was prescribed. Anti-inflammatory therapy was administered to 85.48%, detoxification therapy to 72.58%, desensitiza-tion therapy to 52.57%, and antibacterial therapy to 100% of the children (p<0.01). Additionally, immunotherapy replacement drugs were prescribed to n=2 (3.23%) children in severe condition (Figure 3).

Broad-spectrum antibiotics, such as third-generation cephalosporins, penicillins with p-lactamase inhibitors, and carbapenems, were frequently used depending on the clinical presentation. The duration of the treatment varied depending on the type of complication, with

main microflora according to the results examination (%)

an average of 7-14 days. In severe cases (such as sepsis), therapy was prolonged based on the sensitivity of the pathogens. During therapy, rare adverse reactions, including dysbiosis (5-7%) and allergic reactions (about 3%), were observed. These adverse phenomena were corrected by prescribing probiotics and antihistamines. The combination of antibiotics with anti-inflammatory therapy and detoxification measures contributed to the stabilization of the children in 93.5% of cases. Carbapenems and glycopeptides demonstrated the highest efficacy (up to 92% and 90%, respectively). Third-generation cephalosporins remain the universal choice for moderate infections (Table 4).

■ Anti-inflammatory therapy ■ Detoxification therapy

■ Desensitization therapy ■ Antibacterial therapy

■ Immunotherapy

Figure 3. Frequency of Application of Primary Conservative Treatments (%)

Antibiotics

Table 4.

Effectiveness of Antibiotic Therapy (%)

Recovery Rate (%) Average Duration of Treatment (Days)

Third-Generation Cephalosporins

Carbapenems

Aminoglycosides

Glycopeptides

Polymyxins

Furthermore, by monitoring the indicators of the general blood test before and after antibacterial treatment, we observed certain differences. It was found that there was a significant decrease in the following parameters: leukocytosis before treatment was 65.5%, and after treatment, it decreased to 38.13%; thrombocytosis

85% 7.5 ± 2.3

92% 6.8 ± 1.9

78% 8.2 ± 2.6

90% 6.5 ± 2.1

72% 10.1 ± 3.0

was 45.13% before treatment and 25.22% after treatment; neutrophilia decreased from 73.08% to 18.19%, lymphocytosis from 24.8% to 6.09%, fibrinogen level decreased from 82.15% to 21.26%, CRP decreased from 33.02% to 27.12%, and procalcitonin dropped from 2.23% to 0.13%. A notable observation is that after antibacterial treatment, leukocytosis decreased by 58.21%,

neutrophilia decreased by 75.11%, and fibrinogen decreased by 74.12%, while CRP decreased in only 21.75% of cases (Figure 4).

82,15%

Procalcitonin 2,23%0,13% CRP (C-reactive protein) 133,02% 27,12% Fibrinogen level Lymphocytosis 24,80%6,09%

Neutrophilia Thrombocytosis Leukocytosis

21,26%

73,08%

18119%

45,13%H25,22% 65 50%

38,13%

□ Before Treatment □ After Treatment

Figure 4. Summary of Laboratory Indicators in Patients (%)

in selecting antibiotics based on the child's microbiological profile and the severity of their condition. A comprehensive treatment approach, including immunotherapy for critically ill patients, improves clinical outcomes. Optimizing antibiotic therapy and ensuring adherence to treatment protocols, while considering local microbial resistance, helps reduce the frequency of infectious complications and improves the outcomes of pediatric cardiac surgeries.

Conclusion: The frequency of infectious complications in children after cardiac surgeries requires a comprehensive approach that includes timely diagnosis, appropriate antibiotic therapy, and continuous monitoring of the patient's condition. The study demonstrated high effectiveness in preventing and treating complications with modern antibiotics such as cephalosporins, carbapenems, and glycopeptides, with an efficacy of up to 92%. The results emphasize the need for an individualized approach

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