The impact of COVID-19 pandemic on bloodstream infections in pediatrics and alteration in antimicrobial resistance phenotypes, 2020-2022

The impact of COVID-19 pandemic on bloodstream infections in pediatrics and alteration in antimicrobial resistance phenotypes, 2020-2022 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The impact of COVID-19 pandemic on bloodstream infections in pediatrics and alteration in antimicrobial resistance phenotypes, 2020-2022 Fatemeh Fallah, Abdollah Karimi, Leila Azimi, Ghazale Ghandchi, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4498290/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Oct, 2024 Read the published version in BMC Pediatrics → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Alteration in the etiology of bloodstream infection (BSI) and antimicrobial resistance (AMR) following the COVID-19 pandemic is not well known in children. This study aimed to investigate these changes during 2 years in Tehran, Iran. Methods Children under 18 years old with suspected bacteremia/fungemia who had positive BACTEC blood cultures were included. Characterization of the isolates, antimicrobial susceptibility testing, and detection of multidrug-resistant (MDR) phenotypes were done based on standard protocols. Statistical analysis was done to measure the correlation of COVID-19 infection with BSI and AMR. Results Out of 13,345 COVID-19 tests and 4,194 BACTEC blood culture requests, bacteremia/fungemia were confirmed in 10.34% of the patients who requested both tests simultaneously. The COVID-19 infection was confirmed in 25.3% of the patients with bacteremia/fungemia. The infection with Gram-negative bacteria, Gram-positive bacteria (GPB), and fungi was detected in 59.3%, 32.3%, and 8.31% of the cases, respectively. Pseudomonas spp. (21.3%), Klebsiella spp. (20.2%), CN S (15.8%), Acinetobacter spp. (9.6%), S. aureus (8%), and Enterococcus spp. (5%) were among the common isolates. In the case of BSI with GPB, a significant difference was measured among different hospital wards ( p -value= 0.01). Moreover, a negative correlation was shown between the CN S bacteremia and COVID-19 infection ( p -value= 0.029). Candida spp. and non- Candida yeasts were detected in 6.7% and 13.4% of the cases, respectively. Results of antibiotic susceptibility testing showed the highest frequency of resistance to azithromycin and oxacillin among CN S , azithromycin, tetracycline, and oxacillin among S. aureus , and tetracycline and trimethoprim/sulfamethoxazole among Enterococcus . Methicillin-resistance phenotype in the S. aureus (MR SA ) and coagulase-negative Staphylococcus spp. (MR-CNS) was detected in 40% and 61.5% of the strains, respectively and the Enterococci were resistant to vancomycin in 33.3% of the isolates. Conclusion A decline in the trend of BSI by GPB and an increase in AMR was shown in children during the COVID-19 pandemic. The rise in antibiotic resistance could be described by the overuse of antibiotics in COVID-19 patients, while the difference in types of medical interventions may explain the difference in the etiology of BSI among the hospital wards. Bloodstream infection Children Gram Positive bacteria Yeasts Antimicrobial susceptibility COVID-19 Figures Figure 1 Figure 2 Figure 3 Introduction It is estimated that bloodstream infection (BSI) may be responsible for 11% of deaths annually among children in high-income countries [ 1 ]. However, due to the lack of surveillance programs in low- and middle-income countries (LMICs), accurate estimation of the incidence and associated mortality of community and nosocomial-BSI among children in these countries is not possible. According to available data, the global incidence rate of BSI is 140 and 160 cases per 100,000 per years [ 2 ]. In recent years, due to the improvement in public health systems, the introduction of new antimicrobials, and the implementation of infection, prevention, and control programs, changes in the epidemiology of microbial agents in hospital settings and society are expected; however, little is known about the impact of these factors on the incidence of BSI and the status of antimicrobial resistance (AMR), mainly in children. To reduce mortality in children with BSI, new surveillance studies, especially in LMICs are needed to identify responsible microbial agents and characterize their resistance phenotypes to antimicrobials. Although, like adults, Gram-negative bacteria assume as the main cause of the hospital acquired-BSI (HABSI) in pediatrics, yeasts and Gram-positive bacteria are also responsible for severe infections in this group of patients. In Iran, in a study by Moghaddam SS. et al. changes in the etiology of pediatric BSI were investigated over five years at a single children’s hospital. The results showed CNS, Streptococcus spp. and S. aureus as leading causes of BSI; however, in total Gram-negative bacteria presented a higher frequency compared with Gram-positive bacteria [ 3 ]. Candida albicans and non-albicans Candida spp. and other fungi infections also play an important role in HABSI among children [ 4 , 5 ]. Candida is the first cause of fungemia in hospitalized pediatrics, which could occur in a mixed-type infection with other Gram-negative and Gram-positive bacteria. In a study by Lee W.J et al. on pediatric-BSI, S. aureus showed the highest frequency of co-infection (19%), followed by Klebsiella pneumonia (14.3%) and coagulase-negative Staphylococcus (11.9%) [ 6 ]. There are increasing reports about the emergence of methicillin- and vancomycin-resistant Staphylococcus aureus , methicillin-resistant coagulase-negative Staphylococcus spp. (CNS), vancomycin-resistant Enterococcus spp. (VR E ), macrolide and fluoroquinolone-resistant Streptococcus spp. (Group A and non-Group A) and their involvement in HABSI and sepsis [ 7 , 8 ]. Transmission of mobile genetic resistance markers at inter- and intraspecies levels contributes to the emergence of new variants presenting multi-drug resistance (MDR) phenotypes, which should be considered by clinicians in regions with a high prevalence [ 9 ]. COVID-19 pandemic, over recent years, as the leading cause of infections during 2019–2022, favored the emergence of AMR due to an increase in the children’s hospitalization rate and prescription of antibiotics. There is a lack of data about possible changes in the etiology of HABSI and resistance phenotypes after the pandemic. In a recent retrospective study in China, the impact of COVID-19 on nosocomial infections and the status of MDR pathogens was reported. In this study no significant change in the frequency of Gram-positive bacteria was reported in comparison to the pre-pandemic period; however, an increase in infection with Streptococcus agalactiae and Enterococcus faecalis was measured during the COVID-19 pandemic [ 10 ]. In light of the globally increasing AMR in neonates and pediatrics [ 7 , 11 ], mainly in developing countries, regional studies for the detection of the etiology of BSI and AMR are necessary. In the current study, we investigated the frequency of Gram-positive bacteria and fungi in suspected children of bacteremia during 2 years of COVID-19 pandemic in a referral Children’s hospital in Tehran, Iran. We also investigated the association between bacteremia, AMR and COVID-19 infection. Materials and methods: Patients and Samples Blood samples of children who were clinically suspected of BSI were used for blood culture in a teaching hospital in Tehran, Iran, for 2 years. The study was done during the COVID-19 pandemics. The blood samples were prepared by nurses and inoculated directly into BD BACTEC™ Peds Plus/F culture vials. After reception, the vials were incubated in Becton Dickinson Diagnostic Instrument Systems (BD, USA). The samples belonged to < 17 years old children who were admitted to different wards of the hospital, including Bone Marrow Transplantation, Emergency Department, Gastroenterology, Infectious diseases, Pulmonary, Nephrology, Neurology, Oncology, PICU, Rheumatology, and Surgery. All of the patients were tested for COVID-19 according to the hospital regulations. This study was approved and registered by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1401.060). No additional sampling and medical interventions were done for the patients during the study period. An informed consent form was signed by the guardians or parents of children and demographic data were collected using a questionnaire. Microbial characterization, anti-microbial Susceptibility Testing and detection of Multi-drug Resistant phenotypes The inoculated pediatric BD BACTEC™ Peds Plus/F bottles were followed up in the device for seven days until a positive alarm. The positive vials were used for subculture in conventional and differential culture media, including Sheep Blood agar and MacConkey agar (Condalab, Madrid, Spain), at aerobic conditions at 37°C. Methods and results of Gram-negative bacterial isolates are presented in our previous report [ 12 ]. In the case of Gram-positive bacteria and yeasts, the growth of the colonies on the Blood agar plates was investigated after 24 hours. In conditions where that no growth observed, 2 ml of each bottle was centrifuged and used for the preparation of smear for the Gram- and methylene blue staining. Upon recording a positive smear for fungi and yeasts, the subculture of the sediment on HiCrome™ Candida Differential Agar (HiMedia Laboratories, India) and Sabouraud dextrose agar (Merck, Germany) media was done. Diagnostics of the bacterial genera were done according to standard protocols, mainly including growth and fermentation of mannitol in Mannitol Salt Agar (Merck, Germany), Gram morphology, catalase and oxidase, coagulase for Staphylococcus and Micrococcus spp. isolates, esculin hydrolysis in Enterococcus Selective Agar (BD, USA), colony and Gram stain morphology, catalase for Enterococcus spp., and types of hemolysis in sheep blood, catalase, colony and Gram stain morphology, susceptibility to bacitracin and optochin for Streptococcus spp. [ 13 ]. In the case of Candida spp. and their differentiation from non- Candida yeasts, the interpretation was done according to the formation of chromogenic colonies on HiCrome™ Candida Differential Agar and the microscopic morphology of grown colonies. Susceptibility of the strains to antibiotics was determined for Coagulase-negative Staphylococcus spp. (CN S ), S. aureus , Enterococcus spp., Micrococcus spp., and Non-Group A Streptococcus spp. using antibiotic discs (MAST Group, UK) according to standard protocols (CLSI 2020–2022). Isolation of Corynebacterium spp. in the absence of clinical signs of BSI was considered environmental contamination that indicates no antibiogram need. Multidrug-resistant (MDR) phenotype was determined for each isolate according to Magiorakos et al. [ 14 ] COVID-19 Detection Nasopharyngeal swab samples from all the patients were prepared due to hospital regulation during the COVID-19 pandemic. RNA extraction using viral nucleic acid extraction kits (BEHGEN and SIMBIOLAB companies, Iran) and laboratory diagnosis of COVID-19 virus using real-time quantitative reverse transcription polymerase chain reaction (RT-qrtPCR) and IVD-approved molecular kit (PishtazTeb Diagnostics, Iran) were done according to instruction protocols as described before [ 15 , 16 ]. Statistical Analysis The data were analyzed using the package IBM SPSS Statistics for Windows (version 26) (SPSS Inc., Chicago, IL, USA), and the chi-square test was used for analyzing the data. A p -value < 0.05 was considered significant. Results Analysis of our results showed that out of 13,345 COVID-19 RT-qrtPCR and 4,194 BACTEC blood culture requests from 2020.02.25 to 2022.12.24 in our hospital, bacteremia/fungemia were confirmed in 10.34% of the patients who requested both of the test simultaneously (435/4,194). The COVID-19 infection was confirmed in 25.3% of the patients with bacteremia/fungemia (110/435). Except for 2 patients with no record, the infection with Gram-negative bacteria, Gram-positive bacteria, and fungi was detected in 59.3% (257/433), 32.3% (140/433), and 8.31% (36/433) of the cases, respectively. Out of 433 blood culture samples, Pseudomonas spp. (21.3%), Klebsiella spp. (20.2%), CN S (15.8%), Acinetobacter spp. (9.6%), S. aureus (8%), Enterococcus spp. (5%), Enterobacter (3.9%) and E. coli (2.1%) were among the common isolates associated with BSI in children. Among the patients with positive BACTEC culture for Gram-positive (BSI-GPB) or fungi (BSI-FB), no significant association was found between the microorganisms and underlying diseases, including cancer and chemotherapy, gender and age groups (Table 1). However, a significant difference was measured among different wards of the hospital ( p -value= 0.01). Accordingly, the Pediatric Intensive Care Unit, Emergency Room and Bone Marrow Transplantation wards showed the highest frequency of bloodstream infection with GPB, respectively (30.2%, 21.2% and 14%, respectively) (Table 2) (Figure 1). S. epidermidis and S. aureus were common causes of BSI-GPB in all the hospital wards (Figure 2). Enterococcus was the main cause of infection in the Oncology ward (Two-fold higher than S. aureus ) and the third cause of BSI-GPB in most hospital wards. Candida spp. were detected in 6.7% of the target population, which was lower than the frequency of the infection with non- Candida yeast and fungi infections (13.4%). Candida spp. were mainly isolated from the patients in the Infectious Diseases and Surgery wards. BSI-FB, regardless to their types, were mainly isolated from the blood of the patients in the PICU and Gastroenterology wards (Table 2) (Figure 1). Table 1. The frequency of Gram-positive bacteria and fungi isolates from bloodstream infection of children according to age, gender, and underlying diseases in a pediatric hospital in Tehran, Iran, 2020-2022. Microorganisms Blood culture a Number Frequency Gender COVID-19 Age Cancer Chemotherapy Boy Girl Positive Pathogen % Total % >3 y ≤3 y n/N % n/N % Not recorded 3 1.69% 1 2 2 67% 4.35% 2 1 Candida spp. 12 6.74% 8 4 5 42% 10.87% 7 5 1/12 8.33% 0/12 0 Other yeasts and fungi 24 13.48% 20 4 5 21% 10.87% 10 14 2/24 8.33% 1/24 4.17% Corynebacterium spp. 4 2.25% 2 2 1 25% 2.17% 0 4 1/4 25.00% 0/4 0.00% Micrococcus spp. 3 1.69% 2 1 1 33% 2.17% 1 2 0/3 0.00% 0/3 0.00% S. aureus 36 20.22% 24 12 5 14% 10.87% 17 19 5/36 13.89% 1/36 2.78% Coagulase negative Staphylococci 72 40.45% 45 27 24 33% 52.17% 39 33 4/72 5.56% 2/72 2.78% Streptococcus spp. 2 1.12% 2 0 0 0% 0.00% 2 0 0/2 0.00% 0/2 0.00% Enterococcus spp. 22 12.36% 14 8 3 14% 6.52% 11 11 3/22 13.64% 0/22 0.00% Total 178 100% 118 60 46 100% 89 89 16/175 9.14% 4/175 2.23% a. Aerobic BACTEC system was used for detection of microbial agents responsible for bloodstream infection. Table 2. The frequency and diversity of Gram-positive and yeasts in bloodstream infection of children according to ward of hospitalization in a pediatric hospital in Tehran, Iran, 2020-2022. Microorganisms Wards b Total Not reported BMT a ED GI Infectious diseases Pulmonary Nephrology Neurology Oncology PICU Rheumatology Surgery Not reported c 0 1 0 1 0 0 0 0 0 0 0 3 % within not reported 0.0% 33.3% 0.0% 33.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% % within Ward 0.0% 2.6% 0.0% 10.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.7% Candidia 1 1 1 2 0 0 0 0 5 0 2 12 % within Candida spp. 8.3% 8.3% 8.3% 16.7% 0.0% 0.0% 0.0% 0.0% 41.7% 0.0% 16.7% 100.0% % within Ward 4.0% 2.6% 7.7% 20.0% 0.0% 0.0% 0.0% 0.0% 9.3% 0.0% 18.2% 6.7% Corynebacterium spp. 0 0 2 1 1 0 0 0 0 0 0 4 % within Bacteria 0.0% 0.0% 50.0% 33.3% 33.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% % within Ward 0.0% 0.0% 7.7% 10.0% 16.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.7% Enterococcus spp. 5 9 2 0 1 0 1 2 1 1 0 22 % within Bacteria 22.7% 40.9% 9.1% 0.0% 4.5% 0.0% 4.5% 9.1% 4.5% 4.5% 0.0% 100.0% % within Ward 20.0% 23.7% 15.4% 0.0% 16.7% 0.0% 14.3% 66.7% 1.9% 20.0% 0.0% 12.3% Micrococcus spp. 0 1 0 0 0 0 0 0 1 0 1 3 % within Bacteria 0.0% 33.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 33.3% 0.0% 33.3% 100.0% % within Ward 0.0% 2.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.9% 0.0% 9.1% 1.7% S. aureus 5 9 1 3 0 1 3 1 7 1 5 36 % within Bacteria 13.9% 25.0% 2.8% 8.3% 0.0% 2.8% 8.3% 2.8% 19.4% 2.8% 13.9% 100.0% % within Ward 20.0% 23.7% 7.7% 30.0% 0.0% 16.7% 42.9% 33.3% 13.0% 20.0% 45.5% 20.1% CNS 11 14 1 3 2 4 3 0 31 1 2 72 % within Bacteria 15.5% 19.4% 1.4% 4.2% 2.8% 5.6% 4.2% 0.0% 43.0% 1.4% 2.8% 100.0% % within Ward 44.0% 36.8% 7.7% 30.0% 33.3% 66.7% 42.9% 0.0% 55.6% 20.0% 18.2% 39.7% Streptococcus spp . 1 0 1 0 0 0 0 0 0 0 0 2 % within Bacteria 50.0% 0.0% 50.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 100.0% % within Ward 4.0% 0.0% 7.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.1% Other fungi 2 3 5 0 1 1 0 0 9 2 1 24 % within other fungi 8.3% 12.5% 20.8% 0.0% 4.2% 4.2% 0.0% 0.0% 37.5% 8.3% 4.2% 100.0% % within Ward 8.0% 7.9% 38.5% 0.0% 16.7% 16.7% 0.0% 0.0% 16.7% 40.0% 9.1% 13.4% Total 25 38 13 10 5 6 7 3 54 5 11 178 % within microorganisms 14.0% 21.2% 7.3% 5.6% 2.8% 3.4% 3.9% 1.7% 30.2% 2.8% 6.1% 100.0% % within Ward 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% a. Abbreviations: BMT, Bone marrow transplantation; ED, Emergency room; GI, Gastroenterology; PICU, Pediatric Intensive Care Unit; CNS, Coagulase-negative Staphylococcus spp. b, Percentages of BSI-GPB higher than 10% are shown in bold. c. “Not reported” indicates BSI-GPB samples that have Gram positive staining records, but names of Gram-positive bacteria were not indicated. Results of antibiotic susceptibility testing showed highest frequency of resistance to azithromycin, oxacillin, penicillin among CN S , azithromycin, tetracycline, trimethoprim/sulfamethoxazole, oxacillin and clindamycin among S. aureus , and trimethoprim/sulfamethoxazole, tetracycline, gentamicin, ciprofloxacin, and penicillin among Enterococcus spp. blood isolates (Figure 3). The highest susceptibility was detected to minocycline, linezolid, chloramphenicol, and norfloxacin in CN S , minocycline, doxycycline, rifampicin, and norfloxacin in S. aureus , and linezolid and chloramphenicol in Enterococcus spp. MR phenotype in S. aureus (MR SA ) and coagulase-negative Staphylococcus spp. (MR-CN S ) isolates that showed resistance to cefoxitin was detected in 40% and 61.5% of the strains, while 33.3% of the Enterococcus isolates presented VR E phenotype. VR E , MR SA , and MR-CN S isolates mainly belonged to Emergency Room (3/6, 50%), Infectious Diseases (2/4, 50%), and PICU (11/16, 68.7%) wards, respectively. Details about the resistance frequency for each antibiotic are shown in Table 3. Multidrug resistance (MDR) phenotype was detected in 90.7%, 100%, and 77.7% of the CN S , S. aureus and Enterococcus spp. isolates, respectively. All the CNS strains with resistant phenotype to cefoxitin, oxacillin and penicillin and all vancomycin-resistant strains of Enterococcus spp. showed MDR phenotype (Table 4 and Supplementary Table 1). Statistical analysis did not show a correlation between MDR patterns and COVID-19 infection status for most of the bacterial genera, except for CNS, where an inverse correlation was shown between COVID-19 status and methicillin resistance phenotype ( p -value= 0.029). Accordingly, out of 25 CN S with cefoxitin test, MR-CN S strains mainly belonged to the COVID-19 negative cases in comparison to COVID-19 positive children with CN S -bacteremia (76.4%, 13/17 vs 37.5%, 3/8). Table 3. Antimicrobial susceptibility of Gram-positive bacterial isolates from BSI in pediatrics in a referral Children’s hospital in Tehran, Iran during 2020-2022. Bacteria a Antibiotics b. AZ CIP FOX SXT CHL CLN DOX GEN LNZ MIN NOR OXA PEN RIF TET VAN AMP LEV AMX CEF CFX CN S S 5 21 10 13 53 18 40 27 54 23 36 7 3 38 16 54 I 0 3 0 0 0 0 1 1 1 1 0 0 0 0 0 0 R 50 32 16 42 6 42 17 31 5 0 6 49 17 19 8 4 S % 9% 37.5% 38.5% 23.6% 89.8% 30% 68.9% 45.7% 91.5% 95.8% 85.7% 12.5% 15% 66.6% 66.6% 93.1% S. aureus S 1 11 6 5 14 5 12 11 8 14 3 4 13 1 18 I 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 R 16 10 4 15 6 14 5 6 2 3 12 3 5 10 1 S % 5.8% 52.4% 60% 25% 70% 26.3% 70.6% 64.7% 80% 82.3% 20% 57.1% 72.2% 9% 94.7% Enterococcus spp. S 5 4 1 10 2 17 5 3 12 5 3 I 0 0 0 0 0 0 0 0 0 0 0 R 13 6 9 0 8 0 12 13 6 6 7 S % 27.8% 40% 10% 100% 20% 100% 29.4% 18.8% 66.6% 45.5% 30% Micrococcus spp. S 1 1 1 1 1 1 1 1 1 1 1 1 I 0 0 0 0 0 0 0 0 0 0 0 0 R 0 0 0 0 0 0 0 0 0 0 0 0 S % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Non-Group A Streptococcus spp. S 0 1 1 1 1 1 1 1 1 1 1 1 I 0 0 0 0 0 0 0 0 0 0 0 0 R 1 0 0 0 0 0 0 0 0 0 0 0 S % 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% a. Difference in the number of isolates tested for susceptibility testing of each antibiotic is related to documented data in the hospital microbiology laboratory unit. b. AMP, ampicillin; AMC, Amoxicillin + Clavulanic acid; AMX, Amoxicillin; AZ, Azithromycin; CHL, Chloramphenicol; CIP, Ciprofloxacin; CN, Clindamycin; FOX, Cefoxitin; SXT, Trimethoprim / sulfamethoxazole; DOX, Doxycycline; GEN, Gentamicin; LNZ, Linezolid; MIN, Minocycline; NOR, Norfloxacin; OXA, Oxacillin; PEN, Penicillin; RIF, Rifampicin; TET, Tetracycline; VAN, Vancomycin; AMP-SUL, Ampicillin-Sulbactam; CTR, Ceftriaxone; MER, Meropenem; EV, Levofloxacin; CEF, Cefepime; CFX, Cefuroxime. CNS, Coagulase-negative Staphylococcus spp. Table 4. The frequency and diversity of Multidrug Resistance phenotypes among Gram-positive bacterial isolates from BACTEC vials in a pediatric hospital in Tehran, Iran 2020-2022. Bacteria MDR a Total MDR No MDR Not tested 3DR 4DR 5DR 6DR 7DR 8DR 9DR 10DR CN S 73 6 7 11 11 8 7 3 2 55 6 12 10.9% 12.7% 20% 20% 14.5% 12.7% 5.4% 3.6% 90.1% 8.2% 16.4% S. aureus 35 2 6 4 4 3 1 0 0 20 0 15 10% 30% 20% 20% 15% 5% 0 0 100% 0 42.8% Enterococcus spp. 20 5 3 0 2 2 2 0 0 14 4 2 35.7% 21.4% 0 14.3% 14.3% 14.3% 0 0 77.7% 20% 10% a. Multiple Drug Resistance phenotype (MDR): refers to bacteria that are resistant to at least one antimicrobial agent in three or more antimicrobial classes . The numbers before DR indicate No. of classes of antibiotics that the blood isolates showed resistance phenotypes. Discussion COVID-19 is considered as a risk factor for hospital-acquired infection [17]. Our study analyzed the status of COVID-19 RT-qrtPCR in patients with positive BACTEC results. Due to the lack of related data for all patients about the co-incidence of COVID-19 and BSI during the study period, we were unable to analyze the risk of COVID-19 infection in the occurrence of community or hospital-acquired BSI. Such a correlation was reported by other studies both in adults and children [18-21]. The correlation could be attributed to immunosenescence, organ dysfunction, early mechanical ventilation and use of other medical devices, ICU admission, longer length of hospital stay, and administration of immunosuppressive medications [19, 20]. The increase in secondary infections in admitted patients with COVID-19, mainly Candida spp., S. aureus , Klebsiella spp. and P. aeruginosa , was reported by some studies [18, 22, 23]. To understand the impact of COVID-19 on the etiology of BSI-GPB and AMR phenotypes in hospitalized children during the pandemic, we compared our findings with the pre-COVID-19 results. Accordingly, in a retrospective study in our hospital in 2013-2018, GPB was considered as the cause of BSI in 45% of the cases with positive BACTEC results, which was relatively higher than its frequency in the current study (32.3%). This difference was mainly related to an increase in the frequency of Klebsiella spp. (8.8% vs 20.2%) and decrease in the frequency of CN S (32.5% vs 15.8%) [24]. Although consistent with our results, CN S and S. aureus ,as common members of the skin microbiota, and Enterococci, as a common member of the intestine, were among the most frequent GPB in both periods, the improvement in hand hygiene by healthcare staff during the COVID-19 pandemic may explain the reduction of BSI by CN S . A decrease in the trend of BSI by CN S , mainly S. epidermidis and S. hominis, in children from 2018 to 2021 was similarly reported by a study in China, which indicated a significant impact of COVID-19 on the etiology of BSI [25]. The etiology of BSI differs by region, age group, and the epidemiological status of the responsible pathogens in the community and hospital environment [26]. In a 7-year prospective study in a Children’s hospital in England, Gram-positive bacteria accounted for more BSI episodes (66.2%), compared with Gram-negative bacteria and yeasts (31.3% and 2.2%, respectively) [27]. A relatively two-fold higher crude frequency of Gram-negative bacteria in pediatric-BSI (60% vs 33% Gram positives and 7% fungal) was reported in a referral South African Children’s hospital; however, considering the source of infection, Gram-positive pathogens showed higher prevalence in community-acquired BSI, while in hospital-acquired sepsis Gram-negative and fungal pathogens were more prevalent [28]. Consistent with our results, in a retrospective study in a pediatric hospital in Iran from 2015 to 2019, BSI with Gram-negative bacteria was relatively higher than Gram-positive bacteria (46% and 54%, respectively) [3]. The involvement of CN S and S. aureus as a common cause of BSI-GPB was similarly reported by other studies [29]. In a European point prevalence survey on children and neonates, although Enterobacteriaceae was detected as the most isolated microorganism (28.8%), followed by CN S (20.9%) and S. aureus (10.5%), CN S was reported as the most common bacteria in neonates and infants <12 months of age [30]. In our study, BSI-GPB was mainly detected in the PICU, emergency room, and BMT wards. Among the characterized Gram-positive bacteria, CN S and S. aureus were dominant in most wards of the hospital, while Enterococcus spp. were the main cause of BSI-GPB in the Oncology ward. In a recent study in our hospital, intestinal carriage and endogenous transmission of Enterococcus spp. to the bloodstream was established in children at oncology and BMT wards [31, 32]. Increased permeability of the intestine through the administration of chemotherapeutic drugs and infection control issues are assumed as risk factors for Enterococcus spp. mediated bacteremia. Prolonged stay and the use of invasive medical devices in PICU and NICU seems to be the main cause of HAI, including BSI [30]. In the current study, all the Enterococcus spp. isolates were sensitive to linezolid and chloramphenicol and 66.6% of them were sensitive to vancomycin, which these sensitivities were relatively higher in comparison to our previous results during 2013-2018 (93.2%, 60%, and 46.4%, respectively) [24]. The highest proportion of resistance in the Enterococcus isolates was related to tetracycline (91.2%), trimethoprim/sulfamethoxazole (90%), and gentamicin (80%), respectively that was consistent with the pre-COVID-19 status [24]. In the same comparative view, the CN S isolates showed a relatively similar sensitivity to linezolid (91.5% vs 95.3%) and vancomycin (93.1% vs 96.4%), but higher sensitivity to chloramphenicol (89.8% vs 70%). Methicillin resistance was measured according to resistance phenotype to cefoxitin. The higher frequency of MR-CN S strains compared with MR SA (61.5% vs 40%) was similarly reported by other studies on pediatrics [3, 33]. In our study, the S. aureus isolates showed a relatively higher frequency of AMR to most classes of the antibiotics. The difference in sensitivity was meaningfully higher for azithromycin (50% vs 5.8%), tetracycline (66.6 vs 9%), trimethoprim/sulfamethoxazole (41.5% vs 25%), and clindamycin (51.9% vs 26.3%) in 2013-2018 vs 2020-2022. In line with our findings, a very low frequency of resistance to vancomycin had been reported among the blood S. aureus isolates in children, while controversy exists in the frequency of the sensitivity to trimethoprim/sulfamethoxazole (87%), clindamycin (55%)[3, 24]. A pooled prevalence of 63% (45–78%) for MR SA in hospitalized children with BSI was reported in a meta-analysis in Iran which higher than its frequency in the current study (40%) and those reported by Moghaddam et al. (34%) [3, 34]. In our study, S. aureus isolates demonstrated high resistance to azithromycin, which could be attributed to changes in the AMR frequency after COVID-19 pandemic [35]. The overuse of antibiotics to treat secondary bacterial infections in COVID-19 patients has been proposed as a contributing factor in the increase in antibiotic-resistant bacterial strains [36, 37]. A higher rate of mortality after Candidemia had been reported among neonates compared with pediatrics, which particularly could increase when co-infection with bacteria exists [6]. Our study detected no significant difference in the infection with yeasts and Candida spp. between the defined age groups. Although fungemia showed higher frequency in PICU, Candida spp. were mainly detected in the Infectious Diseases and Surgery wards. High rate of colonization due to an increase in days of hospitalization and medical interventions like the use of central venous line and mechanical ventilation, parenteral nutrition, bacterial infection, immunocompromised status, surgery, underlying diseases like dialysis, and antibiotic therapy seem to be the main cause of infection with yeasts in these units [38]. Conclusion A decline in the trend of BSI by GPB and an increase in resistance to antibiotics was shown in children during the COVID-19 pandemic. CN S , S. aureus and Enterococci remain as main cause of BSI-GPB in all hospital wards, while Candida spp. and yeasts play a major role in specific hospital wards. The increase in antibiotic resistance could be described by the overuse of antibiotics, like azithromycin, in COVID-19 patients; however, differences in types of interventions in the hospital wards may explain the measured difference in the etiology of BSI-GPB. This highlights the importance of well-designed prophylactic regimens and infection prevention and control programs for each ward. Study limitations This study has several limitations due to its retrospective nature. In this study, we were unable to measure the co-incidence of COVID-19 and BSI during the study period and analyze the risk of COVID-19 infection in the occurrence of BSI. Moreover, due to a lack of data about the length of hospital stay, time of BACTEC-positivity after admission, and death rate we couldn’t estimate and differentiate the frequency of community- and hospital-acquired BSI, diversity in AMR phenotypes, and their correlation with mortality. Future studies are needed to improve our understanding of the impact of COVID-19 pandemic on BSI by bacteria and yeasts in children. Abbreviations BSI Bloodstream infection AMR Antimicrobial resistance COVID-19 Coronavirus Disease 2019 RT-qrtPCRReal-Time Quantitative Reverse Transcription Polymerase chain reaction GPB Gram-positive bacteria MR SA Methicillin-resistant phenotype in the S. aureus MR-CN S Methicillin-resistant Coagulase-negative Staphylococcus spp. VI SA Vancomycin-intermediate S. aureus VR E Vancomycin-resistant Enterococcus spp. CLSI Clinical and Laboratory Standards Institute HABSI Hospital acquired-bloodstream infections LMICs Low- and middle-income countries RNA Ribonucleic acid PICU Pediatric Intensive Care Unit Declarations Supplementary Information The online version contains supplementary material available at https://doi. …. [will be addressed by the journal]. Acknowledgments We would like to thank Dr. Saeed Maham who facilized this study in the Microbiology laboratory, the staff of Mofid Children’s Hospital and our colleagues at Pediatric Infections Research Center, Research Institute for Children’s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran for their cooperation. This work was supported by research assistant of the School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Authors contribution Fatemeh Fallah: Conceptualization and Supervision; Abdollah Karimi, Methodological and technical support; Nazanin Ahari Oskooie, Data entry, Data curation; Leila Azimi and Hannan Khodaie, RNA extraction and COVID-19 detection; Shahnaz Armin, Methodology; Nafiseh Abdollahi, data collection, data entry; Ghazale Ghandchi and Zari Gholinejad, data collection, data entry; Masoud Alebouyeh, Writing the original draft, data curation, formal analysis, visualization, review and editing. Azita Behzad,Seyedeh Masumeh Hashemi, andSeyedeh Narjes Ahmadizadeh, medical visits, BACTEC blood culture request, and scientific collaboration. Funding This study was supported by a grant (No: IR.SBMU.MSP.REC.1401.060) from Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Data availability statement The datasets used during the study are available from the corresponding author on reasonable request. Declaration of competing interest The authors declare that they have no competing interests. References Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, Schlapbach LJ, Reinhart K, Kissoon N. The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respiratory Med. 2018;6(3):223–30. Laupland KB. Incidence of bloodstream infection: a review of population-based studies. Clin Microbiol Infect. 2013;19(6):492–500. Sajedi Moghaddam S, Mamishi S, Pourakbari B, Mahmoudi S. 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Chest. 2021;160(2):454–65. Azimi T, Maham S, Fallah F, Azimi L, Gholinejad Z. Evaluating the antimicrobial resistance patterns among major bacterial pathogens isolated from clinical specimens taken from patients in Mofid Children's Hospital, Tehran, Iran: 2013–2018. Infect drug Resist. 2019;12:2089–102. Li L, Ma J, Guo P, Gao K, Yang J, Sun H. Changes of coagulase-negative Staphylococci infections in children before and after the COVID-19 pandemic in Zhengzhou, China. J Infect. 2023;86(2):154–225. Diekema DJ, Hsueh PR, Mendes RE, Pfaller MA, Rolston KV, Sader HS, Jones RN. The Microbiology of Bloodstream Infection: 20-Year Trends from the SENTRY Antimicrobial Surveillance Program. Antimicrob Agents Chemother 2019, 63(7). Gray JW. A 7-year study of bloodstream infections in an English children's hospital. Eur J Pediatrics. 2004;163(9):530–5. Dramowski A, Cotton MF, Rabie H, Whitelaw A. Trends in paediatric bloodstream infections at a South African referral hospital. BMC Pediatr. 2015;15:33. Lisowska-Łysiak K, Lauterbach R, Międzobrodzki J, Kosecka-Strojek M. Epidemiology and Pathogenesis of Staphylococcus Bloodstream Infections in Humans: a Review. Pol J Microbiol. 2021;70(1):13–23. Zingg W, Hopkins S, Gayet-Ageron A, Holmes A, Sharland M, Suetens C. Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European Centre for Disease Prevention and Control point-prevalence survey. Lancet Infect Dis. 2017;17(4):381–9. Alebouyeh M, Shirvani F, Hassanzadeh R, Azimi T, Ghandchi G, Abdollahi N, Gholinejad Z, Behzad A, Sheikhi Z, Fallah F, et al. Intestinal colonization of vancomycin-resistant Enterococcus in children admitted to Mofid children's hospital intensive care unit at admission and at discharge. Mol Biol Rep. 2023;50(4):3271–81. Shirvani F, Hassanzadeh R, Attaran B, Ghandchi G, Abdollahi N, Gholinejad Z, Sheikhi Z, Behzad A, Fallah F, Azimi L, et al. The intestinal carrier status of Enterococcus spp. in children: clonal diversity and alterations in resistance phenotypes before and after admission to a pediatric intensive care unit. BMC Pediatr. 2023;23(1):434. Kolesnichenko SI, Lavrinenko AV, Akhmaltdinova LL. Bloodstream Infection Etiology among Children and Adults. Int J Microbiol 2021, 2021:6657134. Sarrafzadeh F, Sohrevardi SM, Abousaidi H, Mirzaei H. Prevalence of methicillin-resistant Staphylococcus aureus in Iranian children: a systematic review and meta-analysis. Clin experimental Pediatr. 2021;64(8):415–21. Abdelaziz Abdelmoneim S, Mohamed Ghazy R, Anwar Sultan E, Hassaan MA, Anwar Mahgoub M. Antimicrobial resistance burden pre and post-COVID-19 pandemic with mapping the multidrug resistance in Egypt: a comparative cross-sectional study. Sci Rep. 2024;14(1):7176. Golli AL, Zlatian OM, Cara ML, Olteanu M. Pre- and Post-COVID-19 Antimicrobial Resistance Pattern of Pathogens in an Intensive Care Unit. Pharmaceuticals (Basel Switzerland) 2024, 17(4). Taleb MH, Elmanama AA, Taleb AH, Tawfick MM. Pre- and post-COVID-19 antimicrobial resistance profile of bacterial pathogens, a comparative study in a tertiary hospital. J Infect developing Ctries. 2023;17(5):597–609. Brissaud O, Guichoux J, Harambat J, Tandonnet O, Zaoutis T. Invasive fungal disease in PICU: epidemiology and risk factors. Ann Intensiv Care. 2012;2(1):6. Supplementary Table 1. Multiple Drug Resistance phenotypes among Gram-positive bacterial isolates from BACTEC vials in a pediatric hospital in Tehran, Iran 2020–2022. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx Cite Share Download PDF Status: Published Journal Publication published 18 Oct, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 19 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 29 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4498290","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316399359,"identity":"927e7ae2-f194-46ce-8802-e516245609be","order_by":0,"name":"Fatemeh Fallah","email":"","orcid":"","institution":"Department of Medical Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Fatemeh","middleName":"","lastName":"Fallah","suffix":""},{"id":316399360,"identity":"4c4f2fb2-33f9-4bd5-8303-39a4893c0ef3","order_by":1,"name":"Abdollah 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2020-2022.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4498290/v1/11b27c5fd6ea2e7bb395c550.png"},{"id":60171157,"identity":"98c21448-46d7-456c-967c-c12a3be39786","added_by":"auto","created_at":"2024-07-12 15:09:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33257,"visible":true,"origin":"","legend":"\u003cp\u003eThe frequency of Gram-positive bacteria and fungi isolates from children with bloodstream infection in a pediatric hospital in Tehran, Iran 2020-2022.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4498290/v1/4bda0297ab63963327786b9a.png"},{"id":60171160,"identity":"c008ac67-ed51-451b-a839-bbf11d041a0d","added_by":"auto","created_at":"2024-07-12 15:09:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":33938,"visible":true,"origin":"","legend":"\u003cp\u003eThe frequency of sensitivity to different classes of antibiotics in Gram-positive bacterial isolates from BACTEC blood culture of children in a hospital in Tehran, 2020-2022.\u003c/p\u003e\n\u003cp\u003eAMP, ampicillin; AMC, Amoxicillin + Clavulanic acid; AMX, Amoxicillin; AZ, Azithromycin; CHL, Chloramphenicol; CIP, Ciprofloxacin; CN, Clindamycin; FOX, Cefoxitin; SXT, Trimethoprim / sulfamethoxazole; DOX, Doxycycline; GEN, Gentamicin; LNZ, Linezolid; MIN, Minocycline; NOR, Norfloxacin; OXA, Oxacillin; PEN, Penicillin; RIF, Rifampicin; TET, Tetracycline; VAN, Vancomycin; AMP-SUL, Ampicillin-Sulbactam; CTR, Ceftriaxone; MER, Meropenem; EV, Levofloxacin; CEF, Cefepime; CFX, Cefuroxime.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4498290/v1/ce9273d17df48b8ee3a6a2fa.png"},{"id":67148959,"identity":"4ec44348-3c58-4b54-a881-ff9b4d209e33","added_by":"auto","created_at":"2024-10-21 16:10:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1333982,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4498290/v1/66f24a75-81f0-416b-b35a-04e3936935be.pdf"},{"id":60172459,"identity":"522e686d-8917-48f4-a509-5b67a9271e75","added_by":"auto","created_at":"2024-07-12 15:17:13","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17556,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4498290/v1/ebcb9d9869fc27562105d76c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The impact of COVID-19 pandemic on bloodstream infections in pediatrics and alteration in antimicrobial resistance phenotypes, 2020-2022","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIt is estimated that bloodstream infection (BSI) may be responsible for 11% of deaths annually among children in high-income countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, due to the lack of surveillance programs in low- and middle-income countries (LMICs), accurate estimation of the incidence and associated mortality of community and nosocomial-BSI among children in these countries is not possible. According to available data, the global incidence rate of BSI is 140 and 160 cases per 100,000 per years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In recent years, due to the improvement in public health systems, the introduction of new antimicrobials, and the implementation of infection, prevention, and control programs, changes in the epidemiology of microbial agents in hospital settings and society are expected; however, little is known about the impact of these factors on the incidence of BSI and the status of antimicrobial resistance (AMR), mainly in children. To reduce mortality in children with BSI, new surveillance studies, especially in LMICs are needed to identify responsible microbial agents and characterize their resistance phenotypes to antimicrobials.\u003c/p\u003e \u003cp\u003eAlthough, like adults, Gram-negative bacteria assume as the main cause of the hospital acquired-BSI (HABSI) in pediatrics, yeasts and Gram-positive bacteria are also responsible for severe infections in this group of patients. In Iran, in a study by Moghaddam SS. et al. changes in the etiology of pediatric BSI were investigated over five years at a single children\u0026rsquo;s hospital. The results showed CNS, \u003cem\u003eStreptococcus\u003c/em\u003e spp. and \u003cem\u003eS. aureus\u003c/em\u003e as leading causes of BSI; however, in total Gram-negative bacteria presented a higher frequency compared with Gram-positive bacteria [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. \u003cem\u003eCandida albicans\u003c/em\u003e and non-albicans \u003cem\u003eCandida\u003c/em\u003e spp. and other fungi infections also play an important role in HABSI among children [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. \u003cem\u003eCandida\u003c/em\u003e is the first cause of fungemia in hospitalized pediatrics, which could occur in a mixed-type infection with other Gram-negative and Gram-positive bacteria. In a study by Lee W.J et al. on pediatric-BSI, \u003cem\u003eS. aureus\u003c/em\u003e showed the highest frequency of co-infection (19%), followed by \u003cem\u003eKlebsiella pneumonia\u003c/em\u003e (14.3%) and coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e (11.9%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. There are increasing reports about the emergence of methicillin- and vancomycin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, methicillin-resistant coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e spp. (CNS), vancomycin-resistant \u003cem\u003eEnterococcus\u003c/em\u003e spp. (VR\u003cem\u003eE\u003c/em\u003e), macrolide and fluoroquinolone-resistant \u003cem\u003eStreptococcus\u003c/em\u003e spp. (Group A and non-Group A) and their involvement in HABSI and sepsis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTransmission of mobile genetic resistance markers at inter- and intraspecies levels contributes to the emergence of new variants presenting multi-drug resistance (MDR) phenotypes, which should be considered by clinicians in regions with a high prevalence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. COVID-19 pandemic, over recent years, as the leading cause of infections during 2019\u0026ndash;2022, favored the emergence of AMR due to an increase in the children\u0026rsquo;s hospitalization rate and prescription of antibiotics. There is a lack of data about possible changes in the etiology of HABSI and resistance phenotypes after the pandemic. In a recent retrospective study in China, the impact of COVID-19 on nosocomial infections and the status of MDR pathogens was reported. In this study no significant change in the frequency of Gram-positive bacteria was reported in comparison to the pre-pandemic period; however, an increase in infection with \u003cem\u003eStreptococcus agalactiae\u003c/em\u003e and \u003cem\u003eEnterococcus faecalis\u003c/em\u003e was measured during the COVID-19 pandemic [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In light of the globally increasing AMR in neonates and pediatrics [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], mainly in developing countries, regional studies for the detection of the etiology of BSI and AMR are necessary. In the current study, we investigated the frequency of Gram-positive bacteria and fungi in suspected children of bacteremia during 2 years of COVID-19 pandemic in a referral Children\u0026rsquo;s hospital in Tehran, Iran. We also investigated the association between bacteremia, AMR and COVID-19 infection.\u003c/p\u003e"},{"header":"Materials and methods:","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and Samples\u003c/h2\u003e \u003cp\u003eBlood samples of children who were clinically suspected of BSI were used for blood culture in a teaching hospital in Tehran, Iran, for 2 years. The study was done during the COVID-19 pandemics. The blood samples were prepared by nurses and inoculated directly into BD BACTEC\u0026trade; Peds Plus/F culture vials. After reception, the vials were incubated in Becton Dickinson Diagnostic Instrument Systems (BD, USA). The samples belonged to \u0026lt;\u0026thinsp;17 years old children who were admitted to different wards of the hospital, including Bone Marrow Transplantation, Emergency Department, Gastroenterology, Infectious diseases, Pulmonary, Nephrology, Neurology, Oncology, PICU, Rheumatology, and Surgery. All of the patients were tested for COVID-19 according to the hospital regulations. This study was approved and registered by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.MSP.REC.1401.060). No additional sampling and medical interventions were done for the patients during the study period. An informed consent form was signed by the guardians or parents of children and demographic data were collected using a questionnaire.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMicrobial characterization, anti-microbial Susceptibility Testing and detection of Multi-drug Resistant phenotypes\u003c/h2\u003e \u003cp\u003eThe inoculated pediatric BD BACTEC\u0026trade; Peds Plus/F bottles were followed up in the device for seven days until a positive alarm. The positive vials were used for subculture in conventional and differential culture media, including Sheep Blood agar and MacConkey agar (Condalab, Madrid, Spain), at aerobic conditions at 37\u0026deg;C. Methods and results of Gram-negative bacterial isolates are presented in our previous report [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the case of Gram-positive bacteria and yeasts, the growth of the colonies on the Blood agar plates was investigated after 24 hours. In conditions where that no growth observed, 2 ml of each bottle was centrifuged and used for the preparation of smear for the Gram- and methylene blue staining. Upon recording a positive smear for fungi and yeasts, the subculture of the sediment on HiCrome\u0026trade; Candida Differential Agar (HiMedia Laboratories, India) and Sabouraud dextrose agar (Merck, Germany) media was done. Diagnostics of the bacterial genera were done according to standard protocols, mainly including growth and fermentation of mannitol in Mannitol Salt Agar (Merck, Germany), Gram morphology, catalase and oxidase, coagulase for \u003cem\u003eStaphylococcus\u003c/em\u003e and \u003cem\u003eMicrococcus\u003c/em\u003e spp. isolates, esculin hydrolysis in Enterococcus Selective Agar (BD, USA), colony and Gram stain morphology, catalase for \u003cem\u003eEnterococcus\u003c/em\u003e spp., and types of hemolysis in sheep blood, catalase, colony and Gram stain morphology, susceptibility to bacitracin and optochin for Streptococcus spp. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In the case of \u003cem\u003eCandida\u003c/em\u003e spp. and their differentiation from non-\u003cem\u003eCandida\u003c/em\u003e yeasts, the interpretation was done according to the formation of chromogenic colonies on HiCrome\u0026trade; Candida Differential Agar and the microscopic morphology of grown colonies.\u003c/p\u003e \u003cp\u003eSusceptibility of the strains to antibiotics was determined for Coagulase-negative Staphylococcus spp. (CN\u003cem\u003eS\u003c/em\u003e), \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eEnterococcus\u003c/em\u003e spp., \u003cem\u003eMicrococcus\u003c/em\u003e spp., and Non-Group A \u003cem\u003eStreptococcus\u003c/em\u003e spp. using antibiotic discs (MAST Group, UK) according to standard protocols (CLSI 2020\u0026ndash;2022). Isolation of \u003cem\u003eCorynebacterium\u003c/em\u003e spp. in the absence of clinical signs of BSI was considered environmental contamination that indicates no antibiogram need. Multidrug-resistant (MDR) phenotype was determined for each isolate according to Magiorakos et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 Detection\u003c/h2\u003e \u003cp\u003eNasopharyngeal swab samples from all the patients were prepared due to hospital regulation during the COVID-19 pandemic. RNA extraction using viral nucleic acid extraction kits (BEHGEN and SIMBIOLAB companies, Iran) and laboratory diagnosis of COVID-19 virus using real-time quantitative reverse transcription polymerase chain reaction (RT-qrtPCR) and IVD-approved molecular kit (PishtazTeb Diagnostics, Iran) were done according to instruction protocols as described before [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using the package IBM SPSS Statistics for Windows (version 26) (SPSS Inc., Chicago, IL, USA), and the chi-square test was used for analyzing the data. A \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAnalysis of our results showed that out of 13,345 COVID-19 RT-qrtPCR and 4,194 BACTEC blood culture requests from 2020.02.25 to 2022.12.24 in our hospital, bacteremia/fungemia were confirmed in 10.34% of the patients who requested both of the test simultaneously (435/4,194). The COVID-19 infection was confirmed in 25.3% of the patients with bacteremia/fungemia (110/435). Except for 2 patients with no record, the infection with Gram-negative bacteria, Gram-positive bacteria, and fungi was detected in 59.3% (257/433), 32.3% (140/433), and 8.31% (36/433) of the cases, respectively. Out of 433 blood culture samples, \u003cem\u003ePseudomonas\u003c/em\u003e spp. (21.3%), \u003cem\u003eKlebsiella\u003c/em\u003e spp. (20.2%), CN\u003cem\u003eS\u003c/em\u003e (15.8%), \u003cem\u003eAcinetobacter\u003c/em\u003e spp. (9.6%), \u003cem\u003eS. aureus\u003c/em\u003e (8%), \u003cem\u003eEnterococcus\u003c/em\u003e spp. (5%), \u003cem\u003eEnterobacter\u003c/em\u003e (3.9%) and \u003cem\u003eE. coli\u003c/em\u003e (2.1%) were among the common isolates associated with BSI in children. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the patients with positive BACTEC culture for Gram-positive (BSI-GPB) or fungi (BSI-FB), no significant association was found between the microorganisms and underlying diseases, including cancer and chemotherapy, gender and age groups (Table 1). However, a significant difference was measured among different wards of the hospital (\u003cem\u003ep\u003c/em\u003e-value= 0.01). Accordingly, the Pediatric Intensive Care Unit, Emergency Room and Bone Marrow Transplantation wards showed the highest frequency of bloodstream infection with GPB, respectively (30.2%, 21.2% and 14%, respectively) (Table 2) (Figure 1). \u003cem\u003eS. epidermidis\u003c/em\u003e and \u003cem\u003eS. aureus\u003c/em\u003e were common causes of BSI-GPB in all the hospital wards (Figure 2). \u003cem\u003eEnterococcus\u003c/em\u003e was the main cause of infection in the Oncology ward (Two-fold higher than \u003cem\u003eS. aureus\u003c/em\u003e) and the third cause of BSI-GPB in most hospital wards. \u003cem\u003eCandida\u003c/em\u003e spp. were detected in 6.7% of the target population, which was lower than the frequency of the infection with non-\u003cem\u003eCandida\u003c/em\u003e yeast and fungi infections (13.4%). \u003cem\u003eCandida\u003c/em\u003e spp. were mainly isolated from the patients in the Infectious Diseases and Surgery wards. BSI-FB, regardless to their types, were mainly isolated from the blood of the patients in the PICU and Gastroenterology wards (Table 2) (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e The frequency of Gram-positive bacteria and fungi isolates from bloodstream infection of children according to age, gender, and underlying diseases in a pediatric hospital in Tehran, Iran, 2020-2022.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"737\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMicroorganisms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBlood culture\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.23913043478261%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.554347826086957%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.41304347826087%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.451086956521738%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCancer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"6.666666666666667%\"\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.666666666666667%\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.392156862745098%\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.568627450980392%\"\u003e\n \u003cp\u003ePathogen %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.588235294117647%\"\u003e\n \u003cp\u003eTotal %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e\u0026gt;3 y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003e\u0026le;3 y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.411764705882353%\"\u003e\n \u003cp\u003en/N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.235294117647058%\"\u003e\n \u003cp\u003en/N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot recorded\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e1.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e4.35%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCandida\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;spp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e6.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e10.87%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e1/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e8.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther yeasts and fungi\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e13.48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e10.87%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e2/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e8.33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e1/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e4.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorynebacterium\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003espp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e2.25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e1/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e25.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMicrococcus\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003espp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e1.69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e2.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e0/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0/3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eS. aureus\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e20.22%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e10.87%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e5/36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e13.89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e1/36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e2.78%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCoagulase negative Staphylococci\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e40.45%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e52.17%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e4/72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e5.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e2/72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e2.78%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStreptococcus\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;spp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e1.12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e0/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEnterococcus\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003espp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e12.36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e6.52%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e3/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e13.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e0/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e0.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.58695652173913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.744565217391305%\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.619565217391305%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.201086956521739%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.336956521739131%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.521739130434782%\"\u003e\n \u003cp\u003e16/175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e9.14%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.706521739130435%\"\u003e\n \u003cp\u003e4/175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.929347826086956%\"\u003e\n \u003cp\u003e2.23%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea. Aerobic BACTEC system was used for detection of microbial agents responsible for bloodstream infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e The frequency and diversity of Gram-positive and yeasts in bloodstream infection of children according to ward of hospitalization in a pediatric hospital in Tehran, Iran, 2020-2022.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"860\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMicroorganisms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"12\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWards\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNot reported\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBMT\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eED\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInfectious diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePulmonary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNephrology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNeurology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOncology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePICU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRheumatology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNot reported\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within not reported\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e10.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCandidia\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within \u003cem\u003eCandida\u003c/em\u003e spp.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e41.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e18.2%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorynebacterium\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;spp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e50.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e10.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eEnterococcus\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003espp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e22.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e40.9%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e23.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e15.4%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e14.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e66.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e12.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMicrococcus\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;spp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eS. aureus\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e13.9%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e25.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e19.4%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e13.9%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e23.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e30.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e42.9%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e13.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e45.5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.1%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCNS\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e15.5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e19.4%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e43.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e44.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e36.8%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e30.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e33.3%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e66.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e42.9%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e55.6%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e18.2%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e39.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStreptococcus\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003espp\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e50.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e50.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther fungi\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within other fungi\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e12.5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20.8%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e37.5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e38.5%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e16.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e40.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e13.4%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within microorganisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e14.0%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e21.2%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e30.2%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e% within Ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.56910569105691%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.948896631823461%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.59465737514518%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.110336817653891%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.110336817653891%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.110336817653891%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.220673635307781%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.852497096399535%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.084785133565622%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.504065040650406%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"6.039488966318235%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.458768873403019%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"8.478513356562138%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.458768873403019%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"5.458768873403019%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea. Abbreviations: BMT, Bone marrow transplantation; ED, Emergency room; GI, Gastroenterology; PICU, Pediatric Intensive Care Unit; CNS, Coagulase-negative \u003cem\u003eStaphylococcus\u0026nbsp;\u003c/em\u003espp.\u003c/p\u003e\n\u003cp\u003eb, Percentages of BSI-GPB higher than 10% are shown in bold.\u003c/p\u003e\n\u003cp\u003ec. \u0026ldquo;Not reported\u0026rdquo; indicates BSI-GPB samples that have Gram positive staining records, but names of Gram-positive bacteria were not indicated.\u003c/p\u003e\n\u003cp\u003eResults of antibiotic susceptibility testing showed highest frequency of resistance to azithromycin, oxacillin, penicillin among CN\u003cem\u003eS\u003c/em\u003e, azithromycin, tetracycline, trimethoprim/sulfamethoxazole, oxacillin and clindamycin among \u003cem\u003eS. aureus\u003c/em\u003e, and trimethoprim/sulfamethoxazole, tetracycline, gentamicin, ciprofloxacin, and penicillin among \u003cem\u003eEnterococcus\u003c/em\u003e spp. blood isolates (Figure 3). The highest susceptibility was detected to minocycline, linezolid, chloramphenicol, and norfloxacin in CN\u003cem\u003eS\u003c/em\u003e, minocycline, doxycycline, rifampicin, and norfloxacin in \u003cem\u003eS. aureus\u003c/em\u003e, and linezolid and chloramphenicol in \u003cem\u003eEnterococcus\u003c/em\u003e spp. MR phenotype in \u003cem\u003eS. aureus\u003c/em\u003e (MR\u003cem\u003eSA\u003c/em\u003e) and coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e spp. (MR-CN\u003cem\u003eS\u003c/em\u003e) isolates that showed resistance to cefoxitin was detected in 40% and 61.5% of the strains, while 33.3% of the \u003cem\u003eEnterococcus\u003c/em\u003e isolates presented VR\u003cem\u003eE\u003c/em\u003e phenotype. VR\u003cem\u003eE\u003c/em\u003e, MR\u003cem\u003eSA\u003c/em\u003e, and MR-CN\u003cem\u003eS\u003c/em\u003e isolates mainly belonged to Emergency Room (3/6, 50%), Infectious Diseases (2/4, 50%), and PICU (11/16, 68.7%) wards, respectively. Details about the resistance frequency for each antibiotic are shown in Table 3. Multidrug resistance (MDR) phenotype was detected in 90.7%, 100%, and 77.7% of the CN\u003cem\u003eS\u003c/em\u003e, \u003cem\u003eS. aureus\u003c/em\u003e and \u003cem\u003eEnterococcus\u003c/em\u003e spp. isolates, respectively. All the CNS strains with resistant phenotype to cefoxitin, oxacillin and penicillin and all vancomycin-resistant strains of \u003cem\u003eEnterococcus\u003c/em\u003e spp. showed MDR phenotype (Table 4 and Supplementary Table 1). Statistical analysis did not show a correlation between MDR patterns and COVID-19 infection status for most of the bacterial genera, except for CNS, where an inverse correlation was shown between COVID-19 status and methicillin resistance phenotype (\u003cem\u003ep\u003c/em\u003e-value= 0.029). Accordingly, out of 25 CN\u003cem\u003eS\u003c/em\u003e with cefoxitin test, MR-CN\u003cem\u003eS\u003c/em\u003e strains mainly belonged to the COVID-19 negative cases in comparison to COVID-19 positive children with CN\u003cem\u003eS\u003c/em\u003e-bacteremia (76.4%, 13/17 \u003cem\u003evs\u003c/em\u003e 37.5%, 3/8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Antimicrobial susceptibility of Gram-positive bacterial isolates from BSI in pediatrics in a referral Children\u0026rsquo;s hospital in Tehran, Iran during 2020-2022.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"115%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.183673469387756%\" rowspan=\"2\"\u003e\n \u003cp\u003eBacteria\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.061224489795918%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"87.75510204081633%\" colspan=\"21\"\u003e\n \u003cp\u003eAntibiotics\u003csup\u003eb.\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\n \u003cp\u003eAZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eCIP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eFOX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eSXT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eCHL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eCLN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eDOX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eGEN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eLNZ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eMIN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eNOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eOXA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003ePEN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eRIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eTET\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eVAN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.878048780487805%\"\u003e\n \u003cp\u003eAMP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\n \u003cp\u003eLEV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\n \u003cp\u003eAMX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\n \u003cp\u003eCEF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.658536585365854%\"\u003e\n \u003cp\u003eCFX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.89010989010989%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCN\u003cem\u003eS\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003eS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.89010989010989%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.89010989010989%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n 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valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n 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width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.89010989010989%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-Group A\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eStreptococcus\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;spp.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003eS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n 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width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n 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width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.89010989010989%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e\u003cstrong\u003eS %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"4.395604395604396%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.2967032967032965%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ea. Difference in the number of isolates tested for susceptibility testing of each antibiotic is related to documented data in the hospital microbiology laboratory unit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eb. AMP, ampicillin; AMC, Amoxicillin + Clavulanic acid; AMX, Amoxicillin; AZ, Azithromycin; CHL, Chloramphenicol; CIP, Ciprofloxacin; CN, Clindamycin; FOX, Cefoxitin; SXT, Trimethoprim / sulfamethoxazole; DOX, Doxycycline; GEN, Gentamicin; LNZ, Linezolid; MIN, Minocycline; NOR, Norfloxacin; OXA, Oxacillin; PEN, Penicillin; RIF, Rifampicin; TET, Tetracycline; VAN, Vancomycin; AMP-SUL, Ampicillin-Sulbactam; CTR, Ceftriaxone; MER, Meropenem; EV, Levofloxacin; CEF, Cefepime; CFX, Cefuroxime. CNS, Coagulase-negative \u003cem\u003eStaphylococcus\u0026nbsp;\u003c/em\u003espp. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e The frequency and diversity of Multidrug Resistance phenotypes among Gram-positive bacterial isolates from BACTEC vials in a pediatric hospital in Tehran, Iran 2020-2022.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"88%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.26530612244898%\"\u003e\n \u003cp\u003eBacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.122448979591836%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"58.16326530612245%\" colspan=\"8\"\u003e\n \u003cp\u003eMDR\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.142857142857143%\" valign=\"bottom\"\u003e\n \u003cp\u003eTotal MDR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.142857142857143%\" valign=\"top\"\u003e\n \u003cp\u003eNo MDR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.16326530612245%\" valign=\"top\"\u003e\n \u003cp\u003eNot tested\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e3DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"bottom\"\u003e\n \u003cp\u003e4DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"bottom\"\u003e\n \u003cp\u003e5DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e6DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e7DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e8DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e9DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e10DR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003eCN\u003cem\u003eS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e10.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e12.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e12.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e5.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e3.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e90.1%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e8.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e16.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eS. aureus\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e30%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e42.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eEnterococcus\u003c/em\u003e spp.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.68421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e35.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e21.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.315789473684211%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e77.7%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.368421052631579%\" valign=\"top\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.421052631578947%\" valign=\"top\"\u003e\n \u003cp\u003e10%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea. Multiple Drug Resistance phenotype (MDR): refers to bacteria that are resistant to at least one antimicrobial agent in three or more antimicrobial classes\u003cstrong\u003e.\u003c/strong\u003e The numbers before DR indicate No. of classes of antibiotics that the blood isolates showed resistance phenotypes.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCOVID-19 is considered as a risk factor for hospital-acquired infection\u0026nbsp;[17]. Our study analyzed the status of COVID-19 RT-qrtPCR in patients with positive BACTEC results. Due to the lack of related data for all patients about the co-incidence of COVID-19 and BSI during the study period, we were unable to analyze the risk of COVID-19 infection in the occurrence of community or hospital-acquired BSI. Such a correlation was reported by other studies both in adults and children\u0026nbsp;[18-21]. The correlation could be attributed to immunosenescence, organ dysfunction, early mechanical ventilation and use of other medical devices, ICU admission, longer length of hospital stay, and administration of immunosuppressive medications\u0026nbsp;[19, 20]. The increase in secondary infections in admitted patients with COVID-19, mainly \u003cem\u003eCandida\u003c/em\u003e spp., \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eKlebsiella\u003c/em\u003e spp. and \u003cem\u003eP. aeruginosa\u003c/em\u003e, was reported by some studies\u0026nbsp;[18, 22, 23]. To understand the impact of COVID-19 on the etiology of BSI-GPB and AMR phenotypes in hospitalized children during the pandemic, we compared our findings with the pre-COVID-19 results. Accordingly, in a retrospective study in our hospital in 2013-2018, GPB was considered as the cause of BSI in 45% of the cases with positive BACTEC results, which was relatively higher than its frequency in the current study (32.3%). This difference was mainly related to an increase in the frequency of \u003cem\u003eKlebsiella\u003c/em\u003e spp. (8.8% \u003cem\u003evs\u003c/em\u003e 20.2%) and decrease in the frequency of CN\u003cem\u003eS\u003c/em\u003e (32.5% \u003cem\u003evs\u003c/em\u003e 15.8%)\u0026nbsp;[24]. Although consistent with our results, CN\u003cem\u003eS\u0026nbsp;\u003c/em\u003eand \u003cem\u003eS. aureus\u003c/em\u003e,as common members of the skin microbiota, and Enterococci, as a common member of the intestine, were among the most frequent GPB in both periods, the improvement in hand hygiene by healthcare staff during the COVID-19 pandemic may explain the reduction of BSI by CN\u003cem\u003eS\u003c/em\u003e. A decrease in the trend of BSI by CN\u003cem\u003eS\u003c/em\u003e, mainly \u003cem\u003eS. epidermidis\u003c/em\u003e and \u003cem\u003eS. hominis,\u003c/em\u003e in children from 2018 to 2021 was similarly reported by a study in China, which indicated a significant impact of COVID-19 on the etiology of BSI\u0026nbsp;[25].\u003c/p\u003e\n\u003cp\u003eThe etiology of BSI differs by region, age group, and the epidemiological status of the responsible pathogens in the community and hospital environment\u0026nbsp;[26]. In a 7-year prospective study in a Children\u0026rsquo;s hospital in England, Gram-positive bacteria accounted for more BSI episodes (66.2%), compared with Gram-negative bacteria and yeasts (31.3% and 2.2%, respectively)\u0026nbsp;[27]. A relatively two-fold higher crude frequency of Gram-negative bacteria in pediatric-BSI (60% vs 33% Gram positives and 7% fungal) was reported in a referral South African Children\u0026rsquo;s hospital; however, considering the source of infection, Gram-positive pathogens showed higher prevalence in community-acquired BSI, while in hospital-acquired sepsis Gram-negative and fungal pathogens were more prevalent\u0026nbsp;[28]. Consistent with our results, in a retrospective study in a pediatric hospital in Iran from 2015 to 2019, BSI with Gram-negative bacteria was relatively higher than Gram-positive bacteria (46% and 54%, respectively)\u0026nbsp;[3]. The involvement of CN\u003cem\u003eS\u003c/em\u003e and \u003cem\u003eS. aureus\u0026nbsp;\u003c/em\u003eas a common cause of BSI-GPB was similarly reported by other studies\u0026nbsp;[29]. In a European point prevalence survey on children and neonates, although \u003cem\u003eEnterobacteriaceae\u003c/em\u003e was detected as the most isolated microorganism (28.8%), followed by CN\u003cem\u003eS\u003c/em\u003e (20.9%) and \u003cem\u003eS. aureus\u003c/em\u003e (10.5%), CN\u003cem\u003eS\u003c/em\u003e was reported as the most common bacteria in neonates and infants \u0026lt;12 months of age\u0026nbsp;[30]. In our study, BSI-GPB was mainly detected in the PICU, emergency room, and BMT wards. Among the characterized Gram-positive bacteria, CN\u003cem\u003eS\u003c/em\u003e and \u003cem\u003eS. aureus\u003c/em\u003e were dominant in most wards of the hospital, while \u003cem\u003eEnterococcus\u003c/em\u003e spp. were the main cause of BSI-GPB in the Oncology ward. In a recent study in our hospital, intestinal carriage and endogenous transmission of \u003cem\u003eEnterococcus\u003c/em\u003e spp. to the bloodstream was established in children at oncology and BMT wards\u0026nbsp;[31, 32]. Increased permeability of the intestine through the administration of chemotherapeutic drugs and infection control issues are assumed as risk factors for \u003cem\u003eEnterococcus\u003c/em\u003e spp. mediated bacteremia. Prolonged stay and the use of invasive medical devices in PICU and NICU seems to be the main cause of HAI, including BSI\u0026nbsp;[30].\u003c/p\u003e\n\u003cp\u003eIn the current study, all the \u003cem\u003eEnterococcus\u003c/em\u003e spp. isolates were sensitive to linezolid and chloramphenicol and 66.6% of them were sensitive to vancomycin, which these sensitivities were relatively higher in comparison to our previous results during 2013-2018 (93.2%, 60%, and 46.4%, respectively)\u0026nbsp;[24]. The highest proportion of resistance in the \u003cem\u003eEnterococcus\u003c/em\u003e isolates was related to tetracycline (91.2%), trimethoprim/sulfamethoxazole (90%), and gentamicin (80%), respectively that was consistent with the pre-COVID-19 status\u0026nbsp;[24]. In the same comparative view, the CN\u003cem\u003eS\u003c/em\u003e isolates showed a relatively similar sensitivity to linezolid (91.5% \u003cem\u003evs\u0026nbsp;\u003c/em\u003e95.3%) and vancomycin (93.1% \u003cem\u003evs\u0026nbsp;\u003c/em\u003e96.4%), but higher sensitivity to chloramphenicol (89.8% \u003cem\u003evs\u0026nbsp;\u003c/em\u003e70%). Methicillin resistance was measured according to resistance phenotype to cefoxitin. The higher frequency of MR-CN\u003cem\u003eS\u003c/em\u003e strains compared with MR\u003cem\u003eSA\u003c/em\u003e (61.5% vs 40%) was similarly reported by other studies on pediatrics\u0026nbsp;[3, 33]. In our study, the \u003cem\u003eS. aureus\u003c/em\u003e isolates showed a relatively higher frequency of AMR to most classes of the antibiotics. The difference in sensitivity was meaningfully higher for azithromycin (50% \u003cem\u003evs\u003c/em\u003e 5.8%), tetracycline (66.6 \u003cem\u003evs\u0026nbsp;\u003c/em\u003e9%), trimethoprim/sulfamethoxazole (41.5% vs 25%), and clindamycin (51.9% \u003cem\u003evs\u003c/em\u003e 26.3%) in 2013-2018 \u003cem\u003evs\u003c/em\u003e 2020-2022. In line with our findings, a very low frequency of resistance to vancomycin had been reported among the blood \u003cem\u003eS. aureus\u003c/em\u003e isolates in children,\u0026nbsp;while controversy exists in the frequency of the sensitivity to trimethoprim/sulfamethoxazole (87%), clindamycin (55%)[3, 24]. A pooled prevalence of 63% (45\u0026ndash;78%) for MR\u003cem\u003eSA\u003c/em\u003e in hospitalized children with BSI was reported in a meta-analysis in Iran which higher than its frequency in the current study (40%) and those reported by Moghaddam et al. (34%)\u0026nbsp;[3, 34].\u0026nbsp;In our study, \u003cem\u003eS. aureus\u003c/em\u003e isolates demonstrated high resistance to azithromycin, which could be attributed to changes in the AMR frequency after COVID-19 pandemic\u0026nbsp;[35].\u0026nbsp;The overuse of antibiotics to treat secondary bacterial infections in COVID-19 patients has been proposed as a contributing factor in the increase in antibiotic-resistant bacterial strains\u0026nbsp;[36, 37]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA higher rate of mortality after \u003cem\u003eCandidemia\u003c/em\u003e had been reported among neonates compared with pediatrics, which particularly could increase when co-infection with bacteria exists\u0026nbsp;[6]. Our study detected no significant difference in the infection with yeasts and \u003cem\u003eCandida\u003c/em\u003e spp. between the defined age groups. Although fungemia showed higher frequency in PICU, \u003cem\u003eCandida\u003c/em\u003e spp. were mainly detected in the Infectious Diseases and Surgery wards. High rate of colonization due to an increase in days of hospitalization and medical interventions like the use of central venous line and mechanical ventilation, parenteral nutrition, bacterial infection, immunocompromised status, surgery, underlying diseases like dialysis, and antibiotic therapy seem to be the main cause of infection with yeasts in these units [38].\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA decline in the trend of BSI by GPB and an increase in resistance to antibiotics was shown in children during the COVID-19 pandemic. CN\u003cem\u003eS\u003c/em\u003e, \u003cem\u003eS. aureus\u003c/em\u003e and Enterococci remain as main cause of BSI-GPB in all hospital wards, while \u003cem\u003eCandida\u003c/em\u003e spp. and yeasts play a major role in specific hospital wards. The increase in antibiotic resistance could be described by the overuse of antibiotics, like azithromycin, in COVID-19 patients; however, differences in types of interventions in the hospital wards may explain the measured difference in the etiology of BSI-GPB. This highlights the importance of well-designed prophylactic regimens and infection prevention and control programs for each ward.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations due to its retrospective nature. In this study, we were unable to measure the co-incidence of COVID-19 and BSI during the study period and analyze the risk of COVID-19 infection in the occurrence of BSI. Moreover, due to a lack of data about the length of hospital stay, time of BACTEC-positivity after admission, and death rate we couldn\u0026rsquo;t estimate and differentiate the frequency of community- and hospital-acquired BSI, diversity in AMR phenotypes, and their correlation with mortality. Future studies are needed to improve our understanding of the impact of COVID-19 pandemic on BSI by bacteria and yeasts in children. \u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBSI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Bloodstream infection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAMR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Antimicrobial resistance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronavirus Disease 2019\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRT-qrtPCRReal-Time Quantitative Reverse Transcription Polymerase chain reaction\u003c/p\u003e\n\u003cp\u003eGPB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Gram-positive bacteria\u003c/p\u003e\n\u003cp\u003eMR\u003cem\u003eSA\u003c/em\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Methicillin-resistant phenotype in the \u003cem\u003eS. aureus\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMR-CN\u003cem\u003eS\u003c/em\u003e\u0026nbsp; \u0026nbsp;Methicillin-resistant Coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e spp.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVI\u003cem\u003eSA\u003c/em\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Vancomycin-intermediate \u003cem\u003eS. aureus\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eVR\u003cem\u003eE\u003c/em\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Vancomycin-resistant \u003cem\u003eEnterococcus\u003c/em\u003e spp.\u003c/p\u003e\n\u003cp\u003eCLSI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Clinical and Laboratory Standards Institute\u003c/p\u003e\n\u003cp\u003eHABSI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hospital acquired-bloodstream infections\u003c/p\u003e\n\u003cp\u003eLMICs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Low- and middle-income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRNA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ribonucleic acid\u003c/p\u003e\n\u003cp\u003ePICU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pediatric Intensive Care Unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe online version contains supplementary material available at https://doi. \u0026hellip;. [will be addressed by the journal].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank\u0026nbsp;Dr. Saeed Maham who facilized this study in the Microbiology laboratory, the staff of Mofid Children\u0026rsquo;s Hospital and our colleagues at Pediatric Infections Research Center, Research Institute for Children\u0026rsquo;s Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran for their cooperation. This work was supported by\u0026nbsp;research assistant\u0026nbsp;of the School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFatemeh Fallah:\u0026nbsp;Conceptualization and Supervision;\u0026nbsp;Abdollah Karimi, Methodological and technical support;\u0026nbsp;Nazanin Ahari Oskooie, Data entry,\u0026nbsp;Data curation; Leila Azimi and Hannan Khodaie, RNA extraction and COVID-19 detection; Shahnaz Armin, Methodology; Nafiseh Abdollahi, data collection, data entry; Ghazale Ghandchi and Zari Gholinejad, data collection, data entry;\u0026nbsp;Masoud Alebouyeh, Writing the original draft, data curation, formal analysis, visualization, review and editing.\u0026nbsp;Azita Behzad,Seyedeh Masumeh Hashemi, andSeyedeh Narjes Ahmadizadeh, medical visits, BACTEC blood culture request, and scientific collaboration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by a grant (No: IR.SBMU.MSP.REC.1401.060) from Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFleischmann-Struzek C, Goldfarb DM, Schlattmann P, Schlapbach LJ, Reinhart K, Kissoon N. The global burden of paediatric and neonatal sepsis: a systematic review. Lancet Respiratory Med. 2018;6(3):223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaupland KB. Incidence of bloodstream infection: a review of population-based studies. Clin Microbiol Infect. 2013;19(6):492\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSajedi Moghaddam S, Mamishi S, Pourakbari B, Mahmoudi S. Bacterial etiology and antimicrobial resistance pattern of pediatric bloodstream infections: a 5-year experience in an Iranian referral hospital. BMC Infect Dis. 2024;24(1):373.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePfaller MA, Andes DR, Diekema DJ, Horn DL, Reboli AC, Rotstein C, Franks B, Azie NE. Epidemiology and outcomes of invasive candidiasis due to non-albicans species of Candida in 2,496 patients: data from the Prospective Antifungal Therapy (PATH) registry 2004\u0026ndash;2008. 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Clin Infect diseases: official publication Infect Dis Soc Am. 2022;74(10):1748\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSturm LK, Saake K, Roberts PB, Masoudi FA, Fakih MG. Impact of COVID-19 pandemic on hospital onset bloodstream infections (HOBSI) at a large health system. Am J Infect Control. 2022;50(3):245\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSol\u0026iacute;s-Huerta F, Martinez-Guerra BA, Roman-Montes CM, Tamez-Torres KM, Rajme-Lopez S, Ort\u0026iacute;z-Conchi N, L\u0026oacute;pez-Garc\u0026iacute;a NI, Villalobos-Zapata GY, Rangel-Cordero A, Santiago-Cruz J, et al. Risk Factors Associated with the Development of Hospital-Acquired Infections in Hospitalized Patients with Severe COVID-19. Antibiotics. 2023;12(7):1108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCeparano M, Sciurti A, Isonne C, Baccolini V, Migliara G, Marzuillo C, Natale F, Terrin G, Villari P, Group TC. Incidence of Healthcare-Associated Infections in a Neonatal Intensive Care Unit before and during the COVID-19 Pandemic: A Four-Year Retrospective Cohort Study. J Clin Med. 2023;12(7):2621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSloot R, Nsonwu O, Chudasama D, Rooney G, Pearson C, Choi H, Mason E, Springer A, Gerver S, Brown C, et al. Rising rates of hospital-onset Klebsiella spp. and Pseudomonas aeruginosa bacteraemia in NHS acute trusts in England: a review of national surveillance data, August 2020-February 2021. J Hosp Infect. 2022;119:175\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrasselli G, Scaravilli V, Mangioni D, Scudeller L, Alagna L, Bartoletti M, Bellani G, Biagioni E, Bonfanti P, Bottino N, et al. Hospital-Acquired Infections in Critically Ill Patients With COVID-19. Chest. 2021;160(2):454\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzimi T, Maham S, Fallah F, Azimi L, Gholinejad Z. Evaluating the antimicrobial resistance patterns among major bacterial pathogens isolated from clinical specimens taken from patients in Mofid Children's Hospital, Tehran, Iran: 2013\u0026ndash;2018. Infect drug Resist. 2019;12:2089\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi L, Ma J, Guo P, Gao K, Yang J, Sun H. Changes of coagulase-negative Staphylococci infections in children before and after the COVID-19 pandemic in Zhengzhou, China. J Infect. 2023;86(2):154\u0026ndash;225.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiekema DJ, Hsueh PR, Mendes RE, Pfaller MA, Rolston KV, Sader HS, Jones RN. The Microbiology of Bloodstream Infection: 20-Year Trends from the SENTRY Antimicrobial Surveillance Program. Antimicrob Agents Chemother 2019, 63(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGray JW. A 7-year study of bloodstream infections in an English children's hospital. Eur J Pediatrics. 2004;163(9):530\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDramowski A, Cotton MF, Rabie H, Whitelaw A. Trends in paediatric bloodstream infections at a South African referral hospital. BMC Pediatr. 2015;15:33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLisowska-Łysiak K, Lauterbach R, Międzobrodzki J, Kosecka-Strojek M. Epidemiology and Pathogenesis of Staphylococcus Bloodstream Infections in Humans: a Review. Pol J Microbiol. 2021;70(1):13\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZingg W, Hopkins S, Gayet-Ageron A, Holmes A, Sharland M, Suetens C. Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European Centre for Disease Prevention and Control point-prevalence survey. Lancet Infect Dis. 2017;17(4):381\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlebouyeh M, Shirvani F, Hassanzadeh R, Azimi T, Ghandchi G, Abdollahi N, Gholinejad Z, Behzad A, Sheikhi Z, Fallah F, et al. Intestinal colonization of vancomycin-resistant Enterococcus in children admitted to Mofid children's hospital intensive care unit at admission and at discharge. Mol Biol Rep. 2023;50(4):3271\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShirvani F, Hassanzadeh R, Attaran B, Ghandchi G, Abdollahi N, Gholinejad Z, Sheikhi Z, Behzad A, Fallah F, Azimi L, et al. The intestinal carrier status of Enterococcus spp. in children: clonal diversity and alterations in resistance phenotypes before and after admission to a pediatric intensive care unit. BMC Pediatr. 2023;23(1):434.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolesnichenko SI, Lavrinenko AV, Akhmaltdinova LL. Bloodstream Infection Etiology among Children and Adults. \u003cem\u003eInt J Microbiol\u003c/em\u003e 2021, 2021:6657134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarrafzadeh F, Sohrevardi SM, Abousaidi H, Mirzaei H. Prevalence of methicillin-resistant Staphylococcus aureus in Iranian children: a systematic review and meta-analysis. Clin experimental Pediatr. 2021;64(8):415\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdelaziz Abdelmoneim S, Mohamed Ghazy R, Anwar Sultan E, Hassaan MA, Anwar Mahgoub M. Antimicrobial resistance burden pre and post-COVID-19 pandemic with mapping the multidrug resistance in Egypt: a comparative cross-sectional study. Sci Rep. 2024;14(1):7176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolli AL, Zlatian OM, Cara ML, Olteanu M. Pre- and Post-COVID-19 Antimicrobial Resistance Pattern of Pathogens in an Intensive Care Unit. Pharmaceuticals (Basel Switzerland) 2024, 17(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaleb MH, Elmanama AA, Taleb AH, Tawfick MM. Pre- and post-COVID-19 antimicrobial resistance profile of bacterial pathogens, a comparative study in a tertiary hospital. J Infect developing Ctries. 2023;17(5):597\u0026ndash;609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrissaud O, Guichoux J, Harambat J, Tandonnet O, Zaoutis T. Invasive fungal disease in PICU: epidemiology and risk factors. Ann Intensiv Care. 2012;2(1):6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSupplementary Table 1. Multiple Drug Resistance phenotypes among Gram-positive bacterial isolates from BACTEC vials in a pediatric hospital in Tehran, Iran 2020\u0026ndash;2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bloodstream infection, Children, Gram Positive bacteria, Yeasts, Antimicrobial susceptibility, COVID-19","lastPublishedDoi":"10.21203/rs.3.rs-4498290/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4498290/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAlteration in the etiology of bloodstream infection (BSI) and antimicrobial resistance (AMR) following the COVID-19 pandemic is not well known in children. This study aimed to\u003cstrong\u003e \u003c/strong\u003einvestigate these changes during 2 years in Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Children under 18 years old with suspected bacteremia/fungemia who had positive BACTEC blood cultures were included. Characterization of the isolates, antimicrobial susceptibility testing, and detection of multidrug-resistant (MDR) phenotypes were done based on standard protocols. Statistical analysis was done to measure the correlation of COVID-19 infection with BSI and AMR.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Out of 13,345 COVID-19 tests and 4,194 BACTEC blood culture requests, bacteremia/fungemia were confirmed in 10.34% of the patients who requested both tests simultaneously. The COVID-19 infection was confirmed in 25.3% of the patients with bacteremia/fungemia. The infection with Gram-negative bacteria, Gram-positive bacteria (GPB), and fungi was detected in 59.3%, 32.3%, and 8.31% of the cases, respectively. \u003cem\u003ePseudomonas\u003c/em\u003espp. (21.3%), \u003cem\u003eKlebsiella\u003c/em\u003e spp. (20.2%), CN\u003cem\u003eS\u003c/em\u003e (15.8%), \u003cem\u003eAcinetobacter\u003c/em\u003espp. (9.6%), \u003cem\u003eS. aureus\u003c/em\u003e (8%), and \u003cem\u003eEnterococcus\u003c/em\u003e spp. (5%) were among the common isolates. In the case of BSI with GPB, a significant difference was measured among different hospital wards (\u003cem\u003ep\u003c/em\u003e-value= 0.01). Moreover, a negative correlation was shown between the CN\u003cem\u003eS\u003c/em\u003e bacteremia and COVID-19 infection (\u003cem\u003ep\u003c/em\u003e-value= 0.029). \u003cem\u003eCandida\u003c/em\u003e spp. and non-\u003cem\u003eCandida\u003c/em\u003eyeasts were detected in 6.7% and 13.4% of the cases, respectively. Results of antibiotic susceptibility testing showed the highest frequency of resistance to azithromycin and oxacillin among CN\u003cem\u003eS\u003c/em\u003e, azithromycin, tetracycline, and oxacillin among \u003cem\u003eS. aureus\u003c/em\u003e, and tetracycline and trimethoprim/sulfamethoxazole among \u003cem\u003eEnterococcus\u003c/em\u003e. Methicillin-resistance phenotype in the \u003cem\u003eS. aureus\u003c/em\u003e (MR\u003cem\u003eSA\u003c/em\u003e) and coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003espp. (MR-CNS) was detected in 40% and 61.5% of the strains, respectively and the Enterococci were resistant to vancomycin in 33.3% of the isolates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eA decline in the trend of BSI by GPB and an increase in AMR was shown in children during the COVID-19 pandemic. The rise in antibiotic resistance could be described by the overuse of antibiotics in COVID-19 patients, while the difference in types of medical interventions may explain the difference in the etiology of BSI among the hospital wards.\u003c/p\u003e","manuscriptTitle":"The impact of COVID-19 pandemic on bloodstream infections in pediatrics and alteration in antimicrobial resistance phenotypes, 2020-2022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 15:09:08","doi":"10.21203/rs.3.rs-4498290/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-19T12:23:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T10:21:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T10:19:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-05-29T16:01:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a06494ca-fbde-487f-b63d-aa719fa50c02","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-4498290","link":"https://doi.org/10.1186/s12887-024-05146-7","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2024-10-18 15:57:23","publishedOnDateReadable":"October 18th, 2024"},"versionCreatedAt":"2024-07-12 15:09:08","video":"","vorDoi":"10.1186/s12887-024-05146-7","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05146-7","workflowStages":[]},"version":"v1","identity":"rs-4498290","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4498290","identity":"rs-4498290","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}