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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 111-115

Pattern of drug resistance in hospital-acquired pneumonia in a tertiary care hospital: Cross-sectional study


Department of Pulmonary Medicine, J. N. Medical College, Belgaum, Karnataka, India

Date of Web Publication18-May-2018

Correspondence Address:
Dr. Bhagyashri B Patil
Department of Pulmonary Medicine, J. N. Medical College, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_279_17

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  Abstract 


INTRODUCTION: Hospital-acquired pneumonia (HAP) is associated with the highest mortality rate of 35%–50% globally and is the second or the third most frequent nosocomial infections.
AIMS AND OBJECTIVES: The aims of the study were to know the pattern of drug resistance in HAP, study the clinical profile, and treatment outcome in HAP.
MATERIALS AND METHODS: A cross-sectional study was performed from January 2016 to December 2016. A total of 100 patients who developed HAP were enrolled in the study. Totally 88 patients had positive bacterial culture growth and 12 patients had no growth or fungal growth. Hence, 88 patients were screened for further analysis.
RESULTS: A total of 88 patients developed HAP and ventilator-associated pneumonia (VAP) with bacterial growth. The mean age of the patients was 54 ± 7 years. The most common organisms isolated are Acinetobacter (13.6%), Enterobacter species (12.5%), Klebsiella (26.1%), Pseudomonas (18.2%), and Staphylococcus species (22.7%). In early onset (27.2%) and late onset of HAP (23.9%), chronic obstructive pulmonary disease was the most common predisposing disease (41.7%, 47.7%). In early onset (14.8%) and late onset of VAP (34%), cerebrovascular accidents (23.3%) and neurological diseases (26.7%) were the most common diseases. Acinetobacter species were resistant to most of the commonly used antibiotics with sensitive to only Carbapenems. All the strains of Staphylococcal species were sensitive to vancomycin and linezolid (100%). The mortality was highest with Klebsiella (27.9%) and Pseudomonas (23.2%) infections, neurological diseases (72.8%), and in the late onset of VAP (34%).
CONCLUSION: The study demonstrated that the resistance to commonly used antibiotics is on rise to various organisms. Hence, an antibiogram setup needs to be revised for every 6 months.

Keywords: Carbapenems, hospital-acquired pneumonia, ventilator-associated pneumonia


How to cite this article:
Malgere RR, Patil BB. Pattern of drug resistance in hospital-acquired pneumonia in a tertiary care hospital: Cross-sectional study. Indian J Health Sci Biomed Res 2018;11:111-5

How to cite this URL:
Malgere RR, Patil BB. Pattern of drug resistance in hospital-acquired pneumonia in a tertiary care hospital: Cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2018 Dec 19];11:111-5. Available from: http://www.ijournalhs.org/text.asp?2018/11/2/111/232692




  Introduction Top


Pneumonia is an infection of pulmonary parenchyma. For more than a century, it was known that patients acquire infections in the hospital. These are known as hospital-acquired or nosocomial infections.[1] Pneumonia is the second most common nosocomial infection affecting 9%–24% critically ill patients.[2] According to the National Nosocomial Infective Surveillance System of the United States data, nosocomial pneumonia is the second leading cause of mortality and morbidity among critically ill patients.[3] Hospital-acquired pneumonia (HAP) is pneumonia that occurs 48 h or more after admission and did not appear to be incubating at the time of admission. HAP is the leading cause of death among hospital-acquired infections.[4]

Patients in Intensive Care Unit are 5–10 times more likely to acquired nosocomial infections. Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that develops > 48–72 h after endotracheal intubation. Almost 86% of nosocomial pneumonia are due to mechanical ventilation.[5] Late-onset occurs more 96 h, caused by multidrug-resistant pathogens associated with increased morbidity and mortality.[4]

Incidence of nosocomial pneumonia varies among different studies. There are controversies regarding the incidence, epidemiology, diagnosis, treatment, and prognosis of nosocomial pneumonia. Hence, there is need for proposed study.

Hence, the present study is aimed to find out the risk factors, clinical profile, and microbiological flora associated with the development of nosocomial pneumonia, their antibiotic sensitivity pattern and their treatment outcome. This information is utilized to formulate to modify preventable risk factors and help us in formulating an institutional antimicrobial policy.


  Materials and Methods Top


This was a cross-sectional study conducted on 100 patients who were diagnosed with HAP after 48 h of admission as per the American Thoracic Society and Infectious Diseases Society of America guidelines in KLE's Dr. Prabhakar Kore Hospital and Medical Research Centre during January 2016–December 2016.

Inclusion criteria

All patients admitted in KLE's Dr. Prabhakar Kore Hospital and Medical Research Centre with age >18 years showing signs and symptoms of pneumonia, >48 h of hospitalization.

Exclusion criteria

  1. Patients with immune-compromised states such as malignancy and tuberculosis
  2. Patients admitted with a diagnosis of pneumonia
  3. Other causes of radiological infiltrate such as pulmonary hemorrhage, pulmonary embolism, congestive cardiac failure, and acute respiratory distress.


Procedure

The study was approved by the Ethical and Research Committee. The selected patients were briefed about the study and written informed consent was obtained.

All patients >18 years of age, who developed HAP as per inclusion criteria, were included in the study. The patients were investigated clinically, radiologically, and bacteriologically to determine the presence of pneumonia and isolate causative microorganism. Routine investigations such as complete blood count, renal function test, and others such as arterial blood gas analysis were done. The sputum, endotracheal aspirate, bronchoalveolar lavage, and bronchial brush samples were sent for culture and sensitivity. The patients were followed till the time of discharge or death (whichever occurs first during the hospital stay) to study the drug-resistance pattern in the obtained organism and clinical outcomes in the patients.


  Results Top


A total of 100 patients diagnosed with HAP were enrolled in the study. Among 100 patients, 88 patients had positive bacterial culture growth either in sputum, ET aspirate or in BA. A total of 12 patients were excluded from final analysis as they had either negative culture or revealed fungal growth. Of 88 patients, there were 68 (77.27%) male patients and 20 (22.73%) female patients. The mean age was 54 ± 74 years. Maximum number of patients were of >60 years of age, that is, 38 patients (43.18%) [Table 1].
Table 1: Baseline characteristics of the patients in the study

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A total of 45 (51.13%) patients had HAP, and 43 (48.86%) patients had VAP. Among them, 42.04% patients had an early onset, and 57.95% had late onset of the disease. The most common predisposing clinical disease for occurrence of HAP or VAP was chronic obstructive pulmonary disease (COPD) (29.6%) followed by neurology disease (12.5%). Postoperative surgical patients contributed to 15.91%, CKD − 13.64%, and burns − 6.82% for the occurrence of HAP/VAP. The incidence of HAP was high in COPD patients (44.44%) and postoperative surgical patients (17.77%). The incidence of VAP was highest in cerebrovascular accident (CVA) and neurological patients of 20.93% [Table 2].
Table 2: Association of predisposing disease with onset of pneumonia

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The common organisms isolated in the study were Acinetobacter in 13.64% patients, Enterobacter species in 12.50% patients, Klebsiella in 26.14% patients, Pseudomonas in 18.18% patients, Staphylococcus species in 22.73% patients, and mixed flora in 6.82% patients.

The most common organisms isolated in early-onset HAP were Staphylococcus (54.16%) and Acinetobacter (20.83%), and in late-onset HAP, the organisms isolated were Klebsiella (42.85%) and Staphylococcus (9.04).

The most common organisms isolated in early-onset VAP in early onset were Klebsiella (30.76%) and Pseudomonas (30.76%). The pattern was similar in late-onset VAP also with Klebsiella and Pseudomonas (23.33% and 30%, respectively) [Table 3].
Table 3: Organisms isolated in early and late onset in hospital-acquired pneumonia/ventilator-associated pneumonia Pathogens

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Acinetobacter species and Enterobacteriaceae species showed resistance to most of the antibiotics such as amoxicillin and clavulunate, Ampicillin, Aztreonam, Cefazolin, Cefepime, Cefoxitin, Ciprofloxacin, Gentamicin, Nitrofurantoin, Tetracycline, and Tobramycin. Few strains were observed to be sensitive to Imipenem, Meropenem, and Amikacin. Klebsiella and Pseudomonas species showed resistance to Ampicillin, Aztreonam, Cefepime, Nitrofurantoine, and Tobramycin and were sensitive to Ertapenem, Imipenem, and Meropenem. Staphylococcus species was Amikacin, Ampicillin, Cefazolin, Cefoxitin, Ciprofloxacin, and Tobramycin. They are sensitive to Ertapenem, Imipenem, Moxifloxacin, Piperacillin and Tazobactum, Linizolid, and Vancomycin.

The cure rate was observed to be better in early-onset HAP (79.27%) as compared to VAP (58.8%). The mortality was highest with Klebsiella (27.9%) and Pseudomonas infections (23.95%). Mortality was observed to be highest in late-onset VAP (86.67%) with gram-negative organisms with a clinical diagnosis of cerebral vascular accidents (83.33%) and neurological disorders patients (72.73%) [Table 4].
Table 4: Outcome of the disease with onset of the disease, predisposing medical condition and organisms isolated

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  Discussion Top


HAP is associated with the highest mortality rate of all nosocomial infections which is estimated to be between 35% and 50% globally and is the second or the third most frequent nosocomial infections. The administration of accurate and timely initial empirical antibiotic therapy has been shown to have a major impact on mortality from nosocomial pneumonia.[6]

In the present study, of 88 patients, there were 68 (77.27%) male patients and 20 (22.73%) female patients. The mean age was 54 ± 74 years. Maximum number of patients were of >60 years of age, that is, 38 patients (43.18%). In a study by Avci et al.,[7] it was found that the mean age group to be 58.7 years with male predominance of 73%.

In the present study, a total of 45 (51.13%) patients had HAP with 42.04% patients with early onset and 57.95% patients with late onset of the disease. Nearly 43 (48.86%) patients had VAP of which, 14.8% had early onset of VAP and 34% had late onset of VAP. A study done by Golia et al.[8] found that 44.23% had early and 55.77% had late onset of disease.

In the study, it was observed that the comorbidities such as diabetes mellitus (DM) was observed in 49% of patients, other comorbidities such as hypertension and ischemic heart disease were found to be 32% and 19%, respectively. This is similar to the findings of the study done by Eida et al.,[9] who observed that 41% patients had DM and 44% had hypertension and IHD in 14%. Furthermore, the clinical features of HAP include, cough in 40.91%, expectoration in 43.18%, breathlessness in 46.59%, and fever in 54.55% of the total patients.

In the present study, the prevalence of COPD was higher which led to the development of HAP (29.6%). The prevalence of COPD in HAP was 44.44% and in VAP is 13.95%. Other clinical diseases such as CVA (13.64%), CAD (7.95%), neurological disorders (12.50%), postoperative surgery (15.91%), CKD (13.64%), and burns (6.82%) contributed to the rest of predisposing illnesses.

In the present study, the most common organisms isolated in early-onset HAP were Staphylococcus (54.16%) and Acinetobacter (20.83%), and in late-onset HAP, the organisms isolated were Klebsiella (42.85%) and Staphylococcus (9.04%). In the Indian scenario, study by Charles et al.[10] had studied on etiological agents of VAP and they observed that in late-onset VAP Pseudomonas aeruginosa, Klebsiella pneumonia, and  Escherichia More Details coli were isolated while early-onset VAP many members of Enterobacteriaceae, Candida albicans, Staphylococcus aureus, and Acinetobacter baumannii were isolated.

In this study, the most common organisms isolated in early-onset VAP in early onset were Klebsiella (30.76%) and Pseudomonas (30.76%). The pattern was similar in late-onset VAP also with Klebsiella and Pseudomonas (23.33% and 30%, respectively). This result is in accordance with the study done by Joseph et al.,[11] who observed that Pseudomonas species and Acinetobacter species were common isolates in the late-onset VAP.

Acinetobacter showed resistance to most of the antibiotics such as amoxicillin and clavulunate, Ampicillin, Cefazolin, Cefepime, Cefoxitin, Ciprofloxacin, Gentamicin, Nitrofurantoin, Tetracycline, and Tobramycin. Few strains were observed to be sensitive to Imipenem and Meropenem. A study by Ghadiri et al.[12] had similar results of resistance pattern for Acinetobacter isolates with resistance to Ceftazidime, Amikacin, Imipenem, Ampicillin, Cefoxitin, Tetracycline, and Gentamicin which is in accordance with our present study. Similarly, Klebsiella, Enterobacter species, and Pseudomonas species were sensitive to only Carbopenems. All the strains of Staphylococcal species were sensitive to vancomycin and linezolid (100%).

The mortality was high among patients who had late onset of VAP in 86.67%. Patients admitted with the diagnosis of CVA had mortality of 83.33% and in neurological patients, it was 72.73%, and patients who had positive bacterial culture for Klebsiella mortality was 27.90% and with Pseudomonas species presence, it was 23.25%.

The study has some limitations as follows:

  1. It is a single-center study, where the sample size was small (100 patients) in fact which the hospital-acquired infection was more
  2. In the study, only limited risk factors were studied. Other risk factors of reduced level of consciousness, risk of aspiration, infection from mechanical ventilators, and cross infections were not evaluated in detail
  3. The study had limited set of organisms as the common pathogens isolated were only studied. Other organisms such as MRSA and ESBL have to be given importance.



  Conclusion Top


Every hospital should adapt for an antibiotic sensitivity profile as per the incidence of the infection and their resistance pattern so that the initial choice of therapy is started accordingly.[13] The present study gives knowledge about the best approach to manage the problem of HAP and VAP in our tertiary care hospital. It can be concluded from the present study that, empirical antibiotics that can be started for HAP will be combination of cephalosporins, carbopenems, quinolones and aminoglycosides.

Thus, the patient developing HAP/VAP can be empirical started on these antibiotics and remodification in the treatment can be made as per the culture report subsequently.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Seligman R, Ramos-Lima LF, Oliveira Vdo A, Sanvicente C, Sartori J, Pacheco EF, et al. Risk factors for infection with multidrug-resistant bacteria in non-ventilated patients with hospital-acquired pneumonia. J Bras Pneumol 2013;39:339-48.  Back to cited text no. 1
    
2.
Koenig S, Truwit J. Ventilator-associated pneumonia: Diagnosis, treatment, and prevention. Clin Microbiol Rev 2006;19:637-57.  Back to cited text no. 2
    
3.
National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control 2004;32:470-85.  Back to cited text no. 3
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4.
Morrow L, Kollef M. Hospital-acquired pneumonia. Netter's infectious diseases. Clin Infect Dis 2012;137-45.  Back to cited text no. 4
    
5.
Kalanuria AA, Ziai W, Mirski M. Ventilator-associated pneumonia in the ICU. Crit Care 2014;18:208.  Back to cited text no. 5
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6.
Chawla R. Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries. Am J Infect Control 2008;36:S93-100.  Back to cited text no. 6
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7.
Avci M, Ozgenc O, Coskuner A, Bozca B, Kidak L, Mermut G, et al. Hospital-acquired pneumonia in Nonintensive Care Unit wards. Turk J Med Sci 2010;40:57-63.  Back to cited text no. 7
    
8.
Golia S, Sangeeta KT, Vasudha CL. Microbial profile of early and late onset ventilator associated pneumonia in the Intensive Care Unit of a tertiary care hospital in Bangalore, India. J Clin Diagn Res 2013;7:2462-6.  Back to cited text no. 8
    
9.
Eida M, Nasser M, El-Maraghy N, Azab K. Pattern of hospital-acquired pneumonia in Intensive Care Unit of Suez Canal University Hospital. Egypt J Chest Dis Tuberc 2015;64:625-31.  Back to cited text no. 9
    
10.
Charles MP, Easow JM, Joseph NM, Ravishankar M, Kumar S, Sivaraman U, et al. Aetiological agents of ventilator-associated pneumonia and its resistance pattern – A threat for treatment. Australas Med J 2013;6:430-4.  Back to cited text no. 10
    
11.
Joseph NM, Sistla S, Dutta TK, Badhe AS, Rasitha D, Parija SC, et al. Ventilator-associated pneumonia in a tertiary care hospital in India: Role of multi-drug resistant pathogens. J Infect Dev Ctries 2010;4:218-25.  Back to cited text no. 11
    
12.
Ghadiri H, Vaez H, Khosravi S, Soleymani E. The antibiotic resistance profiles of bacterial strains isolated from patients with hospital-acquired bloodstream and urinary tract infections. Crit Care Res Pract 2012;2012:890797.  Back to cited text no. 12
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13.
MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18:638-56.  Back to cited text no. 13
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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