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Prevalence of respiratory pathogens in ventilated patients: a study from South India.

INTRODUCTION: A few hours after intubation, the distal airways become colonized. Although the upper respiratory tract is colonized by mixed aerobic and anaerobic flora, no more than 10 microorganisms are recovered in ventilated patients. Because of their peculiar susceptibility patterns, oxacillin-resistant Staphylococcus aureus (ORSA), Acinetobacter baumannii and Pseudomonas aeruginosa should be considered in the initial decision tree for the choice of an antimicrobial therapy. (1) Antibiotic choice should be institution specific and patient oriented.

There is variability between Intensive care units within the same hospital itself, in susceptibility of bacterial pathogens to various antibiotics. This may have implications in the design of empiric antibiotic strategies and the planning of the hospital formulary. (2)

A European study found out that antibiotic resistance across all species and drugs was, with some exceptions, highest in southern European countries and Russia, and lowest in Scandinavia. They also recommended that effective strategies are needed to control the selection and spread of resistant organisms. (3)

The profound difficulty in treating MDR (multi drug resistant) organisms is unfortunately arriving at a time when we have a dearth of new systemic antibiotics available. Only 2 new classes of antibiotics have been introduced in the past 40 years--namely oxazolidinones (linezolid) and the cyclic lipopeptides (daptomycin). Both of these are for treatment of gram-positive organisms. Options for resistant gram negative organisms is limited. (4, 5 6)

Outbreak of Imipenem resistant Acinetobacter baumannii (IRAB) has also been reported following prior use of the antibiotic imipenem and admission to Intensive care unit and Respiratory care unit. (7)

MATERIALS AND METHODS: This is a retrospective analysis of data from 434 culture reports of ET (endotracheal) tube aspirates taken from ventilated patients in the Intensive Care Unit from Jan 2013 to Feb 2014. The Culture and sensitivity patterns of endotracheal tube aspirate were analyzed.

Identification of bacteria was done by gram staining. Isolation of the organisms was done by inoculation of sample on agar medium. After 24 hours of incubation each organism was identified on the basis of morphology of colony in culture media and biochemical reactions.

Antibiotic sensitivity Testing was carried out on Muller Hinton Medium by Disc Diffusion Method following Kirby Bauer method. (8)

Patients were admitted in 4 critical care units - namely medical, surgical, trauma and neuro ICU. The setting is a 1250 bedded tertiary referral centre in South India. The objective was to find the prevalent strains of bacteria in patients on ventilator, and their drug sensitivity pattern.

RESULTS: A total of 434 endotracheal aspirates were sent for culture and sensitivity. The prevalence of microbes in the study was as follows. Commonest organisms isolated were acinetobacter 33%, pseudomonas 23% and klebsiella 21%.

Analysis of the antibiotic sensitivity pattern of the microbes: Acinetobacter strains were sensitive only to colistin (92.8%), and tigecycline (64.2%). They were resistant to cefuroxime / cefotaxime (100%), ceftazidime (90%), cefipime (90%), ciprofloxacin (92%) and also amikacin (63%).

Pseudomonas aeruginosa strains were sensitive to Netilmycin in 50%, 60% to piperacillin + tazobactam, and 84% to Colistin. They were resistant to carbapenems) resistance ranged from 60% to 100%), to ciprofloxacin, gentamicin and levofloxacin) 70% each), and to amikacin, ampicillin plus sulbactam and ceftazidime (66% each).

Klebsiella Pneumonia: Strains were sensitive to amikacin (51%), imipenem (51%), tigecycline (78%) and colistin (92%). They were resistant to ceftazidime (95%), ciprofloxacin (79%), Levofloxacin (73%), gentamicin (72.5%) and netilmycin (80%).

Enterobacter Aerogenes: These strains were sensitive to imipenem and meropenem (55%), tigecycline (58%), amikacin (75%) and colistin (82%). But they were resistant to quinolones ciprofloxacin (85%) and levofloxacin (83%), and also aminoglycosides gentamicin (85%) and tobramycin (80%).

Of the 18 staphylococcus aureus isolates, only 45% were sensitive to Cloxacillin, and 43% to cephalexin. 100% were sensitive to Vancomycin, Linezolid, Rifampicin, clindamycin.

The 17 Escherichia coli strains isolated were resistant to ciprofloxacin (71%), ceftazidime (85.7%) and Ticarcillin (100%). They were sensitive to gentamicin (66.6%), cotrimoxazole) 66.6%), cefoperazone/sulbactam combination (76%), piperacillin / tazobactam combination (81%), amikacin (88%), imipenem (94%) and colistin & tigecycline (100%).

Of the 12 non fermenting gram negative bacilli isolated, 91% were susceptible to Piperacillin + tazobactam, 72% to cotrimoxazole, and 58% to cefoperazone/sulbactam. But they were resistant to a host of drugs--ticarcillin (100%), tobramycin (80%) gentamicin (75%) and amikacin (66.6%), ciprofloxacin (63.63%) and levofloxacin (62.5%), ceftazidime (70%), imipenem and tigecycline (both 66.6%), colistin (63.63%).

Among the 11 citrobacter growths identified, the carbapenems and tigecycline were very effective (80-88%), colistin in 88.8%, piperacillin/tazobactam in 81.8%, amikacin in 72%. Gentamicin and tobramycin were disappointing (81% and 66% resistance respectively), ceftazidime did poorly (88.8% resistance), and levofloxacin and ciprofloxacin trailing with 50% and 60% resistance respectively.

Stenotrophomonas cases were only 8 in number. 100% responded to tigecycline. 83% responded to cefoperazone plus sulbactam, 71% and 60% respectively to ciprofloxacin and levofloxacin. Ceftazidime (75% resistance), gentamicin (87.5%), and the carbapenems) 85-100% resistance) fared poorly in their antibacterial activity.

There were 4 cases of Elizabeth kingella who responded to ceftazidime, piperacillin, vancomycin and cefotaxime.

The Hemophilus influenza strain was sensitive to ceftriaxone, cefotaxime and Cefuroxime and co-trimoxazole. It was resistant to ampicillin and erythromycin. The moraxella strain was sensitive to cefuroxime, cefotaxime, co-trimoxazole and erythromycin. It was ampicillin resistant.

The single growth of serratia species was sensitive to gentamicin and amikacin, cloxacillin and piperacillin, co trimoxazole, cefoperazone /sulbactam and the carbapenem antibiotics and tigecycline. But it was resistant to cefuroxime.

DISCUSSION: Hospitals may be considered as reservoirs and breeding grounds within the world of antibiotic resistance. Prevention of cross infection and good quality antimicrobial prescribing contribute to the prevention of antimicrobial resistance. Infection Control and Clinical Microbiology are inextricably linked. Drug resistance among Gram Negative Bacilli is on the rise, and for any species, multi resistance is the norm than the exception.

Optimal management of these infections requires knowledge of local epidemiology and practices to control their spread. (9)

CONCLUSION: This study is an attempt to identify the common respiratory pathogens found in ventilated patients in our Intensive Care Units, so as to help formulate the antibiotic protocols to be followed. It is very obvious that this South Indian teaching hospital has the dreaded problem of MDR gram negative organisms.

Colistin is the only effective drug to combat Acinetobacter species. Colistin also gives 84% cover against Pseudomonas and there is no role for ciprofloxacin, levofloxacin and gentamicin or amikacin. Klebsiella pneumonia was sensitive to tigecycline (78%) and colistin (92%). Enterobacter species was sensitive to amikacin (75%) and colistin (82%). Staph aureus isolates were 45% sensitive to cloxacillin. The remaining strains (MRSA) were sensitive to vancomycin and linezolid, also clindamycin.

Piperacillin+Tazobactam shows promise in case of E.coli (80%) sensitive and non- fermenting Gram negative bacilli (91%), also some cases of Elizabethkingella (50%) and in serratia.

Stenotrophomonas species was sensitive best to Tigecycline (100%), then to Cefoperazone/sulbactam (83%). Both H. influenza and the moraxella strain were sensitive to cefuroxime as well as cefotaxime.

DOI: 10.14260/jemds/2014/2466

REFERENCES:

(1.) Rello J, Diaz E. Pneumonia in the intensive care unit. Crit Care Med 2003; 31: 2544-51.

(2.) Namias N, Samiian L, Nino D, Shirazi E, O'Neill K, Kett DH, Ginzburg E, Mc Kenney, Sleeman D, Cohn SM. Incidence and susceptibility of pathogenic bacteria vary between intensive care units within a single hospital: implications for empiric antibiotic strategies. J Trauma 2000 Oct; 49(4):638-45; discussion 645-6.

(3.) Hanberger H, Diekema D, Fluit A, Jones R, Struelens M, Spencer R, Wolff M. Surveillance of antibiotic resistance in European ICUs. J Hosp Infect. 2001 Jul; 48 (3):161-76.

(4.) Wenzel RP. The antibiotic pipeline-challenges, costs, and values. New Engl J Med 2004 Aug 5; 351 (6):523-6.

(5.) Peterson LR. Bad bugs, no drugs: no ESCAPE revisited. Clin Infect Dis 2009Sep15; 49(6):992-3. doi: 10.1086/605539.

(6.) Spellberg B, Guidos R, Gilbert D, Bradley J, Boucher HW, Scheld WM, Barlett JG, Edwards J Jr; Infectious Diseases Society of America. The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis 2008 Jan 15; 46 (2):155-64. doi: 10.1086/524891.

(7.) Jamulitrat S, Thongpiyapoom S, Suwalak N. An outbreak of imipenem-resistant Acinetobacter baumannii at Songklanagarind Hospital: the risk factors and patient prognosis. J Med Assoc Thai.2007 Oct; 90(10):2181-91.

(8.) Bauer AW, Kirby WMM, Sherris JC, Tuck M. Antibiotics susceptibility testing by a standardized single disc method. Am J Clin Pathol 1966; 45: 493-6.

(9.) Clark NM, Patterson J, Lynch JP 3rd. Antimicrobial resistance among gram-negative organisms in the intensive care unit. Curr Opin Crit Care 2003 Oct; 9 (5):413-23.

AUTHORS:

[1.] Jacob C. E.

[2.] Miriam George Fenn

[3.] Sara Korula

[4.] Shareen George

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of ENT, M.O.S.C. Medical College, Kolenchery, Kerala, India.

[2.] Associate Professor, Department of Obstetrics and Gynaecology, M.O.S.C. Medical College, Kolenchery, Kerala, India.

[3.] Associate Professor, Department of Anaesthesiology, M.O.S.C. Medical College, Kolenchery, Kerala, India.

[4.] Associate Professor, Department of Microbiology, M.O.S.C. Medical College, Kolenchery, Kerala, India.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Jacob C. E, Associate Professor, ENT, M.O.S.C. Medical College, Kolenchery- 682311, Ernakulam District, Kerala, India. E-mail: jacobchundamannil68@gmail.com

Date of Submission: 27/03/2014.

Date of Peer Review: 28/03/2014.

Date of Acceptance: 05/04/2014.

Date of Publishing: 23/04/2014.
Fig. 1: Prevalence of Bacteria

Prevalence of Bacteria (n=434)

Serratia               1
Moraxella              1
Haemophilus            1
Elizabethkingella      4
Stenotrophomonas       8
Citrobarter           11
Non-Fermenting GNB    12
E.Coli                17
Staphylococcus        18
Enterobarter          24
Klebsiella            92
Pseudomonas          100
Acinetobacter        145

Note: Table made from bar graph.

Fig. 2: Acinetobacter

Acinetobacter (n=145)

                         Sensitive   Resistant

Amikacin                    51          88
Ampicillin/Sulbactum        12          50
Cefepime                    14         129
Cefuroxime                   0           7
Cefotaxime                   0           6
Cefoperazone+Sulbactum      52          77
Ceftazidime                 13         199
Ciprofloxacin               11         127
Colistin                   128          10
Gentamicin                  24         118
Levofloxacin                11         120
Ertapenem                    1
Doripenem                    7          39
Imipenum                    23         118
Meropenum                   11         104
Netilmycin                   1           4
Piperacillin                 5         132
Pip+Tazobactum              20         122
Tigecycline                 88          49
Tobramycin                  14          54
Ticarcillin                  3          60
cefepime/tazobactum          0           1
Chloramphenicol             12          56

Note: Table made from bar graph.

Fig. 3: Pseudomonas

Pseudomonas (n=100)

                         Sensitive   Resistant

Ampicillin                   1           2
Amikacin                    32          64
Ampicillin/Sulbactum         1           2
Aztreonam                    0           5
Augmentin                    0           2
Cephalexin                   0           4
Cefepime                    40          55
Cefuroxime                   0           3
Co-Trimoxazole               0           6
Cefotaxime                   0           6
Cefoperazone+Sulbactum      40          53
Ceftazidime                 30          63
Ceftriaxone                  2           5
Ciprofloxacin               28          66
Imipenum                    35          60
Meropenum                   36          61
Doripenem                   18          21
Ertapenem                    0           2
Colistin                    75          14
Gentamicin                  29          69
Levofloxacin                18          48
Netilmycin                   3           3
Piperacillin                33          61
Pip+Tazobactum              59          39
Cloxacillin                  2          1
Tigecycline                  4          15
Tobramycin                  10          29
Ticarcillin                  5          37
Vancomycin                   0           1

Note: Table made from bar graph.

Fig. 4: Klebsiella

Klebsiella (n=92)

                         Sensitive   Resistant

Amikacin                    45          43
Cefotaxime                   0
Cefoperazone+Sulbactum      30          53
Ceftazidime                  4          77
Ceftriaxone                  4          24
Ciprofloxacin               18          69
Meropenum                   43          43
Doripenem                   23          27
Imipenum                    45          43
Ertapenem                    0           1
Colistin                    77           6
Gentamicin                  25          66
Levofloxacin                22          61
Netilmycin                   1           4
Pip+Tazobactum              24          64
Cloxacillin                  0           1
Rifampicin                   0           1
Tigecycline                 57          16
Tobramycin                   8          20
Ticarcillin                  0          26
Vancomycin                   0           1
Cefepime /tazobactum         0           1
Chloramphenicol              9          16

Note: Table made from bar graph.

Fig.5: Enterobacter

Enterobacter (n=24)

                         Sensitive   Resistant

Amikacin                    15           5
Ampicillin/Sulbactum         0           1
Aztreonam                    0           2
Augmentin                    0           1
Cephalexin                   1          20
Cefepime                     3          15
Cefuroxime                   0           1
Cefotaxime                   0           2
Cefoperazone+Sulbactum       4          15
Ceftazidime                  0          19
Ceftriaxone                  0          14
Imipenum                    11           9
Meropenum                   11           9
Doripenem                    0           3
Ciprofloxacin                3          17
Colistin                    14           3
Gentamicin                   3          18
Levofloxacin                 3          15
Netilmycin                   0           1
Piperacillin                 0          21
Pip+Tazobactum               7          13
Tigecycline                  7           5
Tobramycin                   3          12
Ticarcillin                  0          14
Linezolid                    2           0
Vancomycin                   3           0

Note: Table made from bar graph.

Fig. 6: Staphylococcus I

Staphylococcus (n=18)

                 Sensitive   Resistant

Ampicillin          0           12
Cephalexin          7           9
Cloxacillin         7           8
Co-Trimoxazole      8           9
Doripenem           1           0
Ciprofloxacin       1           1
Erythromycin        9           8
Colistin            1           0
Gentamicin          9           8
Levofloxacin        0           1
Rifampicin          2           0
Tigecycline         1           0
Linezolid          14           0
Vancomycin         16           0
penicillin          2           12
Quinupri/Dalfo      2           0
Clindamycin         3           0
Chloramphenicol     1           0

Note: Table made from bar graph.

Fig.7: E.Coli

E.Coli(n=17)

                         Sensitive  Resistant

Ampicillin                   0          11
Amikacin                    15           2
Ampicillin/Sulbactum         0           5
Aztreonam                    3           7
Augmentin                    0           1
Cephalexin                   2          13
Cefepime                     2          13
Cefuroxime                   0           2
Co-Trimoxazole               8           4
Cefotaxime                   0           1
Cefoperazone+Sulbactum      13           4
Ceftazidime                  2          12
Ceftriaxone                  1           4
Ciprofloxacin                4          10
Colistin                    14           0
Gentamicin                  10           5
Imipenum                    16           1
Levofloxacin                 6           9
Meropenum                   15           2
Pip+Tazobactum              13           3
Tigecycline                 14           0
Tobramycin                   2           2
Ticarcillin                  0           3

Note: Table made from bar graph.

Fig. 8: Non-Fermenting GNB

Non-Fermenting GNB(n=12)

                         Sensitive   Resistant

Amikacin                     4           8
Ampicillin/Sulbactum         1           3
Aztreonam                    0           1
Augmentin                    1           1
Cephalexin                   0           6
Cefuroxime                   0           2
Co-Trimoxazole               8           3
Cefotaxime                   1           0
Cefoperazone+Sulbactum       7           5
Ceftazidime                  3           7
Ceftriaxone                  1           5
Ciprofloxacin                4           7
Colistin                     4           7
Gentamicin                   3           9
Imipenum                     4           8
Levofloxacin                 3           5
Netilmycin                   0           2
Pip+Tazobactum              11           1
Tigecycline                  3           6
Tobramycin                   1           4
Ticarcillin                  0           5
Vancomycin                   4           0

Note: Table made from bar graph.

Fig.9: Citrobacter

Citrobacter(n=11)

                        Sensitive   Resistant

Ampicillin                   0          8
Amikacin                     8          3
Aztreonam                    0          4
Cephalexin                   0          8
Cefepime                     3          7
Co-Trimoxazole               0          3
Cefoperazone+Sulbactum       5          4
Ceftazidime                  1          8
Ceftriaxone                  2          4
Doripenem                    3          1
Ciprofloxacin                4          6
Colistin                     8          1
Gentamicin                   2          9
Imipenum                     8          2
Levofloxacin                 5          5
Meropenum                    8          1
Pip+Tazobactum               9          2
Tigecycline                  8          1
Trimetho/Sulfa               4          3

Note: Table made from bar graph.

Fig. 10: Stenotrophomonas

Stenotrophomonas (n=8)

                         Sensitive   Resistant

Ampicillin                   0          4
Amikacin                     0          8
Aztreonam                    0          6
Augmentin                    0          1
Cephalexin                   0          5
Cefepime                     0          7
Cefuroxime                   0          1
Co-Trimoxazole               1          1
Cefoperazone+Sulbactum       5          1
Ceftazidime                  2          6
Doripenem                    0          4
Ciprofloxacin                5          2
Colistin                     3          4
Gentamicin                   1          7
Imipenum                     0          8
Levofloxacin                 3          2
Meropenum                    1          6
Pip+Tazobactum               1          7
Tigecycline                  4          0
Trimetho/Sulfa               3          1

Note: Table made from bar graph.

Fig.11. Elizabethkingella

Elizabethkingella (n=4)

                         Sensitive   Resistant

Amikacin                     0           4
Ampicillin/Sulbactum         0           1
Cefepime                     0           4
Cefuroxime                   0           1
Co-Trimoxazole               2           2
Cefotaxime                   1           0
Cefoperazone+Sulbactum       0           3
Ceftazidime                  0           3
Doripenem                    0           1
Ciprofloxacin                0           4
Colistin                     0           3
Gentamicin                   0           4
Imipenum                     0           4
Levofloxacin                 0           3
Meropenum                    0           4
Netilmycin                   0           1
Pip+Tazobactum               2           2
Tigecycline                  0           3
Tobramycin                   0           1
Ticarcillin                  0           1
Vancomycin                   1           0
Chloramphenicol              0           1
Tetracycline                 0           1

Note: Table made from bar graph.
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Jacob, C.E.; Fenn, Miriam George; Korula, Sara; George, Shareen
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Clinical report
Geographic Code:9INDI
Date:Apr 28, 2014
Words:2463
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