A Study Of Antibiotic Resistance And Sensitivity Pattern Of Nosocomial Infection (Bacterial) In Medical Intensivecare Unit In N.S.C.B. Medical College, Jabalpur

Nosocomial infection also referred to as Health care-associated infection (HCAI), or "hospital" infection, is an infection occurring in a patient during the process of care in a hospital or other health care facility (more than 48 hours after admission) but was not present or incubating at the time of admission. (1)

The most common types of nosocomial infections were Catherter associated urinary tract infection (CAUTI), Central line associated blood stream infection (CLABSI), Hospital acquired pneumonia (HAP) or nosocomial pneumonia.

CAUTI was most commonly acquired nosocomial infection as almost all the patients admitted to Intensive care units and even wards are catheterized for vwrious purposes. E. Coli was most commonly found CAUTI agent (2). CLABSI occurs when bacteria on the skin proliferate along the external portion of the catheter toward the

intravascular part (3). Contamination of the CVC during insertion or manipulation

process or by hematogenous seeding are other ways CLABSI can occur. Bacterial and fungal pathogens were frequently responsible. HAP is the second most common nosocomial infection occuring 48-72 hours after admission and accounts for mortality (4).

The aim of the present study is to find out the common bacteria that is involved in causing nosocomial infection, its antibacterial resistance and sensitivity pattern. The secondary objective was to review traditional antibiotic use and its susceptibility in preventing nosocomial infections.

After obtaining ethical committee approval, the present study was carried out in Department of General Medicine and Microbiology, at Netaji Subhash Chandra Bose Medical College & Hospital, in the city of Jabalpur of state Madhya Pradesh, India. 120 patients who were admitted in Medical Intensive Care Unit were taken up for the study. Informed and written consent was obtained from the patients’ attendants.

Patients who were newly admitted or were admitted for more than 48 hours, irrespective of their primary illness; those requiring intravenous medications; patients with new onset chest infection, fever or burning micturition after 48 hours of admission to the hospital were taken up for our study. Patients who were referred from other hospitals; patients having definitive focus of infection, or fever, or investigations suggesting infection at the time of admission were excluded from our study. 

First sample was obtained on admission into ICU before administering antibiotics and the second sample was obtained 48 hours after admission.

These samples mostly obtained were venous blood, endotracheal aspirate in intubated patients and urine sample in catheterized patients. The most commonly obtained sample in our study was endotracheal sample. The samples obtained were transported in suitable media and were incubated in suitable culture media and observed for bacterial growth for 48-72 hours. Antibiotic culture and sensitivity testing was done using Kirby-bauer method.

 

 

 

 

 

 

Nosocomial infections or hospital acquired infections form a major cause of mortality in patients getting admitted in ICU. It is of utmost importance to start with appropriate empirical antibiotic therapy to prevent complications. Since bacteria gets resistant to various antibiotics over time, it is essential to identify the sensitivity pattern and treat the patients to obtain better outcome.

In the present study, out of 120 subjects male predominance was reported in 74(61.7%) in comparison to females 46 (38.3%). The study by Umar Rashid Khan et in 2020, in 32 study subject salso had males (62.5%) more than females (32.5%) which coincides with study. (5)

In present study majority of patients were in the age group of 46-60 years

i.e. 41(34.2%) subjects followed by 31 - 45 years i.e. 28 (23.3%) subjects. In the age group 15 -25 years belongs to 22(18.3%), age group 61-75 years belongs to 21(17.5%) and 76 - 90 years belongs to 8(6.7%) subjects. The mean age was calculated as- 48.97 ±17.91 years. Study by P Sreenivasulu Reddy et al in 2015 also had Majority of patients belongs to age group >66 yrs had44 subjects (44%) and 55-65 years had 16 subjects (16%) respectively which almost coincides with the study. (6)

In present study, majority of patients have been received as empirical antibiotic   therapy   Ceftriaxone   in      88   patients (73.33%), Amoxicillin+clavulanate given to 14 patients (11.6%), Piperacillin +Tazobactam to 5 patients (4.16%), Ceftriaxone along with Clindamycin given 3 patients (2.5%), Ceftriaxone   along   with   Metronidazole   given   to   3   (2.5%), Amoxicillin+clavulanate along with    Vancomycin to 1 patients 0.8% and Piperacillin+Tazobactam along with Clindamycin to 2 patients (1.66%),4 patients (3.3%) has not received initial antibiotic therapy.

Study by Neeta P. Pradhan et al in 2013, this study there has been 32 study subjects in majority of patients antibiotic used Penicillin’s37.9 %, cephalosporins

29.7%, Macrolides (11.3%), Aminoglycoside (12.1%), Quinolones 5%, Vancomycin 5% and Carbapenems 1.9% patients. (7)

Reason for this difference in above study might be due to study was conducted at different step up, location and different years. It might be also due to selection bias.

In present there were 120 patients (n=120),single culture isolates was obtained from 110 patients i.e., 47 Endotracheal aspirate culture isolates (39.1%), 36 urine culture isolates (30%) ,24 blood culture isolates (20%) and 3 sputum culture isolates (2.5%) .From 10 patients ,and cultures were isolated from 2 different sites i.e., from Blood along with Endotracheal aspirate from 4 patients (3.33%), from Blood along with Sputum culture is obtained from 1 patient (0.8%), from Blood along with urine culture is obtained from 1 patient (0.8%) and from Endotracheal aspirate along with urine culture is obtained from 4 patients (3.33%).

Study by Hadi Hamishekar et al in 2016 in 328 subjects most common isolates were of endotracheal aspirate in (51.7%) followed by urinary (24.8%) and blood (10.4%). Which almost coincides with study. (8)

In present study, there were 120 study patients of which single cultures were collected are Klebsiella pneumoniae from 53 patients (44.1%), Pseudomonas aeruginosa from 22 patients (18.3%) and Escherichia coli from 17 patients (14.1% ). Acinetobacter baumannii isolates from 4 patients (3.33%), Non lactose fermenting gram negative bacilli isolates from 3 patients (2.5%), and from Staphylococcus aureus from 5 patients (4.16%).Mixed cultures isolated were of Enterobacter sp.+ Klebsiella pneumoniae from 2 patients (1.66%), Escherichia coli (2 different sites) from 1patient (0.8%), Non lactose fermenting gram negative bacilli+ Escherichia coli from 1patient (0.8%),Escherichia coli+ Pseudomonas aeruginosa from 3 patients (2.5%) and Pseudomonas aeruginosa+ Klebsiella pneumoniae from 3 patients (2.5%).Majority of samples isolated were of gram negative bacteria i.e. Klebsiella pneumoniae followed by Pseudomonas aeruginosa and Escherichia coli respectively.

Study by Umar Rashid et al in 2020 ,study population of 32 patients.Majority of isolates were of Gram negative bacteria i.e Acinetobacter baumannii in 12 isolates (33.4%),Klebsiella pneumoniae in 7 isolates (19.4%),Escherichia coli in 6 isolates (16.6%) ,Pseudomonas aeruginosa in 2 isolates (5.5%) , Providentia in 1 isolate (2.8%) and Burkholderia cepacie in 1 isolate (2.8%) .Gram positive isolates were staphylococcus aureus in 5 isolates (8.4%) and staphylococcus epidermidis 1 isolate (2.8%) . which almost coincides with study.(5).

In the present study out of 120, Acinetobacter baumannii is isolated from 4 patients and showed resistance towards majority     of antibiotics Amikacin, Cefepime, Ceftazidime, Cefotaxime, ciprofloxacin, levofloxacin, gentamicin and is susceptible to Colistin. Study by Mohan B. et al in 2021 in study population of 1890 subjects. The Acinetobacter baumannii was resistant to amikacin, gentamicin ciprofloxacin, imipenem, meropenem, and piperacillin-tazobactam ceftazidime and ceftriaxone. Acinetobacter baumannii is sensitive to colistin in this study, which coincides with study. (9)

In the present study Escherichia coli was isolated from 23 samples showed resistance to antibiotic Cefixime, Cefuroxime, Cefotaxime, Doxycycline and Norfloxacin in cases. Study by P Sreenivasulu Reddy et al in 2015 in 100 study subjects Escherichia coli isolated in 44 patients, of which showed resistance Ampicillin, Doxycycline, Ceftriaxone and showed sensitivity to piperacillin-tazobactam, Colistin and Imipenem. (6)

In the present study Klebsiella pneumoniae is found in 58 isolates, all isolates showed resistance towards antibiotic Amoxicllin +clavulanate combination, Ampicillin, Cefazolin, Ceftazidime, Ceftriaxone, Cefotaxime, Gentamicin, Aztreonam, Aztreonam, Amikacin and Doxycycline. It showed sensitivity towards Piperacillin +Tazobactam, Imipenem and Colistin.

Study by Sneha S Savanur in 2019et al in 167 subjects, Klebsiella pneumoniae showed high resistance to cephalosporins amikacin, gentamicin and meropenem and imipenem. Klebsiella pneumoniae showed sensitivity to Colistin. (10)

In the present study Pseudomonas aeruginosa samples was isolated in 28 samples, all 28 isolates showed resistance towards antibiotics Amoxicillin+ clavulanate, Amikacin, Ceftazidime, ceftriaxone, cefuroxime, cefotaxime ciprofloxacin, levofloxacin and Gentamicin. It showed sensitivity towards Imipenem, Meropenem and colistin

Study by Rasool Sultani et al in 2019, there were 449 infections,

Pseudomonas aeruginosa was associated in 41 cases. Pseudomonas aeruginosa were resistant to antibiotics Ceftazidime, Ciprofloxacin, Levofloxacin and Meropenem. It showed sensitivity towards Colistin. (11)

In present study gram negative bacteria is associated with high mortality are Non -Lactose fermenting gram negative bacilli, Staphylococcus aureus, Klebsiella and Pseudomonas aeruginosa.

In study by Ghanshani et at in 2015, on 487 study subjects. In his study there is high mortality of patients in which bacteria Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter sp. was found (10) and were resistant to meropenem and imipenem. Klebsiella pneumoniae showed sensitivity to Colistin.

In the present study Pseudomonas aeruginosa samples was isolated in 28 samples, all 28 isolates showed resistance towards antibiotics Amoxicillin+ clavulanate, Amikacin, Ceftazidime, ceftriaxone, cefuroxime, cefotaxime ciprofloxacin, levofloxacin and Gentamicin. It showed sensitivity towards Imipenem, Meropenem and colistin

Study by Rasool Sultani et al in 2019, there were 449 infections,

Pseudomonas aeruginosa was associated in 41 cases. Pseudomonas aeruginosa were resistant to antibiotics Ceftazidime, Ciprofloxacin, Levofloxacin and Meropenem. It showed sensitivity towards Colistin. (11)

In present study gram negative bacteria is associated with high mortality are Non -Lactose fermenting gram negative bacilli, Staphylococcus aureus, klebsiella and Pseudomonas aeruginosa.

In study by Ghanshani et at in 2015, on 487 study subjects. In his study there is high mortality of patients in which bacteria Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and Enterobacter sp. was found (10).

From the present study, it can be concluded that it is of utmost importance to keep a watch on every patient for the symptoms and early diagnosis of nosocomial infections is required for the prompt treatment. It is also important to select empirical antibiotic therapy for the prevention of complications amongst the patients. It is also essential to know the common isolates to be collected and bacteria resistance and sensitivity pattern to available antibiotics for further definitive management of Nosocomial           infection.

The limitations of our study were limited sample size and duration of our study and inability to calculate the response after definitive antibiotics were administered to the patients.