Bacteriological Profile and antibiogram of isolates from tracheal secretions of patients in an intensive care unit

Hospital-acquired pneumonia (HAP) is defined as an infection in patients admitted in hospital for more than 48hours, and ventilator associated pneumonia (VAP) can be defined as infection occurring in patients admitted in ICU after 48hrs endotracheal intubation and mechanical ventilation. VAP has a mean of 7.3/1000 ventilator days for medical ICU patients and 13.2/1000 ventilator days for surgical ICU patients. The crude mortality rates for HAP are approximately 10% and are higher for VAP, ranging from 20% to 60%. The culture of endotracheal (ET) aspirates will help know the etiological agent and formulate the antibiotic policy for early treatment. To isolate the bacterial pathogens of ET secretions from patients with VAP and know their antibiotic susceptibility pattern. In the present study, out of 102 endotracheal secretions from cases of VAP, 88 samples (86.27%) were culture positive, and the remaining 14 samples (13.73%) were culture negative. Out of the 88 positive cultures, 62 samples (60.78%) showed growth of single isolates, and 26 samples (25.49%) showed multiple isolates. Out of the 114 isolates, 18 isolates (15.8%) were gram positive organisms, and 96 isolates (84.2%) were gram negative organisms. Of the gram positive isolates, the predominant organism was Methicillin resistant (MRSA) (55.56%), followed by Methicillin sensitive (MSSA) (22.22%) and (22.22%). Out of the gram negative isolates, the predominant organism was (36.46%), followed by Acinetobacter spp (25%), (23.96%), (12.5%), (1.04%), and Proteus mirabilis (1.04%). In the present study, Gram positives isolates showed the highest susceptibility to vancomycin and linezolid (100%), and gram negative isolates showed the highest susceptibility to polymyxin B (100%) and meropenem (47.92%). The study gives insight into the bacterial pathogens and their antibiotic susceptibility patterns of isolates from endotracheal secretions of mechanically ventilated patients to prevent the mortality and morbidity of mechanical ventilation and VAP, helping in formulating an antibiotic policy for appropriate empirical therapy.

Impact of a restrictive antibiotic policy on the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in an endemic region: a before-and-after, propensity-matched cohort study in a Caribbean intensive care unit

Background High-level antibiotic consumption plays a critical role in the selection and spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) in the ICU. Implementation of a stewardship program including a restrictive antibiotic policy was evaluated with respect to ESBL-E acquisition (carriage and infection). Methods We implemented a 2-year, before-and-after intervention study including all consecutive adult patients admitted for > 48 h in the medical-surgical 26-bed ICU of Guadeloupe University Hospital (French West Indies). A conventional strategy period (CSP) including a broad-spectrum antibiotic as initial empirical treatment, followed by de-escalation (period before), was compared to a restrictive strategy period (RSP) limiting broad-spectrum antibiotics and shortening their duration. Antibiotic therapy was delayed and initiated only after microbiological identification, except for septic shock, severe acute respiratory distress syndrome and meningitis (period after). A multivariate Cox proportional hazard regression model adjusted on propensity score values was performed. The main outcome was the median time of being ESBL-E-free in the ICU. Secondary outcome included all-cause ICU mortality. Results The study included 1541 patients: 738 in the CSP and 803 in the RSP. During the RSP, less patients were treated with antibiotics (46.8% vs. 57.9%; p < 0.01), treatment duration was shorter (5 vs. 6 days; p < 0.01), and administration of antibiotics targeting anaerobic pathogens significantly decreased (65.3% vs. 33.5%; p < 0.01) compared to the CSP. The incidence of ICU-acquired ESBL-E was lower (12.1% vs. 19%; p < 0.01) during the RSP. The median time of being ESBL-E-free was 22 days (95% CI 16-NA) in the RSP and 18 days (95% CI 16–21) in the CSP. After propensity score weighting and adjusted analysis, the median time of being ESBL-E-free was independently associated with the RSP (hazard ratio, 0.746 [95% CI 0.575–0.968]; p = 0.02, and hazard ratio 0.751 [95% CI 0.578–0.977]; p = 0.03, respectively). All-cause ICU mortality was lower in the RSP than in the CSP (22.5% vs. 28.6%; p < 0.01). Conclusions Implementation of a program including a restrictive antibiotic strategy is feasible and is associated with less ESBL-E acquisition in the ICU without any worsening of patient outcome.

Rationalising antibiotic use after low-risk vaginal deliveries in a hospital setting in India

BackgroundIn 2017, a postoperative multidrug resistant case of urinary tract infection made obstetricians at Sitaram Bhartia Institute of Science and Research introspect the antibiotic usage in labouring mothers. Random case file reviews indicated overuse and variability of practice among care providers. This prompted us to explore ways to rationalise antibiotic use.MethodsA multidisciplinary team of obstetricians, paediatricians and quality officers was formed to run this improvement initiative at a private hospital facility in India. Review of literature advocated formulating a departmental antibiotic policy. Creating this policy and implementing it using improvement methodology helped us rationalise antibiotic usage.InterventionsWe aimed to reduce the use of antibiotics from 42% to less than 10% in uncomplicated vaginal deliveries. We tested a series of sequential interventions using the improvement methodology of Plan–Do–Study–Act (PDSA) cycles, an approach recommended by the Institute for Healthcare Improvement. Learning from the PDSA cycle of the previous intervention helped decide the subsequent change ideas. The interventions included creation of a departmental antibiotic policy, staff engagement, and modification in documentation, concept of dual responsibility and team huddles as feedback opportunities. Information was analysed to understand the progress and improvement with change ideas.ResultsBackground analysis revealed that antibiotic usage ranged from 24% to 69% and average rate of antibiotic prophylaxis was high (42.28%) in low-risk uncomplicated vaginal deliveries. The sequential changes resulted in reduction in antibiotic usage to 10% in the target population by 4 months. Sustained improvement was noted in the following months.ConclusionWe succeeded in implementing a departmental antibiotic policy aligning it with existing international guidelines and our local challenges. Antibiotic stewardship was one of the first major steps in our journey to avoid multidrug-resistant infections. Sustaining outcomes will involve continuous feedback to ensure engagement of all stakeholders in a hospital setting.

Systematic review and meta-analysis of the epidemiology of vancomycin-resistance Staphylococcus aureus isolates

Background Vancomycin‑resistant Staphylococcus aureus (VRSA) is a serious public health challenging concern worldwide. Objectives Therefore, the objective of present study of 62 published studies was to evaluate the prevalence of VRSA based on different years, areas, isolate source, antimicrobial susceptibility testing, and the genetic determinants. Methods We searched the relevant articles that focused on the prevalence rates of VRSA in PubMed, Scopus, Embase, and Web of Science from 2000 to 2019. Statistical analyses were conducted using STATA software (version 14.0). Results The prevalence of VRSA was 2% before 2006, 5% in 2006–2014, and 7% in 2015–2020 that showed a 3.5-fold increase in the frequency of VRSA between before 2006 and 2020 years. The prevalence of VRSA was 5% in Asia, 1% in Europe, 4% in America, 3% in South America, and 16% in Africa. The frequencies of VRSA isolated from clinical, non-clinical, and mixed samples were 6%, 7%, and 14%, respectively. The prevalence of VRSA was 12% using disk diffusion agar method, 7% using MIC-base methods, and 4% using mixed-methods. The prevalence of vanA, vanB, and vanC1 positive were 71%, 26%, and 4% among VRSA strains. The most prevalent genotype was staphylococcal cassette chromosomemec (SCCmec) II, which accounted for 57% of VRSA. The most prevalent staphylococcal protein A (spa) types were t002, t030, and t037. Conclusion The prevalence of VRSA has been increasing in recent years particularly in Africa/Asia than Europe/America. The most prevalent of genetic determinants associated with VRSA were vanA and SCCmec II. This study clarifies that the rigorous monitoring of definite antibiotic policy, regular surveillance/control of nosocomial-associated infections and intensive surveillance of vancomycin-resistance are required for preventing emergence and further spreading of VRSA.

Evaluation of bacteriological contamination pattern of open fractures of extremities in tertiary care hospital

<p class="abstract"><strong>Background:</strong> Open fractures and associated complications like infection are fairly common in developing countries due to rising incidence of high velocity trauma. Primary goal of study is to evaluate the pattern of bacteriological contamination of open fractures of extremities in tertiary care hospital.</p><p class="abstract"><strong>Methods:</strong> A total of<strong> </strong>316 patients of all the age group, both the sexes with open fractures of extremities presented within 6 hours were taken in to study. 1^st swab taken at the time of primary wound examination followed by 2^nd culture swab on just after debridement followed by 3^rd culture swab on the day of 1^st aseptic dressing followed by 4^th culture swab if infection continues or asepsis score is more than 20 till the duration of 4 days. Culture and sensitivity reports were collected for studying pattern of bacterial isolates and their sensitivity.<strong></strong></p><p class="abstract"><strong>Results:</strong> Infection developed in 22.5% of the patients with open fractures of extremities in whom most of bacterial infections were caused by gram-negative organisms (80.3%). Cultures on admission were positive in 41 patients, out of which 11 patients had developed infection in the final cultures but with different flora. While cultures taken at 1^st aseptic dressing were found to be positive in 51 cases, out of which 31 had developed infection with prognostic value of 57%.</p><p class="abstract"><strong>Conclusions:</strong> We concluded that cultures obtained at 1^st aseptic dressing are far more predictive than pre and post-debridement cultures in management of patients with open fractures of extremities and are important in formulating an antibiotic policy.</p>

Prevalence of Extended-Spectrum β-Lactamase and Antimicrobial Susceptibility Pattern of Clinical Isolates of Pseudomonas in Tertiary Care Centre of Kutch

Aim: The current research was performed with an aim to discover the prevalence of ESBL producing P. aeruginosa and also to provide as a direct for doctors administration subjects by executing suitable infection control events as well as inventing an efficient antibiotic policy. Materials and Methods: The current research was performed in the Department of Microbiology at Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat over a period for one year. All 250 isolates of Pseudomonas aeruginosa acquired from different clinical samples established in microbiology laboratory from IPD & OPD were incorporated in the research. Different clinical specimens established in our laboratory were coursed and Pseudomonas aeruginosa was recognized as apiece normal microbiological method. All isolates were subjected for ESBL screening test. Antimicrobial susceptibility test was performed by Kirby. Results: Highest samples established from middle age group (30- 50). Out of 250 isolates, 177 (70.7%) isolates of Pseudomonas aeruginosa demonstrated zone of inhibition≤ 22 mm for Ceftazidime. All ESBL positive Pseudomonas aeruginosa isolates demonstrated elevated confrontation to ciprofloxacin 43 (91.04%), Gentamicin 34 (72.3%) and tobramycin 33 (70.21%). Conclusion: The majority of isolates were from hospitalized subjects which point out additional probability of their nosocomial predominance.

A review on Antibiotic Policy and Antimicrobial Stewardship Program (AMSP) – Need of the hour

Emerging trends of antimicrobial resistance and development of multidrug resistance and pan resistant strains have become a significant public health problem worldwide. The rate at which newer drugs are developing has slowed down and clinicians are left with only limited therapeutic options for treatment of the patient. We are heading towards the pre antibiotic discovery phase where mortality was high due to unavailability of appropriate drugs; however, in current situation due to misuse or over use of antibiotics, microbes have developed newer methods of resistance, thus rendering these antimicrobials ineffective in their action which has resulted in increased morbidity and mortality among patient and increase in the health care expenditure. Antimicrobial resistance continues to be a major public health problem of international concern. As there is alarming situation globally due to development of multi and pan resistant bacteria which are also known as superbugs, these superbugs have resulted in havoc as these infections are not treatable and is of great concern to the treating physician. Judicious use of antibiotics and implementation of antibiotic stewardship program are the only ways to combat the current situation. The present review aims to provide information on framing of antibiotic policy and implementation of antimicrobial stewardship program.

CLINICOAETIOLOGICAL STUDY ON RESPIRATORY TRACT INFECTION IN CRITICAL CARE UNITOF ATERTIARY CARE HOSPITAL

Introduction: Infections of the lower respiratory tract is one of the common and important causes of human disease from the points of view of morbidity, mortality and economic cost to society. A new study has found that about 3.6 million people have died due to the two most common chronic lung diseases in 2015.1 According to the study, in 2015, about 3.2 million people worldwide succumbed to chronic obstructive pulmonary disease (COPD) - caused mainly by smoking and pollution - while 400,000 people died from asthma. Aims And Objective: Study of clinical, laboratory and radiological features of LRTI cases in CCU, Identication of organisms causing LRTI and their resistance pattern. To study the outcome of treatment. Materials And Methods: In Patients Department CCU of Carmichael Hospital for Tropical Diseases (CHTD), School of Tropical Medicine (STM), Kolkata. July 2018 to June 2019 Patients >18 years of age of both sexes with LRTI diagnosed by history, clinical ndings, laboratory tests, radiological ndings. Result And Analysis: 11(22.0%) patients had BI LAT lower lobe patchy pneumonitis, 12(24.0%) patients had BI LAT syn pneumonic effusion, 6(12.05) patients had L lower lobe consolidation, 6(12.0%) patients had L sided pneumonitis, 14(28.0%) patients had R sided pneumonitis and 1(2.0%) patient had R upper lobe pneumonitis. 26(52.0%) patients had ventilation. 24(48.0%) patients had sputum. 26(52.0%) patients had ET tube suction. 14(28.0%) patients had Acinetobacterbaunnii complex, 20(40.0%) patients had Klebsiellapneumoniae, 3(6.0%) patients had Proteus mirabilis, 7(14.0%) patients had Pseudomonas aeruginosa, 5(10.0%) patients had Staphylococcus aureus and 1(2.0%) patients had Staphylococcus haemolyticus. Conclusion:There is use and misuse of the broad spectrum antibiotics that has given rise to this problem. The lack of a denite antibiotic policy is a matter of great concern in management of LRTI. To conclude, this study suggests that the most common organism isolated in lower respiratory tract infections is Acinetobacterbaunnii complex, Klebsiella pneumonia, Pseudomonas aeruginosa, Staphylococcus haemolyticus and Proteus mirabilis among Gram negative bacilli and Gram positive cocci respectively of which mortality rate is very signicant in Acinetobacterbaunnii complex and Klebsiella pneumonia infection. By knowing the etiological organism and their antibiotic sensitivity pattern of this organism every institution have their specic use of antibiotic policy can be drafted.