Top

Antimicrobial Resistance & Infection Control

Published in:

Open Access 01-12-2017 | Research

High burden of antimicrobial resistance among gram negative bacteria causing healthcare associated infections in a critical care unit of Nepal

Authors: Narayan Prasad Parajuli, Subhash Prasad Acharya, Shyam Kumar Mishra, Keshab Parajuli, Basista Prasad Rijal, Bharat Mani Pokhrel

Published in: Antimicrobial Resistance & Infection Control | Issue 1/2017

Abstract

Background

Healthcare associated infections (HCAI) and antimicrobial resistance are principal threats to the patients of intensive care units and are the major determining factors for patient outcome. They are associated with increased morbidity, mortality, excess hospitalization and financial costs. The present study is an attempt to investigate the spectrum and antimicrobial resistance of bacterial isolates involved in healthcare associated infections (HCAI) in the patients of a critical care unit at a tertiary care university hospital in Kathmandu, Nepal.

Methods

A laboratory based study was conducted over the period of 15 months (January 2014 to March 2015) among the patients of intensive care unit of Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Clinical specimens from patients with suspected healthcare-associated infection were processed and bacterial isolates were identified with standard microbiological methods. Antimicrobial susceptibilities of the isolated strains were determined according to the CLSI guidelines and β-lactamases (ESBL, AmpC, MBL and KPC) were detected by various phenotypic tests.

Results

One hundred and forty nine clinical specimens received from 135 patients suspected of HCAI (out of 491 patients) were found with significant bacterial growth. Specimens were from patients suspected of hospital-acquired pneumonia (16%, 79/491), bloodstream infections (5.7%, 28/491), surgical site infections (4.7%, 23/491), and urinary tract infections (3.9%, 19/491). Acinetobacter spp., Klebsiella spp., Escherichia coli and Burkholderia cepacia were the leading bacterial pathogens. Extremely high level of drug resistance (95.8%) along with the production of β-lactamases (ESBL; 43.7%, AmpC; 27.5%), MBL; 50.2% and KPC; 4.2%) was observed among Gram negative bacterial isolates.

Conclusion

Healthcare associated infections are very common in our ICU. Gram negative bacterial pathogens are major culprits associated with these infections and there is alarming state of drug resistance among these isolates. Continuous surveillance and establishment of preventive and control measures of healthcare associated infections are urgently needed in our setting.

Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302(21):2323–9.CrossRefPubMed

Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA. 1995;274(8):639–44.CrossRefPubMed

Trilla A. Epidemiology of nosocomial infections in adult intensive care units. Intensive Care Med. 1994;20(Suppl 3):S1–4.CrossRefPubMed

Majumdar SS, Padiglione AA. Nosocomial infections in the intensive care unit. Anaesth Intens Care Med. 13(5):204–8.

Brusselaers N, Vogelaers D, Blot S. The rising problem of antimicrobial resistance in the intensive care unit. Ann Intensive Care. 2011;1:47.CrossRefPubMedPubMedCentral

Meric M, Baykara N, Aksoy S, Kol IO, Yilmaz G, Beyazit N, et al. Epidemiology and risk factors of intensive care unit-acquired infections: a prospective multicentre cohort study in a middle-income country. Singap Med J. 2012;53(4):260–3.

Laxminarayan R, Duse A, Wattal C, Zaidi AKM, Wertheim HFL, Sumpradit N, Vlieghe E, Hara GL, Gould IM, Goossens H, Greko C, So AD, Bigdeli M, Tomson G, Woodhouse W, Ombaka E, Peralta AQ, Qamar FN, Mir F, Kariuki S, Bhutta ZA, Coates A, Bergstrom R, Wright GD, Brown ED, Cars O. Antibiotic resistance the need for global solutions. The Lancet Infectious Diseases. 2013;13(12):1057–98

Vasudevan A, Memon BI, Mukhopadhyay A, Li J, Tambyah PA. The costs of nosocomial resistant gram negative intensive care unit infections among patients with the systemic inflammatory response syndrome- a propensity matched case control study. Antimicrob Resist Infect Control. 2015;4(1):1–8.CrossRef

Horcajada JP, Belvis F, Castells X, Grau S, Riu M, Morales E, et al. Hospital costs of nosocomial multi-drug resistant Pseudomonas aeruginosa acquisition. BMC Health Serv Res. 2012;12

10.

Kollef MH. Optimizing antibiotic therapy in the intensive care unit setting. Crit Care. 2001;5(4):189–95.CrossRefPubMedPubMedCentral

11.

Byarugaba DK. Antimicrobial resistance in developing countries and responsible risk factors. Int J Antimicrob Agents. 24(2):105–10.

12.

Fraimow HS, Tsigrelis C. Antimicrobial resistance in the intensive care unit: mechanisms, epidemiology, and management of specific resistant pathogens. Crit Care Clin. 27(1):163–205.

13.

Rahal JJ. Antimicrobial resistance among and therapeutic options against gram-negative pathogens. Clin Infect Dis. 2009;49(Suppl 1):S4–s10.CrossRefPubMed

14.

Yamamoto M, Pop-Vicas AE. Treatment for infections with carbapenem-resistant Enterobacteriaceae: what options do we still have? Crit Care. 2014;18(3):1–8.CrossRef

15.

Ruppé É, Woerther P-L, Barbier F. Mechanisms of antimicrobial resistance in Gram-negative bacilli. Ann Intensive Care. 2015;5:21.CrossRefPubMedCentral

16.

Isenberg HD. Clinical Microbiology procedure handbook, vol. 1. 2nd ed. Washington DC: American Society for Microbiology; ASM press; 2004.

17.

Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med. 1977;296(23):1305–9.CrossRefPubMed

18.

CLSI. Performance standards for antimicrobial disk susceptibility tests, vol. M02-A11. Wayne: Clinical and Laboratory Standards Institute; 2012.

19.

Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268–81.CrossRefPubMed

20.

Yong D, Lee K, Yum JH, Shin HB, Rossolini GM, Chong Y. Imipenem-EDTA disk method for differentiation of metallo-beta-lactamase-producing clinical isolates of pseudomonas spp. and acinetobacter spp. J Clin Microbiol. 2002;40(10):3798–801.CrossRefPubMedPubMedCentral

21.

Coudron PE. Inhibitor-based methods for detection of plasmid mediated AmpC β-lactamases in Klebsiella spp., Escherichia coli, and Proteus mirabilis. J Clin Microbiol. 2005;43:5.CrossRef

22.

Tsakris A, Poulou A, Pournaras S, Voulgari E, Vrioni G, Themeli-Digalaki K, et al. A simple phenotypic method for the differentiation of metallo-beta-lactamases and class A KPC carbapenemases in Enterobacteriaceae clinical isolates. J Antimicrob Chemother. 2010;65(8):1664–71.CrossRefPubMed

23.

Shrestha S, Tada T, Miyoshi-Akiyama T, Ohara H, Shimada K, Satou K, et al. Molecular epidemiology of multidrug-resistant Acinetobacter baumannii isolates in a university hospital in Nepal reveals the emergence of a novel epidemic clonal lineage. Int J Antimicrob Agents. 2015;46(5):526–31.CrossRefPubMed

24.

Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet (London, England). 2011;377(9761):228–41.CrossRef

25.

Gastmeier P, Sohr D, Just HM, Nassauer A, Daschner F, Ruden H. How to survey nosocomial infections. Infect Control Hosp Epidemiol. 2000;21(6):366–70.CrossRefPubMed

26.

Sah M, Mishra S, Ohora H, Kirikae T, Sherchan J, Rijal B. Nosocomial bacterial infection and antimicrobial resistant pattern in a tertiary care hospital in Nepal. J Inst Med. 2015:38(1).

27.

Mythri H, Kashinath K. Nosocomial infections in patients admitted in intensive care unit of a tertiary health center, India. Ann Med Health Sci Res. 2014;4(5):738–41.CrossRefPubMedPubMedCentral

28.

Dasgupta S, Das S, Chawan NS, Hazra A. Nosocomial infections in the intensive care unit: Incidence, risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India. Indian J Crit Care Med. 2015;19(1):14–20.CrossRefPubMedPubMedCentral

29.

Alberti C, Brun-Buisson C, Burchardi H, Martin C, Goodman S, Artigas A, et al. Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study. Intensive Care Med. 2002;28(2):108–21.CrossRefPubMed

30.

Toufen C Jr, Hovnanian AL, Franca SA, Carvalho CR. Prevalence rates of infection in intensive care units of a tertiary teaching hospital. Rev Hosp Clin Fac Med Sao Paulo. 2003;58(5):254–9.CrossRef

31.

Ćosić Gorana ĐJ, Smiljana R, Ristić M, Ikonić N. nosocomial infections and microbiological agents in an intensive care unit. Arch Biol Sci Belgrade. 2012;64(4):6.

32.

Mehrad B, Clark NM, Zhanel GG, Lynch JP 3rd. Antimicrobial resistance in hospital-acquired gram-negative bacterial infections. Chest. 2015;147(5):1413–21.CrossRefPubMedPubMedCentral

33.

Habibi S, Wig N, Agarwal S, Sharma SK, Lodha R, Pandey RM, et al. Epidemiology of nosocomial infections in medicine intensive care unit at a tertiary care hospital in northern India. Trop Dr. 2008;38(4):233–5.CrossRef

34.

Bhatia R, Narain JP. The growing challenge of antimicrobial resistance in the South-East Asia Region - Are we losing the battle? Indian J Med Res. 2010;132(5):482–6.PubMedPubMedCentral

35.

Mishra SK, Rijal BP, Pokhrel BM. Emerging threat of multidrug resistant bugs--Acinetobacter calcoaceticus baumannii complex and methicillin resistant Staphylococcus aureus. BMC Res Notes. 2013;6:98.CrossRefPubMedPubMedCentral

36.

Khanal S, Joshi DR, Bhatta DR, Devkota U, Pokhrel BM. beta -lactamase-producing multidrug-resistant bacterial pathogens from tracheal aspirates of intensive care unit patients at national institute of neurological and allied sciences, Nepal. ISRN Microbiol. 2013;2013:847569.CrossRefPubMedPubMedCentral

37.

Tenover FC. Mechanisms of antimicrobial resistance in bacteria. Am J Med. 2006;119(6 Suppl 1):S3–10. discussion S62-70CrossRefPubMed

38.

Xie DS, Xiong W, Lai RP, Liu L, Gan XM, Wang XH, et al. Ventilator-associated pneumonia in intensive care units in Hubei Province, China: a multicentre prospective cohort survey. J Hospital Infect. 2011;78(4):284–8.CrossRef

39.

Fatima A, Naqvi SB, Khaliq SA, Perveen S, Jabeen S. Antimicrobial susceptibility pattern of clinical isolates of Pseudomonas aeruginosa isolated from patients of lower respiratory tract infections. SpringerPlus. 2012;1(1):70.CrossRefPubMedPubMedCentral

40.

Gales AC, Jones RN, Sader HS. Contemporary activity of colistin and polymyxin B against a worldwide collection of Gram-negative pathogens: results from the SENTRY Antimicrobial Surveillance Program (2006-09). J Antimicrob Chemother. 2011;66(9):2070–4.CrossRefPubMed

41.

Joseph NM, Sistla S, Dutta TK, Badhe AS, Rasitha D, Parija SC. Ventilator-associated pneumonia in a tertiary care hospital in India: role of multi-drug resistant pathogens. J Infect Dev Ctries. 2010;4(4):218–25.PubMed

42.

Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: emergence of a successful pathogen. Clin Microbiol Rev. 2008;21(3):538–82.CrossRefPubMedPubMedCentral

43.

Hancock RE. Resistance mechanisms in Pseudomonas aeruginosa and other nonfermentative gram-negative bacteria. Clin Infect Dis. 1998;27(Suppl 1):S93–9.CrossRefPubMed

44.

Mishra SK, Awal BK, Kattel HP, Acharya J, Gyawali P, Bhatt CP, et al. Drug resistant bacteria are growing menace in a University Hospital in Nepal. Am J Epidemiol Infect Dis. 2014;2(1):19–23.

45.

Livermore DM. Current epidemiology and growing resistance of gram-negative pathogens. Korean J Intern Med. 2012;27(2):128–42.CrossRefPubMedPubMedCentral

46.

Shrestha S, Kattel HP, Mishra SK, Dahal RK, Ohara H, Pokhrel BM. Prevalence of nosocomial lower respiratory tract infections caused by Multidrug resistance pathologens. J Inst Med. 2011;33:8.

47.

Baral P, Neupane S, Shrestha B, Ghimire KR, Marasini BP, Lekhak B. Clinical and microbiological observational study on AmpC beta-lactamase-producing Enterobacteriaceae in a hospital of Nepal. Braz J Infect Dis. 2013;17(2):256–9.CrossRefPubMed

48.

Grover N, Sahni AK, Bhattacharya S. Therapeutic challenges of ESBLS and AmpC beta-lactamase producers in a tertiary care center. Med J Armed Forces India. 2013;69(1):4–10.CrossRefPubMed

49.

Mishra SK, Acharya J, Kattel HP, Koirala J, Rijal BP, Pokhrel BM. Metallo-beta-lactamase producing gram-negative bacterial isolates. J Nepal Health Res Counc. 2012;10(22):208–13.PubMed

50.

Walsh TR, Weeks J, Livermore DM, Toleman MA. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study. Lancet Infect Dis. 2011;11(5):355–62.CrossRefPubMed

Title: High burden of antimicrobial resistance among gram negative bacteria causing healthcare associated infections in a critical care unit of Nepal
Authors: Narayan Prasad Parajuli
Subhash Prasad Acharya
Shyam Kumar Mishra
Keshab Parajuli
Basista Prasad Rijal
Bharat Mani Pokhrel
Publication date: 01-12-2017
Publisher: BioMed Central
Published in: Antimicrobial Resistance & Infection Control / Issue 1/2017
Electronic ISSN: 2047-2994
DOI: https://doi.org/10.1186/s13756-017-0222-z

Epidemic characterization and molecular genotyping of Shigella flexneri isolated from calves with diarrhea in Northwest China

Open Access
Research

Pervasive antibiotic misuse in the Cambodian community: antibiotic-seeking behaviour with unrestricted access

Open Access
Research

Genotypic characterization of gentamicin and cephalosporin resistant Escherichia coli isolates from blood cultures in a Norwegian university hospital 2011–2015

Open Access
Research

Plasmid-mediated mcr-1 colistin resistance in Escherichia coli and Klebsiella spp. clinical isolates from the Western Cape region of South Africa

Open Access
Research

“First-person view” of pathogen transmission and hand hygiene – use of a new head-mounted video capture and coding tool

Open Access
Research

Clinical and molecular characteristics, risk factors and outcomes of Carbapenem-resistant Klebsiella pneumoniae bloodstream infections in the intensive care unit

Open Access
Research

Keynote webinar | Spotlight on menopause

Menopause
Video Series

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the broader systemic effects of menopause, so you can help patients in your clinics through the transition.

Prof. Martha Hickey

Dr. Claudia Barth

Dr. Samar El Khoudary

Developed by: Springer Medicine

Watch now

Keynote webinar | Spotlight on adolescent vaping

Live
Webinar | 29-01-2025 | 18:00 (CET)

Growing numbers of young people are using e-cigarettes, despite warnings of respiratory effects and addiction. How can doctors tackle the epidemic, and what health effects should you prepare to manage in your clinics?

Watch it live: Wednesday 29th January, 18:00-19:30 CET

Prof. Ann McNeill

Dr. Debbie Robson

Benji Horwell

Developed by: Springer Medicine

Join the webinar

Keynote webinar | Spotlight on modern management of frailty

Frailty in Geriatric Patients
On-demand webinar

Frailty has a significant impact on health and wellbeing, especially in older adults. Our experts explain the factors that contribute to the development of frailty and how you can manage the condition and reduce the risk of disability, dependency, and mortality in your patients.

Prof. Alfonso Cruz-Jentoft

Prof. Barbara C. van Munster

Prof. Mirko Petrovic

Developed by: Springer Medicine

Watch now

A quick guide to ECGs

Electrocardiography
Training Course

Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date.

PD Dr. Carsten W. Israel

Developed by: Springer Medizin

Start the cases

At a glance: The STEP trials

Obesity
Clinical Trial Summary

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Keynote webinar | Spotlight on adolescent vaping

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content