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Study of Nosocomial Infections and Molecular Diagnosis of Bacterial Resistance in Patients Admitted in Intensive Care Units of Regional Cancer Center
ISSN: 2161-0703

Journal of Medical Microbiology & Diagnosis
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Study of Nosocomial Infections and Molecular Diagnosis of Bacterial Resistance in Patients Admitted in Intensive Care Units of Regional Cancer Center

Foram Maulin Patel*
Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
*Corresponding Author: Foram Maulin Patel, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, Tel: +91-79-2268 8000, Email: drf[email protected]

Received Date: May 15, 2018 / Accepted Date: Jun 15, 2018 / Published Date: Jul 05, 2018

Keywords: Imidazole; Heterocyclic; Aromatic; Anti-convulsant; Antiulcer; Antiallergic; Antiviral

Introduction

Infection is a major factor determining clinical outcome among patients requiring intensive care unit (ICU) support. The causes of infection within ICU are multi-factorial, and consequences depend on source involved, organisms associated, underlying morbidity, timeliness and appropriateness of the treatment/interventions received [1,2]. It is associated with increased morbidity and mortality. Nosocomial infection (NI) or health care associated infection is defined as an infection developing in hospitalized patients after 48 hrs., neither present nor in incubation at the time of their admission [3]. NI is amongst the most difficult problems confronting clinicians who deal with severally ill patients. The incidence of NI is estimated at 9% to 37% in tertiary care hospitals reaching up to 28% in ICU of different population and different definitions [4].

Clinical profile of patients requiring intensive care support

Any clinical event, which compromises the airway, breathing, circulation (ABC) of a patient or breaches significantly the integrity and functioning of tissues and organs (post-surgery, post trauma) may results in the requirement of ICU or high dependency unit (HDU) support [1].

Sources of hospital infections

Predisposing factors for infection in the hospital are: A susceptible host, a microbe capable of producing an infection, an environment that is congenial for the multiplication of the microbe. The source of the infecting organism may be exogenous – either from another patient or a member of the hospital staff, or from the inanimate environment in the hospital; or it may be endogenous from the patient’s own flora at the time of infection may include organisms brought into the hospital at admission. Infecting organisms may spontaneously invade the tissues of the patient or may be introduced into them by surgical procedures, instrumental manipulation or nursing procedures. The inanimate environment of the hospital that acts as an important source comprises of: Contaminated air, water, food and medicaments, used equipment and instruments, soiled linen and hospital waste (Biomedical waste) [5].

Infections among patients in the intensive care unit

Infection among ICU patients might be community acquired (viral encephalitis, bacterial meningitis, pneumonia, endocarditis, intravisceral abscesses, and urinary tract infections-UTIs) or hospital and health care associated infections (surgical site infections-SSIs, hospital acquired pneumonia-HAP, catheter related blood stream infections CRBSI, and catheter associated UTI) [6].

Common Health Care Associated Infections in Intensive Care Unit Patients are as follows [1]:

1. Ventilator associated pneumonia.

2. Skin and soft tissue infection.

3. Blood stream infections (BSIs) including catheter related.

4. Urinary tract infection.

In the past, staphylococci, pseudomonas, and Escherichia coli have been the main cause of nosocomial infection. Nosocomial pneumonia, surgical wound infections, and vascular access–related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance. In addition to their association with increased morbidity and mortality, nosocomial infections are frequently associated with drug-resistant micro-organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum - lactamase (ESBL)-producing gramnegative bacteria, Carbapenamases producers and multi drug resistance Acinetobacter which can pose considerable therapeutic problems [6,7].

This study is to determine the frequency and pattern of nosocomial infection in cancer patients admitted in ICU of tertiary cancer hospital and to detect the etiological agent with their antimicrobial resistance by molecular methods and potential source of infection.

Materials and Methods

This hospital-based study was conducted at Intensive care units of The Gujarat Cancer and Research Institute (GCRI), a tertiary cancer care hospital. All patients who are admitted in the ICUs for more than 48 hours with different complaints and presentations and develop clinical evidence of infection that is not originate from patient's original admitting diagnosis, was included in this study.

Critical patients from different oncology departments like: medical, surgical, gynecology, neurology, pediatric, nephrology, urology and emergency which referred for monitoring, observation and management were included. A Performa was designed and used for data collection. This study was approved by Ethics and Scientific board of hospital.

From study periods of January 2014 to March 2014, total 100 different types of samples were collected from patients who are having history of fever after 48 hours of admission, like urine from urinary catheter, stool, peripheral blood, catheter blood, tracheal tube aspirate, wound secretion from surgical wound or bedsore. All samples were transferred to a microbiology laboratory by trained technicians according to standard microbiology protocol. After receiving samples in laboratory all samples were followed according to standard CLSI guidelines for identification of etiological agent using automated bacteriological system (Vitek 2 compact, Biomerieux). Antibiotic sensitivity testing was done by MIC technique using same system.

Resistance mechanism detected by molecular methods. Then organisms are subjected to DNA extraction by Nucleo pore fungus/ bacteria kit (Genetix Biotech Asia Pvt. Ltd.) and then they were subjected for detection of different resistance gene by PCR and reverse hybridization method like mec A gene for MRSA, OXA family for Carbapenamases, TEM and SHV gene detection for ESBL producers using Multiplex PCR module and Multiplex Hybridization module (Krishgen biosystem).

Result

During the study periods of January 2014 to March 2014, total of 100 patients were identified who acquired infection during their stay in all ICUs, like medical ICU, post-operative ICU, surgical ICU, bone marrow transplant unit from total 330 admitted patients. Demographic data of patients who acquire infection are summarized in Table 1. Out of 100 patients 48 were from urban area and 52 from rural area. Patient’s Unit wise data is mentioned in Table 2. Common infections observed in such patients is given in Table 3. Nosocomial infections caused by different pathogens like E. coli, Klebsiella, and Pseudomonas etc. details are given in Table 4. Prevalence of antibiotic resistance in Nosocomial infection given in Table 5. Antibiotic resistance profile revealed that majority of bacterial isolates was resistance to multiple antibiotics. Different types of resistance mechanisms were observed in isolated organisms by molecular methods. Data are given in Table 6.

S.no Age group (yrs.) No. of males No. of females
1 1-10 4 3
2 11 - 20 3 0
3 21 - 30 6 6
4 31 - 40 5 7
5 51-60 10 11
6 61-70 11 19
7 71-80 9 4
8 81-90 1 1
Total 49 51

Table 1: Demographic data of patients, n=100.

S.no Unit of referral No. of patients
1 Surgery 45
2 Medicine 21
3 Gynecology 16
4 Pediatric 10
5 Neurology 8

Table 2: Patient's unit wise data, n=100.

S.no Type of Infection Type of samples received No. of Patients
1 wound infection Pus, Pus swab 49
2 respiratory infection Sputum, BAL, ET secretion, Tracheostomy, ET tip etc 19
3 Blood stream infection Peripheral and Catheter blood 16
4 Urinary tract infection Urine 10
5 Gastrointestinal infection Stool 6

Table 3: Pattern of nosocomial infection in critical care areas, n=100.

S. no Organism Wound Infection Respiratory Infection Blood Stream Infection Urinary tract Infection Gastrointestinal Infection Total
1 E. coli 21 2 3 6 6 38
2 Klebsiella 7 4 4 2 0 17
3 Pseudomonas aeruginosa 8 4 2 2 0 16
4 Acinetobacter 6 4 1 0 0 11
5 Enterobacter 2 2 0 0 0 4
6 Burkholderia 0 0 2 0 0 2
7 S. aureus 2 0 2 0 0 4
8 CONS 3 3 2 0 0 8
Total 49 19 16 10 6 100

Table 4: Nosocomial infection cause by different pathogens, n=100.

Antibiotics E. coli
(n=38)
Klebsiella
(n=17)
Pseudomonas aeruginosa
(n=16)
Acinetobacter
(n=11)
Enterobacter
(n=4)
Burkholderia
(n=2)
S. aureus
(n=4)
CONS
(n=8)
B- lactam N=100
Ampicillin 20 11 0 0 2 I 4 4
Amoxicillin/ Clavulanic Acid 14 10 0 0 2 1 0 0
Piperacillin/tazobactam 12 9 4 2 2 1 0 0
Cefuroxime 22 11 0 0 1 1 0 0
Ceftriaxone 22 11 0 0 1 1 0 0
Cefoperazone/Sulbactam 10 9 5 3 2 1 0 0
Cefepime 27 11 5 6 2 1 0 0
Amino Glycosides
Amikacin 4 9 4 3 2 1 0 0
Gentamycin 14 8 3 7 2 1 3 5
Quinolones  
Ciprofloxacin 24 12 4 7 1 0 3 4
Levofloxacin 2 3 5 6 2 2 2 3
Carbapenems
Imipenem 5 9 4 6 2 1 3 5
Meropenem 5 9 3 2 2 1 2 4
Ertapenem 3 7 0 0 0 0 0 0
Others
Aztreonam 0 0 0 4 1 0 0 0
Minocycline 0 0 8 2 0 0 0 0
Tigecycline 0 4 8 2 1 0 0 0

Table 5: Prevalence of antibiotic resistance in nosocomial infection.

S.no Organism group Resistance pattern Number Percentage
1 GNB (n=88) ESBL 36 40.9
2 Carbapenemases 6 6.81
3 GPC (n=12) MRSA 2 16.6
4 VRSA 0 0

Table 6: Resistance mechanism in isolated organisms by molecular methods.

Discussion

Cancer patients having treatment in intensive care units are at a higher risk of nosocomial infection due to different causes like disruption of barriers to infection by endotracheal intubation and tracheostomy, urinary bladder catheterization and central venous catheterization.

Nosocomial infection in critical areas

The percentages of nosocomial infection in our study were 30.30%. In recent study by Muhammad et al., the frequency of nosocomial infection in Immuno-compromised patients in ICU was 39.7% [8]. Common infections observed in ICUs are wound infection, respiratory infection including VAP, bloodstream infection, urinary tract and gastrointestinal infections. The most common infection in ICU was wound infection (49%) followed by respiratory infection (19%).

Wound infection is the most common because surgical patients are highest admitted in ICU (49/100). Most common isolated organism from wound infection is E. coli followed by Pseudomonas.

Nosocomial pneumonia is the second most common nosocomial infection in critical patients. Frequencies of VAP reported in different studies are 9%, 18% and 21%. In current study, 19% patients acquired VAP in ICU. The predominant pathogens causing VAP are Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella, coagulase negative staphylococcus.

Blood stream infection is also a common infection observed in ICU patients. Frequency of blood stream infection in our study was 16%, while in the study by Muhammad et al., it was 27% [9]. It was high in their study because study was conducted amongst nephrology patients. The pathogens isolated from these patients are Klebsiella, E. coli, Pseudomonas aeruginosa, Burkholderia, Staphylococcus aureus.

In our study, urinary tract infection found in 10 patients, was caused by E. coli, Pseudomonas and Klebsiella and gastrointestinal infection in six patients was caused by E. coli.

Prevalence of antibiotic resistance in nosocomial infection

Antibiotic resistance profile revealed that majority of bacterial isolates were resistance to multiple antibiotics (Table 5). More than 50% of E. coli was resistant to all B-lactams and B-lactams inhibitors, Quinolones. Klebsiella shows 70% resistance to B-lactams and B-lactams inhibitors, Quinolones and to amino glycosides. Acinetobacter shows 50% resistance to amino glycosides, Quinolones and to Imipenem. Resistance to antibiotics in Gram positive bacteria was less as compared to Gram negative pathogens. In the study conducted by Kailash Mulchandani et al., from south India shows similar resistance pattern in ICU [10]. In their study E. coli shows 60-90% of resistance to B-lactams and B-lactams inhibitors, Quinolones and to amino glycosides. Klebsiella and Acinetobacter show 44% to 83% and 45% to 90% of resistance to same class of antibiotics respectively.

Antibiotic resistance mechanism in isolated pathogens

Amongst Gram negative pathogens, 40.90% were ESBL producers, 15.90% were Amp C producer and 4.54 to 6.81% were positive for Carbapenamases production. 25% of Gram positive cocci were MRSA positive.

Conclusion

Infections that develop in people who have cancer or who are getting cancer treatment can be more serious than those in people who are otherwise healthy. They can also be harder to treat. Joint efforts of microbiologist and clinicians can save more lives.

Key action plan of clinical microbiology for infection control in ICUs [1]:

1. Regular Rounds in ICU by microbiologist [11].

2. Prompt information about critical microbiology results.

3. Change, stoppage and optimization of antibiotic therapy as per local antibiotic policy.

4. Use of ‘Care bundles’ in ICU for management of ICU infection [12- 14].

5. Antibiotic resistance, audit and policy implantation [15].

We concluded as follows:

a. Critically ill cancer patients admitted to ICU are at a greater risk of acquiring nosocomial infection.

b. The common infections observed in our study were wound infection, nosocomial pneumonia including VAP, blood stream infection.

c. E. coli, Klebsiella and Pseudomonas were most common pathogens in ICU, and they were multidrug resistant.

d. Production of ESBL and Carbapenamases were high in ICU pathogens.

It is suggested that proper nursing care, sterilization and disinfection of equipment and proper handling of invasive devise are the best guidelines to control ICU infection. Education and awareness among health care workers as well as adherence to standard guidelines for prevention of nosocomial infection should be followed to reduce frequency of nosocomial infection in intensive care unit. Further studies regarding surveillance of nosocomial infection are required and it will play an important role in the monitoring of infection and assessment of action plans to prevent ICU infection.

References

Citation: Patel FM (2018) Study of Nosocomial Infections and Molecular Diagnosis of Bacterial Resistance in Patients Admitted in Intensive Care Units of Regional Cancer Center. J Med Microb Diagn 7:277. DOI: 10.4172/2161-0703.1000277

Copyright: © 2018 Patel FM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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