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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 27-31

An epidemiological study of ventilator-associated pneumonia in Intensive Care Unit and antibiotics sensitivity pattern of organism causing ventilator-associated pneumonia (2012—2016) at Al Qassim Region of Saudi Arabia


1 Department of Infection Prevention and Control, Saudi Arabia
2 Department of Infection Prevention and Control, Al Rass General Hospital, Al Qassim, Saudi Arabia

Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Sanjay Kumar Gupta
Al Rass General Hospital, Al Qassim
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_27_17

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  Abstract 


Background: Ventilator-associated pneumonia (VAP) is defined as pneumonia that occurs after 48—72 h following endotracheal intubation, characterised by the presence of a new or progressive infiltrate showing in X-ray, signs and symptom of systemic infection such as fever, change in white blood cell count, changes in sputum characteristics and the detection of a causative agent in the sample.
Aim: This study aims to find out the epidemiological pattern of the VAP in Intensive Care Unit and their sensitivity pattern.
Materials and Methods: This was retrospective observational study.
Results: In the past 5 years, 69 (20.24%) cases of VAP were reported out of total healthcare-associated infections (n = 331). The male cases 54 (78%) were nearly four times higher than that of female cases 15 (22%), and difference is statistically significant (χ2 = 15.2, P = 0.01). Most of the cases observed were above 60 years of age (n = 24) whereas, least cases observed in cases below 15 years of age (n = 4). In the present study, VAP was observed in increasing trend (2012—2015) 16% to 27%. Mean hospital-wide infection rate was higher in 2015 (4.34; standard deviation [SD] =3.33) than 2016 (2.14; SD = 2.25). The most common organism isolated from VAP was Acinetobacter baumannii followed by Pseudomonas aeruginosa.
Conclusion: The VAP cases reported four times higher among males than females and common above 60 years of age, most common causative organism isolated from VAP patients was A. baumannii. Majority of the isolates of A. baumannii and P. aeruginosa were resistant to commonly used antibiotics.

Keywords: Antibiotics sensitivity, endotracheal intubation, mechanical ventilation, pneumonia, sputum


How to cite this article:
Gupta SK, Al Khaleefah FK, Al Harbi IS, Torre MA, Jabar S, Mathias SL, Al Romaih O. An epidemiological study of ventilator-associated pneumonia in Intensive Care Unit and antibiotics sensitivity pattern of organism causing ventilator-associated pneumonia (2012—2016) at Al Qassim Region of Saudi Arabia. J Patient Saf Infect Control 2018;6:27-31

How to cite this URL:
Gupta SK, Al Khaleefah FK, Al Harbi IS, Torre MA, Jabar S, Mathias SL, Al Romaih O. An epidemiological study of ventilator-associated pneumonia in Intensive Care Unit and antibiotics sensitivity pattern of organism causing ventilator-associated pneumonia (2012—2016) at Al Qassim Region of Saudi Arabia. J Patient Saf Infect Control [serial online] 2018 [cited 2018 Aug 15];6:27-31. Available from: http://www.jpsiconline.com/text.asp?2018/6/1/27/238597




  Introduction Top


Healthcare-associated infections, or 'nosocomial' infections, affect patients in a hospital or other health-care facility, and are not present or incubating at the time of admission. They also include infections acquired by patients in the hospital or facility but appearing after discharge, and occupational infections among staff. The prevalence of healthcare-associated infection in developed countries varies between 3.5% and 12%.[1] The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries. The centre estimates that 4,131,000 patients are affected by approximately 4544 100 episodes of healthcare-associated infection every year in Europe.[1] The estimated incidence rate in the United States of America was 4.5% in 2002, corresponding to 9.3 infections per 1000 patient-days and 1.7 million affected patients. At any given point of time, the prevalence of healthcare-associated infection varies between 5.7% and 19.1% in low- and middle-income countries. Newborns are also at higher risk, with infection rates in developing countries 3—20 times higher than in high-income countries.[1] Among hospital-born babies in developing countries, healthcare-associated infections are responsible for 4%—56% of all causes of death in the neonatal period, and 75% in South-East Asia and Sub-Saharan Africa.[2]

Pneumonia that presents 48—72 h or after following endotracheal intubation, characterised by the presence of a new or progressive infiltrate, signs and symptom of systemic infection such as fever, change in white blood cell count, sputum characteristics and detection of a causative agent.[3] Fifty per cent of hospital-acquired pneumonia occurred in hospital are ventilator-associated pneumonia (VAP).

VAP occurs in range from 9% to 27% of all mechanically ventilated patients.[4],[5],[6] The VAP is second-most common nosocomial infection in the Intensive Care Unit (ICU).[7],[8] VAP rates range from 1.2 to 8.5 per 1000 ventilator days.[9],[10] Mechanical ventilated person Risk for developing VAP is more during the first 5 days (3%) with the mean duration of occurrence of VAP being 3.3 days.[11],[12] This risk of developing pneumonia rate is declines to per day 2% between days 5 and 10 of ventilation, and 1% per day thereafter.[13] Earlier studies demonstrate that the attributable mortality for VAP range from 33% to 50%, but this rate is changeable and depends mainly on the underlying medical problems.[7] The attributable risk of death from VAP has decreased and is more recently estimated at 9%—13%. Thus, endotracheal intubated adult patients in ICUs worldwide increases the chance of VAP and leads to poor outcomes and increase health-care costs.[14],[15]

Objective

The objective of this study is to find the epidemiological pattern and hospital-wide rates of the VAP and their antibiotics sensitivity patterns.


  Materials and Methods Top


The present observational retrospective study was carried out by Infection Prevention and Control Department in ICU from January 2017 to July 2017 in tertiary care hospital, at Al Qassim provenance of Saudi Arabia.

Inclusion criteria

Patients who admitted to the ICU during the period of the study and fall under defined CDC criteria of VAP were selected for the study.

Exclusion criteria

Patients who admitted before or after the study period admitted to ICU but not ventilated and not fall under defined criteria of CDC.

No sample size was calculated, total patients admitted to ICU during the study periods (2012—2016) were 5475 (Males = 3285 and Females = 2190); out of all admitted patients reported VAP during the study period were 69 (1.26%) of total. Predesigned and pretested pro forma was used for collection of data. In the present study, following variables were studied: age, gender, hospital-wide rate, microbial aetiology, sensitivity patterns, etc., Hospital-wide infection rate was calculated on the basis of total number of VAP cases in the hospital divided by total number of patient's day during the same period and multiply by 1000.

Statistical analysis

Data analysis was performed using SPSS version 20 (IBM, Armonk, New York, United States). Chi-square test was applied, a value of P ≤ 0.05 was considered statistically significant.

Ethical clearance

Not needed, because no direct human subjects involvement or intervention only secondary data were analysed from records, confidentiality of data were maintained by not mentioning the name.


  Results Top


In the present study, total number of cases of healthcare-associated infection (HAIs) reported from the hospital during the study (2012—2016) were 331, out of these cases, 157 (48%) contributed from ICU, out of combined ICU cases 69 (44%) were of VAP [Table 1]. In the past 5 years, 20.24% of cases of VAP were reported out of total HAIs. Total cases admitted to ICU during the study periods 5475 (Males = 3285 and Females = 2190). Male cases 54 (1.64%) were nearly two and half times higher than female cases 15 (0.68%) and difference was found to be statistically significant (χ2 = 15.2, P = 0.01) [Table 2]. VAP cases were observed commonly in patients above 60 years of age (n = 24, 35%) and least common in patients below 15 years of age (n = 4, 6%), the difference between two age groups is statistically significant (χ2 = 12.1 and P = 0.02) [Table 2]. The distribution of VAP cases was observed retrospectively and found increasing from 2012 to 2015 (16%, 20%, 26% and 27%, respectively), but in the year 2016 VAP cases decreased (10%) [Table 1]. The most common organism reported in VAP cases was Acinetobacter baumannii 50 (72%) followed by Pseudomonas aeruginosa 14 (20%), Klebsiella pneumoniae 2 (3%), Streptococcus pneumoniae 1 (1.5%) and Staphylococcus spp. One (1.5%), respectively [Table 3]. Average mean hospital-wide VAP infection rate for the study period was 4.2 per thousand ventilator days, was highest in 2012 (5.1) and lowest in 2016 (2.14) [Figure 1] and [Figure 2].
Table 1: Distribution of ventilator-associated pneumonia cases in Intensive Care Unit from 2012 to 2016

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Table 2: Distribution of ventilator-associated pneumonia cases according to their age and gender from 2012 to 2016

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Table 3: Distribution of ventilator-associated pneumonia cases according to type of organism isolated from 2012 to 2016 in Intensive Care Unit

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Figure 1: Comparison of ventilator-associated pneumonia mean rate (per 1000 ventilator days) in Intensive Care Unit between years 2012 and 2016

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Figure 2: Comparison of ventilator-associated pneumonia rates monthly (per 1000 ventilator days) in Intensive Care Unit between years 2015 and 2016

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The antibiogram of microorganism commonly responsible for HAIs were observed but here discussed only related to VAP, 56% isolates of A. baumannii were sensitive to aztreonam followed by imipenem 54%, ceftazidime 47%, ciprofloxacin 47%, gentamicin 42%, meropenem 40% and amikacin 36%. Second-common organism reported was P. aeruginosa, the majority of isolates of this were sensitive to imipenem 79% followed by amikacin 68%, ceftazidime 53%, aztreonam and ciprofloxacin 49% and least sensitive to meropenem 9%. Most of the K. pneumoniae strains during the same period sensitive to imipenem 94% followed by piperacillin/tazobactam 71%, amikacin 69%, cefepime 59% and ceftriaxone 56%.


  Discussion Top


The present study was conducted to find the status of VAP and their antimicrobial sensitivity pattern in the ICU of the hospital. The study conducted by Gadani et al. regarding VAP incidence, outcome and risk factors, the most common organism they discovered was Pseudomonas in the present study. Most common organism was A. baumannii followed by Pseudomonas and significantly related to VAP cases, other risk factors were observed old age, male sex and days of ventilation, difference may be due to the study setting.[16] The study carried out by Lambert et al. about the prevention of VAP in ICUs: they studied various preventive methods, but in the present study, we do not analysed preventive methods we discussed associated factors, hospital-wide VAP infection rate, common causative microorganism and their sensitivity patterns.[17] Another study conducted by Behnia et al. regarding nosocomial and VAP in a community hospital ICU they found A. baumannii, Klebsiella and Pseudomonas species had the highest prevalence of multidrug resistant, similar type of finding also reported in the present study.[18] The study conducted by Mietto et al. regarding VAP most common infection in intubated patients, in the present study, we also observed same and also discussed about demographic profile and found significant association between male sex and older age with VAP and their common organism/sensitivity and contributing factors for VAP.[19]

The study conducted by Alqurashi et al. regarding antibiotic susceptibility patterns of different bacteria isolated from patients with VAP they studied susceptibility of various antibiotics isolated from VAP patients, it shows that K. pneumoniae 22 (100%) were sensitive to aztreonam, followed by 20 (91%) to imipenem, 19 (86.3%) to cefuroxime, 18 (82%) to ciprofloxacin. Only 2 (9%) were intermediately sensitive to sulbactam-ampicillin, while 22 (100%) were resistant to ampicillin and amoxicillin-clavulanic acid, similar type of finding also reported in the present study.[20] The study conducted by Maksum Radji et al. regarding antibiotic sensitivity pattern of bacterial pathogens in the ICU, they observed most common isolate was P. aeruginosa (26.5%) followed by K. pneumoniae (15.3%), in the present study A.baumannii is commonest organism followed by P.aeruginosa, difference may be due to study settings. P. aeruginosa isolates showed amikacin was the most effective (84.4%) followed by imipenem (81.2%), and meropenem (75.0%), in the present study, we found imipenem more sensitive than amikacin.[21] The another study conducted by Nidhi Goel et al. about antibiotic sensitivity pattern of Gram-negative bacilli (GNB) isolated from the lower respiratory tract of ventilated patients in the ICU they observed most common GNB were P. aeruginosa (35%), followed by A. baumannii (23.6%), and K. pneumoniae (13.6%), in the present study, most common isolates were A. baumannii (72%) followed by P. aeruginosa (20%) and K. pneumoniae (3%) of cases only, difference may be due to difference in the study settings. A very high rate of resistance (80%—100%) was observed among predominant GNB to ciprofloxacin, ceftazidime, co-trimoxazole and amoxicillin/clavulanic acid combination. Least resistance was noted to meropenem and doxycycline — similar kind of finding was also reported in the present study — but more sensitive to imipenem, aztreonam and amikacin.[22]

This study showed the epidemiology of common organisms in our ICU environment and their sensitivity pattern so it would be very helpful for administrator/health-care providers for future planning and management, for better prevention and control of VAP in ICU and rational use of antibiotics according to antibiogram.

Limitation of the study

The study conducted retrospectively, and data were collected from medical records and monthly reports, findings depend on quality of medical record data.


  Conclusion Top


The VAP was associated with male gender and older age (above 60 years) and most common causative microorganism for that A. baumannii, this difference was significantly higher. The health care facility based antibiogram is very helpful for knowing the sensitivity pattern of microorganism and control of MDRO, It would also helpful for treating physician to choose best available antibiotics.

Acknowledgements

We are very thankful for the kind support from laboratory and ICU staffs for helping during data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.  Back to cited text no. 3
    
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Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-32.  Back to cited text no. 4
    
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Horan TC, Gayness RP. Surveillance of nosocomial infections. In: Mayhall CG, editor. Hospital Epidemiology and Infection Control. Philadelphia: Lippincott Williams and Wilkins; 2004. p. 1659-702.  Back to cited text no. 5
    
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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;274:639-44.  Back to cited text no. 7
    
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Chastre J, Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867-903.  Back to cited text no. 8
    
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Hunter JD. Ventilator associated pneumonia. BMJ 2012;344:e3325.  Back to cited text no. 9
    
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Skrupky LP, McConnell K, Dallas J, Kollef MH. A comparison of ventilator-associated pneumonia rates as identified according to the national healthcare safety network and American College of Chest Physicians Criteria. Crit Care Med 2012;40:281-4.  Back to cited text no. 11
    
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Melsen WG, Rovers MM, Koeman M, Bonten MJ. Estimating the attributable mortality of ventilator-associated pneumonia from randomized prevention studies. Crit Care Med 2011;39:2736-42.  Back to cited text no. 14
    
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Melsen WG, Rovers MM, Groenwold RH, Bergmans DC, Camus C, Bauer TT, et al. Attributable mortality of ventilator-associated pneumonia: A meta-analysis of individual patient data from randomised prevention studies. Lancet Infect Dis 2013;13:665-71.  Back to cited text no. 15
    
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Gadani H, Vyas A, Kar AK. A study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention. Indian J Anaesth 2010;54:535-40.  Back to cited text no. 16
[PUBMED]  [Full text]  
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Alqurashi AM. Antibiotic susceptibility patterns of different bacteria isolated from patients with ventilator associated pneumonia (VAP). J Family Community Med 2005;12:139-44.  Back to cited text no. 20
    
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[PUBMED]  [Full text]  


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