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Nosocomial Infections: Multicenter Surveillance of Antimicrobial Resistance in Tehran During 2015 - 2017

AUTHORS

Saman Dorodgar 1 , Hossein Hatami 2 , Davood Yadegarynia 1 , * , Zahra Arab-Mazar ORCID 1

AUTHORS INFORMATION

1 Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran

How to Cite: Dorodgar S, Hatami H, Yadegarynia D, Arab-Mazar Z. Nosocomial Infections: Multicenter Surveillance of Antimicrobial Resistance in Tehran During 2015 - 2017, Arch Clin Infect Dis. 2018 ; 13(5):e64246. doi: 10.5812/archcid.64246.

ARTICLE INFORMATION

Archives of Clinical Infectious Diseases: 13 (5); e64246
Published Online: August 20, 2018
Article Type: Research Article
Received: November 20, 2017
Revised: April 3, 2018
Accepted: April 8, 2018
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Abstract

Background: Rapid increase in nosocomial infections (NIs) due to antibiotic resistant organisms is a global issue, which causes significant morbidity in both patients and healthcare professionals ultimately leading to an extra cost on health care systems. Thus, studying NIs is a public health priority.

Methods: The study was designed as a cross-sectional investigation between 2015 - 2017. Inpatient cases of selected hospitals with nosocomial infections were included. Demographics, source of infections, causative agents, and their antibiotic susceptibility through E-test method were collected. All data were analyzed using SPSS statistical software (version 19).

Results: A total of 168 patients with NIs were identified. Of the patients, 100 (59.5%) cases were male. The intensive care unit had the highest infection rate (N = 100 (59.5%)) and bronchoalveolar lavage (BAL) (N = 58 (34.5%)) and Acinetobacter (N = 76 (47.5%)) were the most common source and organism of NI.

Conclusions: Results of this study showed the dangerously high nosocomial infection rates, which necessitates considering surveillance of antibiotic usage and restriction of using broad spectrum antibiotics in infections.

Keywords

Nosocomial Infection Bacterial Agent Resistance Susceptibility

Copyright © 2018, Archives of Clinical Infectious Diseases. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

The problem of hospital acquired infection, in spite of vast advances in the treatment of infectious diseases during past decades, remains a vital issue and the importance of this issue is increasing every day. According to different studies, 8.7% of hospitalized patients acquire this infection worldwide, in both developed and developing countries. This kind of infection leads to an increasing rate of deaths, organ rejection, and surgeries failure (1). Nosocomial infection definition is an infection in those occurring in 72 hours of hospital admission, 3 days of discharge, or 30 days after surgery. Bacteria, viruses, fungi, and parasites can cause nosocomial infections (2, 3). The main gram-negative agent bacilli are including E. coli, Klebsiella pneumonia, and Pseudomonas aeruginosa (4). The estimated rate of nosocomial pneumonia is 5 - 10 episodes per 1000 hospitalizations. The length of mechanical ventilation is directly related to the rate of ventilator associated pneumonia (5). Gram negatives bacilli like Pseudomonas aeruginosa, Klebsiella pneumonia, Acintobacter species, and staphylococci are the main etiological factors. Increasing frequency of antibiotic resistant organisms is a common problem in the treatment of NIs. Studies regarding antimicrobial drug resistance effective for the control of bacterial pathogens and vital in any region, hospital epidemiologic plans, and antibiotic susceptibility patterns in hospitals should be monitored regularly (6).

2. Objectives

The aim of this study was to evaluate the frequency of nosocomial infections and antibiotic susceptibility patterns of selected hospitals in Tehran, Iran, to help the physician in choosing better antibiotics for initial empiric therapy, which is due to the fact that there is a significant knowledge gap regarding the Nis due to the fact that lack of enough data from epidemiological studies and reports coming from Iran are not enough.

3. Methods

This cross sectional study survey was conducted from June 2015 to June 2017 in selected referral hospital in Iran, located in Tehran. In the first step, a questionnaire that included the demographic and clinical characteristics, type of nosocomial infection, and sort of culture was provided. The antibiotic susceptibility was determined by the E-test method. Next, we took out the list of patients with nosocomial infection that was provided by the hospital infection control nurse and then we went to the archive file of the patients one by one. We extracted our required patient data and entered them in the information form. Finally, the collected data were analyzed using the SPSS Version 19 (7).

4. Results

A total 168 patients were infected. Of these patients, 100 were males and 68 were females. The average age was 71.64 years. The most of nosocomial infection was seen in the ICU with 100 patients. BAL (58) and sputum (37) were the most sources of infection. The most common organisms were Acintobacter and Klebsiella (76 and 30 cases, respectively). The prevalence of NIs in various wards is shown in Table 1. The prevalence of various causative agents and source of infection is listed in Table 2. Antibiotic sensitivity patterns of the bacteria that cause NIs are listed in Tables 3 and 4.

Table 1. Distribution of Patients According the Ward Typea
ICUCCUCardiovascularGeneralSurgeryNeurology
Acinetobacter48 (63.2)16 (21.1)2 (2.6)4 (5.3)2 (2.6)4 (5.3)
Klebsiella24 (80)3 (10)3 (10)
Enterococcus4 (28.6)2 (14.3)2 (14.3)4 (28.6)2 (14.3)
Pseudomonas8 (44.4)2 (11.1)8 (44.4)
Staphylococcus aureus16 (72.7)6 (27.3)

aValues are presented as No. (%).

Table 2. Causative Agent and Source of Infectiona
BALCSFFoley CatheterPleuralSputumTrachea SampleWoundBloodTotal
Acinetobacter28 (36.8)10 (13.2)2 (2.6)2 (2.6)22 (28.9)2 (2.6)10 (13.2)76
Klebsiella15 ( 50)6 (20)3 (10)6 (20)30
Enterococcus4 (28.6)4 (28.6)2 ( 14.3)14
Pseudomonas3 (16.7)6 (33.3)6 (33.3)3 (16.7)18
Staphylococcus aureus12 (54.4)6 (27.3)2 (9.1)2 (9.1)22

aValues are presented as No. (%).

Table 3. Antibiotic Susceptibility of Gram Negative Bacterial Isolated from Infection Sites
Acinetobacter spp. Pseudomans spp. Klebsiella spp.
RIRIRI
Amikacin28.968.450-303.3
Piperacillin100---30-
Cefepime100-1005040
Rifampicin7.157.1-
Gentamicin9425030
Meropenem63-1002010
Colistin066.661010
Ceftazidim9216.790
Imipenem02070
Co-trimoxazol4050
Table 4. Antibiotic Susceptibility of Gram Positive Bacteria Isolated from Infection Site
S. aureusEntrococcus
RIRI
Rifampicin85.785
linozolid1090
Amikacin100
Vancomycine09.1
Piperacillin100100
Co-trimaxozol00

5. Discussion

In the current study, detection of NIs in most of cases was based on the clinical grounds; therefore, it is increasing the possibility of missing patients with subclinical infections. In addition, due to the fact that the laboratory reports might contain false negative results, the average age of our cases was 71.64 years. The average of over 50 years old has a higher risk of infections (8). Furthermore, it was mentioned that people over 50 years are the most resistance antibiotics (9).

In this study most of our patients were hospitalized in the ICU and the most common source of infection was BAL. The most common bacteria isolated from patients was Acinetobacter spp. In Javanbakht et al. (10), study in Mashhad the highest frequency of pathogen was Acinetobacter spp., which is similar to our result. In a study, which was conducted by Kazemi et al. (11), A. baumannii isolates from ICU wards of hospital was very high and antibiotic resistance against meropenem, piperacilin, and ceftazidin had a rate of 100%, 98%, and 96%, respectively, which is consistent with our results. In another study, most of the Acinetobacter samples were isolated from the ICU (12). In the Atlantic region, prevalence of the multi-drug resistance of Acinetobacter spp. has been reported to 29.3%. Unfortunately, due to increasing multi-drug resistant strains, treatment of infectious diseases, which coursed by Acinetobacter spp. is difficult (13, 14). According to different studies, the rate of mortality from NIs caused by Acinetobacter spp. is around 7.8% to 23% (14).

In our study, resistance to amikacin was low in gram negative bacteria except Pseudomans spp. in Hosain Zadegan’s study, which was done in the Baghiattalah hospital; the most common germ in bronchial samples was Pseudomans spp. (15). In another study, Nan et al. (16), reported that the prevalence of Pseudomans spp. in nosocomial infection was 20%. In our study, the prevalence is 10%. These differences could be due to hospital environment and health (17).

S. aurous had a very high rate of resistance. Molaabbaszadeh et al. , studied the rate of resistance in S. aurous to ciproflaxin, clindamycin, and cotrimoxazol and observed that the resistance was low, and similar to our study, cotrimaxazol was 100% sensitive (18). In the study of Yadegarynia et al., S. aurous resistance was low in linozolind and vancomycine. In our study, resistance to vancomycin and co-trimaxozol were not observed (19).

Although Acinetobacter spp. and Klebsiella spp. is the most common cause of NIs in the ICU, with source of BAL in the current study, they are resistance to a wide range of antibiotics. Furthermore, in many studies in nosocomial infection the main infection was UTI infected by E. coli (20).

In our study, the second common microorganism that was isolated in culture was Klebsiella spp. (30 patients, 17%). Yedagarynia et al. studied the rate of Klebsiella spp. infection and antimicrobial resistance by E-test in Khatam-ol-Anbiya Hospital (21). In that study, the most resistance was observed in ciprofloxacin, ceftriaxone, and gentamicin. In the current study ceftazidim had the highest resistance.

Since our study design, as a respective study and test of susceptibility, was limited, we had some limitations.

5.1. Conclusions

In conclusion, our study showed the antibiotic resistance of bacteria isolated in selected hospitals during 2015 - 2017. It seems that we are facing the increasing rate of antibiotic resistance in our hospitals and region. The result confirms that it is necessary to evaluate precise reporting and improving control of infection procedure in hospitals. We must gain sufficient knowledge about antimicrobial resistance in our country; therefore, we can monitor the prevalence and antimicrobial resistance of bacteria by administrating appropriate treatments.

Acknowledgements

Footnotes

References

  • 1. Ducel G, Fabry J, Nicolle L; World Health Organization. Prevention of hospital-acquired infections: a practical guide. 2nd ed. World Health Organization; 2002.
  • 2. Karam GH, Heffner JE. Emerging issues in antibiotic resistance in blood-borne infections. Am J Respir Crit Care Med. 2000;162(5):1610-6. doi: 10.1164/ajrccm.162.5.pc10-00. [PubMed: 11069784].
  • 3. Robinson TP, Bu DP, Carrique-Mas J, Fevre EM, Gilbert M, Grace D, et al. Antibiotic resistance is the quintessential One Health issue. Trans R Soc Trop Med Hyg. 2016;110(7):377-80. doi: 10.1093/trstmh/trw048. [PubMed: 27475987]. [PubMed Central: PMC4975175].
  • 4. Hartstein AI, Garber SB, Ward TT, Jones SR, Morthland VH. Nosocomial urinary tract infection: a prospective evaluation of 108 catheterized patients. Infect Cont. 2015;2(5):380-6. doi: 10.1017/s0195941700055533.
  • 5. Magret M, Amaya-Villar R, Garnacho J, Lisboa T, Diaz E, Dewaele J, et al. Ventilator-associated pneumonia in trauma patients is associated with lower mortality: results from EU-VAP study. J Trauma. 2010;69(4):849-54. doi: 10.1097/TA.0b013e3181e4d7be. [PubMed: 20938271].
  • 6. Rozanska A, Wojkowska-Mach J, Bulanda M, Heczko PB. Organization and scope of surveillance of infections in Polish hospitals. Results of the project prohibit. Przegl Epidemiol. 2014;68(1):27-32. 117-20. [PubMed: 25004628].
  • 7. Yadegarynia D, Rahmati Roodsari S, Arab-Mazar Z. Evaluation of antimicrobial susceptibility among Enterococcus species by E-test method at Khatam-ol-Anbia Hospital during 2013 – 2014. Arch Clin Infect Dis. 2016;11(1). doi: 10.5812/archcid.29526.
  • 8. Zolldann D, Haefner H, Poetter C, Buzello S, Sohr D, Luetticken R, et al. Assessment of a selective surveillance method for detecting nosocomial infections in patients in the intensive care department. Am J Infect Control. 2003;31(5):261-5. [PubMed: 12888760].
  • 9. Wurtz R, Karajovic M, Dacumos E, Jovanovic B, Hanumadass M. Nosocomial infections in a burn intensive care unit. Burns. 1995;21(3):181-4. [PubMed: 7794498].
  • 10. Javanbakht A, Askari E, Danesh L, Moghadas N, Mostafavi I, Naderinasab M. The incidence of cross infections in Imam Reza hospital, Mashhad, Iran. Iran J Microbiol. 2012;4(4):177-9. [PubMed: 23205248]. [PubMed Central: PMC3507306].
  • 11. Kazemi H, Yadegarynia D, Rahmati Roodsari S, Arab-Mazar Z. Evaluation of antimicrobial susceptibility among Acintobacter baumannii by E-test method at Khatam-Al-Anbia Hospital during 2013 - 2015. Zahedan J Res Med Sci. 2017;19(1). doi: 10.17795/zjrms-6522.
  • 12. Yadegarynia D, Azad MK, Gachkar L, Roodsari SR, Arab-Mazar Z. Drug resistance of acinetobacter in selected hospitals. Novelty Biomed. 2015;3(3):103-10.
  • 13. Falagas ME, Rafailidis PI. Attributable mortality of Acinetobacter baumannii: no longer a controversial issue. Crit Care. 2007;11(3):134. doi: 10.1186/cc5911. [PubMed: 17543135]. [PubMed Central: PMC2206403].
  • 14. Falagas ME, Kasiakou SK, Rafailidis PI, Zouglakis G, Morfou P. Comparison of mortality of patients with Acinetobacter baumannii bacteraemia receiving appropriate and inappropriate empirical therapy. J Antimicrob Chemother. 2006;57(6):1251-4. doi: 10.1093/jac/dkl130. [PubMed: 16627593].
  • 15. Hosain Zadegan H, Ramazanzadeh R, Hasany A. Cross-sectional study of extended spectrum beta-lactamase producing gram-negative bacilli from clinical cases in Khorramabad, Iran. Iran J Microbiol. 2009;1(3):16-9.
  • 16. Nan DN, Fernandez-Ayala M, Farinas-Alvarez C, Mons R, Ortega FJ, Gonzalez-Macias J, et al. Nosocomial infection after lung surgery: incidence and risk factors. Chest. 2005;128(4):2647-52. doi: 10.1378/chest.128.4.2647. [PubMed: 16236938].
  • 17. Arora D, Jindal N, Kumar R, Romit E. Emerging antibiotic resistance in Pseudomonas aeruginosa. Int J Pharm Pharm Sci. 2011;3(2):82-4.
  • 18. Behzadnia S, Davoudi A, Rezai MS, Ahangarkani F. Nosocomial infections in pediatric population and antibiotic resistance of the causative organisms in north of iran. Iran Red Crescent Med J. 2014;16(2). e14562. doi: 10.5812/ircmj.14562. [PubMed: 24719744]. [PubMed Central: PMC3965877].
  • 19. Yadegarynia D, Taheri M, Arabmazar Z, Darvishi A. [Evaluation of antimicrobial susceptibility among Staphylococcus aureus by E-test method at Khatam-Ol-Anbia hospital during 2013 – 2015]. Res Med. 2016;40(1):24-9. Persian.
  • 20. Davoudi AR, Najafi N, Hoseini Shirazi M, Ahangarkani F. Frequency of bacterial agents isolated from patients with nosocomial infection in teaching hospitals of Mazandaran University of Medical Sciences in 2012. Caspian J Intern Med. 2014;5(4):227-31. [PubMed: 25489435]. [PubMed Central: PMC4247487].
  • 21. Yadegarynia D, Karimi J, Rahmati Roodsari S, Arab-Mazar Z. Evaluation of the antimicrobial resistance of klebsiella pneumoniae by E-test method in Khatam_ol_Anbia Hospital, Tehran, Iran, during 2015. Infec Epidemiol Med. 2017;3(1):9-11. doi: 10.18869/modares.iem.3.1.9.
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