International Journal of Research in Medical Sciences

Ranjan N et al. Int J Res Med Sci. 2014 Feb;2(1):228-233
www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: 10.5455/2320-6012.ijrms20140244
Research Article

Antimicrobial resistance in bacteria causing ventilator-associated
pneumonia in a tertiary care hospital: one year prospective study
Neelima Ranjan1, K. P. Ranjan1, Uma Chaudhary2, Dhruva Chaudhry3
1
Department of Microbiology, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
2
Department of Microbiology, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
3
Department of Critical Care and Pulmonary Medicine, Postgraduate Institute of Medical Sciences, Rohtak, Haryana,
India

Received: 4 November 2013
Accepted: 13 November 2013

*Correspondence:
Dr. K. P. Ranjan,
E-mail: drkpranjan@gmail.com

© 2014 Ranjan N et al. This is an open-access article distributed under the terms of the Creative Commons Attribution
Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.

ABSTRACT

Background: Ventilator-associated pneumonia (VAP) is the most common infection diagnosed in intensive care
units (ICUs). The causative organisms of VAP vary among different populations and are increasingly associated with
resistance against various antimicrobial agents. Objective of current study was to determine the bacteriological
etiology of VAP, antimicrobial susceptibility pattern of the isolates and detect the presence of extended-spectrum -
lactamases (ESBL), metallo β-lactamases (MBL) and AmpC -lactamases in multidrug resistant isolates causing VAP
in the medical ICU.
Methods: A prospective study was carried out over a year to know the various etiological agents of VAP and their
drug susceptibility patterns. ESBL, MBL and AmpC -lactamases were detected in various isolates by combination
disk method, imipenem-EDTA combined disk method and AmpC disk method respectively.
Results: The majority of bacterial isolates causing VAP were found to be gram negative bacilli. Acinetobacter spp
accounted for 34.28% of VAP cases followed by Pseudomonas aeruginosa which was responsible for 25.71% cases.
Other gram negative bacilli isolated were Klebsiella pneumoniae, Citrobacter freundii, Enterobacter spp, and
Escherichia coli. Out of the total 70 isolates, 67 (95.7%) were multidrug resistant and not even a single isolate was
sensitive to all the drugs tested.
Conclusions: Most of the pathogens causing VAP in our institute were multidrug resistant and in many isolates this
resistance was due to production of ESBL, MBL, and AmpC β-latamases. Polymixin-B and colistin were found to be
highly effective against multidrug resistant Acinetobacter spp and P. aeruginosa.

Keywords: Ventilator-associated pneumonia, Intensive care unit, ESBL, MBL, AmpC -lactamases

INTRODUCTION ventilation, usually carries a better prognosis, and is more
likely to be caused by antibiotic sensitive bacteria. Late
Ventilator associated pneumonia (VAP) is the most onset VAP occuring 5 days or more after mechanical
common infection diagnosed in intensive care units ventilation is more likely to be caused by multidrug
(ICUs). VAP is defined as pneumonia that occurs 48 resistant (MDR) pathogens, and is associated with
hours or more after endotracheal intubation or increased patient mortality and morbidity.2 The specific
tracheostomy, caused by infectious agents not present or microbial causes of VAP are many and varied. Gram
incubating at the time mechanical ventilation was negative bacteria, including Pseudomonas aeruginosa,
started.1 It can be of two types. Early-onset VAP, defined Acinetobacter spp and enteric gram negative rods are
as occurring within the first 4 days of mechanical implicated in 55-85% of VAP cases. High rates of

International Journal of Research in Medical Sciences | January-March 2014 | Vol 2 | Issue 1 Page 228

In threshold for endotracheal aspirates while growth >104 the monomicrobial episodes gram negative isolates CFU/ml was taken as cutoff for BAL.12 etiology of VAP and the antimicrobial susceptibility pattern of the isolates. Gram staining was done after making smears Klebsiella pneumoniae. The diagnosis was confirmed when significant growth The majority i. 13 MBL detection was done and Acinetobacter spp. Other gram negative bacilli isolated were processing. In relation to gender the incidence of VAP was VAP was based on clinical and microbiological criteria. In critically ill patients requiring flattening or indentation of the cefoxitin inhibition zone prolong mechanical ventilation in ICUs.2(1):228-233 Haemophilus influenzae. account for 30-40% of VAP. 3 considered to be ESBL producer if there was ≥5 mm Prompt usage of appropriate antibiotics is essential to increase in zone diameter of ceftazidime-clavulanate disk optimize the outcome of VAP. The pneumonias per 1.4 Appropriate increase in inhibition zone with the imipenem and EDTA choice of antibiotics requires awareness of relevant disk was ≥7 mm than the imipenem disk alone.5 Patients who incidence of VAP in our study was 57. The diagnosis of group. isolate was identified using standard Methicillin sensitive Staphylococcus aureus (MSSA). P value less than 0. aeruginosa which was responsible for immediately to the laboratory for microbiological 25. Out of the 60 cases 21 (35%) were categorized infection score (CPIS) was followed as a screening under early onset group and 39 (65%) under the late onset method to clinically diagnose VAP. quantitative cultures were done. Streptococcus pneumoniae.7% of bacterial isolates causing VAP was obtained in the culture of the samples. We also aimed to detect the Statistical analysis presence of extended-spectrum -lactamases (ESBL). If the antibiotics.28% of VAP cases samples of the patients were collected and sent followed by P. more among males (65%) than females (35%) and in A clinical suspicion of VAP was made in patients with different age groups the incidence of VAP was highest in modified CPIS score >6. tests.7 per 1000 ventilator were included in the study. Fisher’s exact test was applied when two or more set of variables were compared. If the inhibition zone evolution of antibiotic resistance.8. and multi drug resistant gram negative bacteria detected by combination disk method. Int J Res Med Sci.12 Amp C β-lactamases detection was the past decade and has created obstacles to effective done by Amp C disk method. only 3 isolates were gram positive bacteria. 95. aeruginosa.71% cases.10 Antibiotic testing was done susceptible Enterobactericeae were constantly found in by Kirby Bauer disk diffusion method for each isolate. VAP rate was study. Enterobacter of the samples and the samples were then inoculated on spp. P.7 The MacConkey plates Among them 2 isolates were of Staphylococcus aureus were incubated at 370C while blood agar and chocolate and 1 was Enterococcus spp. ESBL was (MRSA). whereas P.9 Samples showing accounted for 96% (48/50) and even in polymicrobial growth less than these thresholds were assumed to be due episodes of VAP gram negative bacilli were predominant to colonization or contamination. growth.000 ventilator days.14% and the received mechanical ventilation for more than 48 hours incidence density of VAP was 31. Acinetobacter An isolate was considered as MDR. Ranjan N et al.05 METHODS was considered statistically significant. as compared to zone diameter of disk containing antimicrobial resistance has escalated dramatically within ceftazidime alone. and the host considered as MBL positive. or microbiological techniques. Modified clinical pulmonary days. Endotracheal were found to be gram negative bacilli. A positive test appeared as antibiotic choices. if it was resistant to spp. Citrobacter freundii. Organism was were significantly more frequent in late onset VAP. 11 early onset VAP. which are resistant to many by imipenem-EDTA combined disk method. and Escherichia coli (Table 1).14 MRSA detection was done and demographic factors that may lead to infection and/or by cefoxitin disk diffusion method. metallo β-lactamases (MBL) and AmpC -lactamases in The statistical analysis was performed using standard multidrug resistant isolates causing VAP in the ICU. 10 episodes of VAP were dioxide. MacConkey agar and chocolate agar. 2014 Feb. aeruginosa in the vicinity of the test disk. isolates. Among the total 60 episodes agar were incubated at 370C in presence of 5-10% carbon of VAP reported. In case of significant accounting for 90% of etiological agents. A prospective study was conducted in Department of RESULTS Microbiology in association with the multidisciplinary ICU of the Pulmonary and Critical Care Medicine A total of 105 patients who were on mechanical Department of our institute for a period of one year ventilation for more than 48 hours were included in the extending from June 2009 to May 2010. Among gram International Journal of Research in Medical Sciences | January-March 2014 | Vol 2 | Issue 1 Page 229 . Out of the total 70 blood agar. Unfortunately. it was pathogens. Semi.6 patients more than 55 years of age (73. Acinetobacter spp aspirates (ETA) and bronchoalveolar lavage (BAL) accounted for a maximum 34. antimicrobial resistance patterns.68%). Methicillin resistant Staphylococcus aureus at least three classes of antimicrobial agents. Sixty patients fulfilled the clinical and defined as the number of ventilator-associated microbiological criteria for the diagnosis of VAP. around the cefoxitin disk was >22 mm then the isolate was considered MSSA and if the zone was <21 mm then The aim of our study was to determine the bacteriological it was considered as MRSA.e. Growth >105 CFU/ml was taken as the cutoff polymicrobial and 50 episodes were monomicrobial.

maximum by A. Vancomycin (Va).2% isolates. The single isolate of Enterococcus spp was in K. AmpC β-lactamase and MBLs within these pathogens. of Ce E Cd G Cf Va Do Lz Cp Gf Ac Pm isolates isolates Staphylococcus 1 0 0 0 1 0 1 0 2 0 0 1 2 aureus (50) (0) (0) (0) (50) (0) (50) (0) (100) (0) (0) (50) Enterococcus 1 1 1 0 1 0 0 1 1 1 1 1 - spp (100) (100) (100) (0) (100) (0) (0) (100) (100) (100) (100) Cefoxitin (Ce). The ESBL pristinamycin (Table 2). ciprofloxacin.It was also found to be highly resistant to various drugs such as also produced by 66. Gram negative bacteria were production was highest in case of E.42 bacteria Pseudomonas aeruginosa 18 25.28 Escherichia coli 1 1. produced MBL (Table 4). and in C. 12 (50%) isolates produced AmpC β-lactamase. to the presence of various degradative enzymes like freundii. Erythromicin (E). No.71 Klebsiella pneumoniae 15 21. doxycycline. one was MRSA spp.43 Total 70 100 Table 2: Antibiotic susceptibility pattern of gram positive bacteria isolated from VAP patients. freundii.86 Gram negative Acinetobacter lwoffii 1 1.67% isolates. amikacin. In case of Acinetobacter spp.67% isolates. meropenem. 67 (95. Cephalexin (Cp). Clindamycin (Cd). In P.52% of early Out of the total 70 isolates. piperacillin/ isolates. the drugs tested. doxycycline and aeruginosa. Ciprofloxacin (Cf). it sulbactam combination were found to be quite effective was 20. Gatifloxacin (Gf).85 Enterococcus spp 1 1. Gentamicin (G). Linezolide (Lz). C. Int J Res Med Sci. International Journal of Research in Medical Sciences | January-March 2014 | Vol 2 | Issue 1 Page 230 . pneumoniae ceftazidime. pneumoniae. which was resistant to cephalexin. aureus accounted for 9.34% of K. 3 4. The MBL production was maximum in case of tazobactam. Some of this rsistance can be attributed baumannii followed by P. and Pristinamycin (Pm). aeruginosa (27. it was seen to be produced by 66. also found to be resistant to vancomycin. Colistin. co-trimoxazole. aeruginosa. (%) of resistant strains Bacterial No.83% and in K. polymixin-B and cefoperazone / P. 16.18%). 2014 Feb.58 Enterobacter spp. Doxycycline (Do).67% of Enterobacter spp isolates. ESBLs. aztreonam. gatifloxacin. Table 1: Distribution of organisms isolated from samples in VAP patients. it was seen to be produced by 22.67% of C.7%) were multidrug onset VAP. coli (100%). and Enterobacter spp.2(1):228-233 positive bacteria S. Majority of late onset VAP episodes were resistant and not even a single isolate was sensitive to all also caused by gram negative bacteria. freundii and 13. K. ciprofloxacin. Out of the total 24 isolates of Acinetobacter Out of the two isolates of S. aureus.43 Acinetobacter baumannii 23 32. Bacterial isolates Number Percentage Gram positive bacteria Staphylococcus aureus 2 2. pneumoniae by 26. Ranjan N et al. pneumoniae only one isolate (Table 3). Amoxyclav (Ac).43 Citrobacter freundii 6 8.

The incidence density of resistant. Aztreonam (Ao).7 0 increased among a number of gram negative pathogens.3) (100) (0) (33. Ranjan N et al.7 13.3) (100) (26) (78) (0) (0) (8. including the penicillins. Ceftazidime (Ca). 2014 Feb. Amikacin (Ak).7 16. it was observed that vancomycin Diagnosing VAP requires a high clinical suspicion and linezolide were the most effective antibiotics for S. radiographic aureus.7) (83.2(1):228-233 Table 3: Antibiotic susceptibility pattern of gram negative bacteria other than pseudomonas aeruginosa isolated from VAP patients. and Ticarcillin/clavuanalate (Tc) Table 4: Distribution of AmpC.14%. and MBL in the study and the study duration was less as compared to bacterial isolates from VAP patients. The higher incidence of VAP in our study can 27.3) (20) (13.7) (26) Klebsiella 10 8 8 10 14 14 3 2 0 0 0 0 15 pneumoniae (66. Escherichia coli 0 100 0 especially P. doxycyline and ciprofloxacin were found to understanding local factors leading to VAP and the be effective against Enteroccus spp. aureus was MRSA.7) (100) (66.2 aeruginosa bacteria is common in ICUs mainly because of heavy use Klebsiella of antibiotics.7 per 1000 ventilator days highly effective. Int J Res Med Sci. Colistin (Cl). Ciprofloxacin (Cf).7 0 aminoglycosides.3) Escherichia 1 1 1 0 0 1 1 0 0 0 0 0 0 coli (100) (100) (0) (0) (100) (100) (0) (0) (0) (0) (0) (0) Acinetobacter 0 0 0 0 0 1 0 0 0 0 0 0 1 lwoffii (0) (0) (0) (0) (0) (100) (0) (0) (0) (0) (0) (0) Co-trimoxazole (Co). Cefoperazone/ Sulbactam (Cfs). Acinetobacter spp.3) (50) (50) (66.6) (93. Citrobacter freundii 66.6) (87) (91. examination.e.3) (0) (0) (0) (33.7) (100) (0) (33. All strains of P. When considering gram negative bacteria Acinetobacter In our study the incidence of VAP was 57. other studies showing fewer incidences. ESBL. cephalosporins.7 pneumoniae antibiotics. Acinetobacter spp 50 0 20.8% strains showed resistance to meropenem. (%) of strains resistant Bacterial No of Co Do Ak Cf Ca Ao Mr Pt Pb Cl Cfs Tc isolates isolates Acinetobacter 22 19 19 20 21 23 6 18 0 0 2 6 23 baumannii (95.3) (53.3) (93. Polymixin-B and colistin were found to be VAP in our study was 31. K. International Journal of Research in Medical Sciences | January-March 2014 | Vol 2 | Issue 1 Page 231 . combined with bed side examination.3) Enterobacter 3 3 2 3 2 3 0 1 0 0 0 1 3 spp (100) (100) (66.3) (66. secretions.6) (53. No.3 6. This resistance microbiologic milieu of a given unit. aeruginosa. In our study the incidence of MRSA was 50% i.16 DISCUSSION On performing the antimicrobial susceptibility testing of VAP is the most frequent ICU acquired infection gram positive bacteria and studying their antibiotic occurring in 10% to 65% of the ventilated patients.8 Pseudomonas The development and spread of antibiotic resistant 22.17 plague ICUs and critically ill patients.3) (0) (0) (0) (33.3) (0) (0) (0) (0) Citrobacter 5 3 3 4 5 6 0 2 0 0 0 2 6 freundii (83. pneumoniae and Enterobacter spp. Meropenem (Mr). One more reason for this high incidence can be the lack of adequate AmpC ESBL MBL nursing staff (which should ideally be 1:1 as compared to Bacterial isolates producer producer producer 4:1 in our institute) which may have adversely affected (%) (%) (%) the quality of care given to the patients. has gradually Enterobacter species 33. Multiple antibiotic resistance to useful 26. 15 susceptibility pattern. Doxycycline (Do).6) (82. This spp was the most common isolate and its resistance figure is at the higher end of the range of 15-58% as pattern showed that majority of isolates were multi-drug reported by other investigators. and microbiological analysis of respiratory one of the two isolates of S. In other be attributed to the fact that the total number of cases in gram negative bacilli also resistance to multiple drugs was seen.2 0 27. Aggressive surveillance is vital in Linezolide.6) (82. Polymixin B (Pb). Judicious antibiotic pattern of gram positive bacteria isolated from patients of usage is essential as resistant organisms continue to VAP was in accordance with other studies.3 66. Piperacillin/Tazobactam (Pt). aeruginosa were also which were high but compatible with ICUs in developing uniformly sensitive to polymixin-B and colistin but countries. and fluoroquinolones.

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