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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012077 doi:10.1088/1755-1315/125/1/012077

Incidence of multidrug-resistant, extensively drug-resistant

and pan-drug-resistant bacteria in children hospitalized at
Dr. Hasan Sadikin general hospital Bandung Indonesia

R Adrizain1 *, F Suryaningrat1, A Alam1 and D Setiabudi1

1
Department of Pediatrics, Hasan-Sadikin General Hospital-Universitas Padjadjaran,
Bandung, Indonesia
*
Corresponding author: riyadispa@gmail.com

Abstract. Antibiotic resistance has become a global issue, with 700,000 deaths attributable to
multidrug-resistance (MDR) occurring each year. Centers for Disease Control and Prevention
(CDC) show rapidly increasing rates of infection due to antibiotic-resistant bacteria. The aim
of the study isto describe the incidence of MDR, extensively drug-resistant (XDR) and pan
drug-resistant (PDR) in Enterococcus spp., Staphylococcus aureus, K. pneumonia,
Acinetobacter baumanii, P. aeruginosin, and Enterobacter spp. (ESKAPE) pathogens in
children admitted to Dr. Hasan Sadikin Hospital. All pediatric patients having blood culture
drawn from January 2015 to December 2016 were retrospectively studied. Data include the
number of drawn blood culture, number of positive results, type of bacteria, sensitivity pattern.
International standard definitions for acquired resistance by ECDC and CDC was used as
definitions for MDR, XDR and PDR bacteria. From January 2015 to December 2016, 299
from 2.542 (11.7%) blood culture was positive, with Staphylococcus aureus, Enterococcus
spp., Enterobacteriaceae, Pseudomonas aeruginosa, Acinetobacter spp., respectively 5, 6, 24,
5, 20 with total 60 (20%). The MDR and XDR pathogen found were 47 and 13 patients,
respectively.

1. Introduction
Antibiotic resistance is considered as an urgent global issue, and the US Centers for Disease Control
and Prevention (CDC) has reported that around two million US individuals are infected by antibiotic-
resistant microorganisms annually, hence resulting in 23,000 deaths. CDC also reported that
approximately more than half inward patients receive an antibiotic and around one-third receive a
broad-spectrum antibiotic during their stay.[1] Besides the high incidence of antibiotic-resistance
infections reported by CDC, the public is demanded to pay attention to the high estimated deaths in
which an estimated annual 700,000 deaths worldwide are attributable to infections by multidrug-
resistance microorganisms. It is estimated that by the year 2050, around 10 million people worldwide
will die due to this issue.[2] These infections are mainly caused by methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus faecium (VRE),
fluoroquinolone-resistant Pseudomonas aeruginosa, ESBL-producing E. coli and Klebsiella sp.,
Klebsiella pneumonia and E. coli producing carbapenemase, Acinetobacter baumanii, and
Pseudomonas aeruginosin in general. These antibiotic-resistant bacteria including Enterococcus
faecium, Staphylococcus aureus, K. pneumonia that included in Enterobacteriaceae, Acinetobacter
baumanii, P. aeruginosa, and Enterobacter sp. are altogether referred as “ESKAPE.”[3, 4]

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ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012077 doi:10.1088/1755-1315/125/1/012077

We aimed to study the incidence of multidrug-resistant (MDR), extensively drug-resistant (XDR)

and pan drug-resistant (PDR) in ESKAPE pathogens in children admitted to Dr. Hasan Sadikin
General Hospital, Bandung.

2. Methods
This descriptive retrospective study includes all pediatric patients admitted to Dr. Hasan Sadikin
General Hospital having their blood drawn for culture from January 2015 to December 2016. The data
described in this study include the number of blood culture obtained, positive results, type of bacteria
cultured, and the sensitivity pattern of antibiotics. To describe acquired resistance profiles in
Enterococcus spp., Staphylococcus aureus, Enterobacteriaceae including Klebsiella pneumonia,
Acinetobacter baumanii, P. aeruginosa, and Enterobacter spp. International standard definitions for
acquired resistance from ajoint initiative by the European Centre for Disease Prevention and Control
(ECDC), as well as the US Centers for Disease Control and Prevention, was used in defining MDR,
XDR, and PDR bacteria. According to ECDC and CDC, for Enterococcus faecium; Staphylococcus
aureus; Enterobacteriaceae that include Klebsiella pneumonia, Escherichia coli, Enterobacter spp.,
Serratia spp., Proteus spp., Providencia spp, and Morganella spp.; Acinetobacter baumanii; P.
aeruginosa; and Enterobacter sp.[5,6] MDR was defined as non-susceptibility to at least one agent in
>3 antimicrobial categories defined by the organizations, while XDR is referred as the isolate being
non-susceptible to at least one agent in all but two or fewer antimicrobial categories listed. As for
PDR, it is defined as non-susceptibility to all agents in all antimicrobial categories for each bacterium
listed.[6]

3. Results
We performed blood culture examination in 2542 pediatric patients and 299 (11,7%) blood samples
were positive for Staphylococcus aureus, Enterococcus spp., Enterobacteriaceae, Pseudomonas
aeruginosin, and Acinetobacter spp., and others bacterium such as Achromobacterxylosoxidans,
Kocuriakristinae, Leuconostocmesenteroides, Micrococcus, Salmonella spp. Staphylococcus
epidermidis, Staphylococcus haemolyticus, Staphylococcus hominis spp., Staphylococcus lentus,
Staphylococcus sciuri, Staphylococcus warneri, Staphylococcus xylosus, Streptococcus agalctiae,
Streptococcus mitis, Sphigomonaspaucimobilisand many others bacterium. We found that
Enterobacteriaceae is the most identified bacteria followed by Acinetobacter sp., Staphylococcus
aureus, Enterococcus sp., and Pseudomonas aeruginosin (table 1).

Table 1. Number of culturesperformed and positive

results.
Number of cultures performed 2547
Positive results n (%)
Staphylococcus aureus 9 0.35
Enterococcus sp. 8 0.31
Enterobacteriaceae 54 2.1
Pseudomonas aeruginosin 5 0.2
Acinetobactersp. 24 0.94
Other bacterium 199 7.8
Total 299 11.7

Blood cultures results showed 86 MDR bacteria were found, while XDR bacteria were found in
only 14 samples. From 86 positive for MDR bacteria, 47 samples (54.6%) were Enterobacteriaceae,
and out of 14 XDR bacteria, 7 (50%) were Enterobacteriaceae. PDR microorganism was not
identified (table 2).

2
ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012077 doi:10.1088/1755-1315/125/1/012077

Table 2. Positive culture results for MDR, XDR, and PDR bacteria.
Microorganism MDR XDR PDR Total
Staphylococcus aureus 8 1 0 9
Enterococcus sp. 6 2 0 8
Enterobacteriaceae 47 7 0 54
Pseudomonas aeruginosa 5 0 0 5
Acinetobactersp. 20 4 0 24
Total 86 14 0 100

4. Discussion
The most common bacteria identified in this study are Enterobacteriaceae followed by Acinetobacter
spp., Staphylococcus aureus, Enterococcus spp., and Pseudomonas aeruginosa. Approximately 86
(28.7%) of all 299 isolates were found to be MDR bacteria while 14 (4.7%) were XDR. Compared to
another study worldwide, including those in the United States, Europe, Kenya, and India,
Enterobacteriaceae seem to be a common MDR isolate.[5, 7-9] Folgori et al. reported the prevalence
of MDR Gram-negative bloodstream infections in a tertiary hospital and discovered that the most
frequently isolated bacteria were Escherichia Coliand P. aeruginosa (67.6%), in which 39% of each
species isolated were MDR.[5] Compared to our study, Enterobacteriaceae was found in only 2% of
the isolates, while P. aeruginosa 0.2%. However, it is interesting that of all Enterobacteriaceae and P.
aeruginosa isolate, all of them were found to be either MDR or XDR. Apondi et al. reported MDR K.
pneumonia in a newborn unit in a tertiary hospital in Kenya in which 23% Klebsiella pneumonia, in
which it is included in Enterobacteriaceae group and the prevalence of MDR K. pneumonia was
high.[7] According to World Health Organization (WHO), carbapenem-resistant Acinetobacter sp.,
Pseudomonas aeruginosa, and Enterobacteriaceae (including Klebsiella pneumonia, Escherichia coli,
Enterobacter spp., Serratia spp., Proteus spp., Providencia spp., and Morganella spp.) are considered
as critical or priority number 1 of WHO priority pathogen list for research, discovery, and
development of new antibiotics, while those bacteria included in priority number 2 include
vancomycin-resistant Enterococcusfaecium (VRE), methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-intermediate and resistant S. aureus.[10] Our research found 78 from 100
(78%) ESKAPE pathogen was Acinetobacter sp. and Enterobacteriaceae, this data showed that our
country also needs to increase the awareness for critical priority pathogen because of similarity
pathogen pattern with WHO recommendation.[6]
The dominant factors contributing to the emergence of resistant strains of bacteria include overuse
of antibiotics both in clinical settings and in theanimal industry and also the selective pressure
generated.[3] According to CDC, more than half inward patients receive an antibiotic, and at least one
third receive broad-spectrum antibiotics.[1] This current developing issue of antibiotics resistance
needs full international attention and effort including policies, the discovery of new tools to eliminate
bacteria by introducing new antibiotics and other innovative treatments. In the hospital setting, it is
important to consider hand washing as a priority to minimize and prevent infection. The CDC also
recommends an antibiotic stewardship program conducted by each hospital, including relying on
infrastructures providing physicians proper information and tools to make decisions regarding
theantibiotic prescription.[3] Since it is a retrospective study, therefore we could not do the test for
antimicrobial resistance genes that may be carried on the bacterial chromosomes to show the type of
resistance that occurred, and also we were not able to separate between hospital-acquired bacteria or
community-acquired bacteria that we found in this study.

5. Conclusion
The prevalence of MDR and XDR pathogens in pediatric patients in Dr. Hasan Sadikin General
Hospital Bandung is not as high as the prevalence reported in other studies worldwide, however,
despite the low number, antibiotic resistance remains one of the main challenging issues demanding
for further attention.

3
ICTROMI IOP Publishing
IOP Conf. Series: Earth and Environmental Science1234567890
125 (2018) 012077 doi:10.1088/1755-1315/125/1/012077

References
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[3] Borghesi A and Stronati M 2015 Superbugs and antibiotics in the newborn J. Pediatr. Neonatal
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[4] Boucher H W, Talbot G H, Bradley J S, John E, Edwards J, Gilbert D, Rice L B, et al. 2009 Bad
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