Mode of transmission of HIV among study population: Among 263 cases, 145 (55.13%) were male and 118 (44.87%) were female. Heterosexual activities were the most dominant route of transmission accounting for 78.33% whereas the least rate of transmission, 0.76% (n=2) was observed via a vertical route from mother to infants (Figure 1).
Bacterial growth according to age and gender of patients
Out of 263 sputum samples from HIV-positive individuals, 67 (25.48%) samples were positive for bacterial growth. The bacterial infection of LRT was found highest (50%) in the age group 61-70 years followed by 40% (n=10) among the male of age group 51-60 years. No infection was observed below 20 years (Table 1).
Table 1
Age and sex-wise distribution of Microbial growth
Age group (years)
|
Male
|
Female
|
Total number (growth %)
|
No. of sample
|
Growth (%)
|
No. of sample
|
Growth (%)
|
Below 20
|
3
|
0
|
1
|
0
|
4 (0)
|
21-30
|
29
|
8 (27.59)
|
20
|
5 (25)
|
49 (26.53)
|
31-40
|
40
|
9 (22.5)
|
52
|
12 (23.08)
|
92 (22.83)
|
41-50
|
42
|
10 (23.81)
|
32
|
10 (31.25)
|
74 (27.03)
|
51-60
|
25
|
10 (40)
|
11
|
1 (9.09)
|
36 (30.56)
|
61-70
|
6
|
3 (50)
|
2
|
1 (50)
|
8 (50)
|
Total
|
145
|
40 (27.59)
|
118
|
27 (22.88)
|
263 (25.48)
|
Bacterial co-infection and predisposing factors: Bacterial infection was observed significantly higher (p=0.02) among HIV patients with CD4 count <200 cells/µl. Similarly, bacterial infections were found to be higher among smokers and those with a history of pulmonary tuberculosis but the data was not statistically significant (Table 2).
Table 2
Relation bacterial infection with predisposing factors
Predisposing factors
|
Status of predisposing factors
|
Bacterial Growth
|
Total
|
p-value
|
Negative (%)
|
Positive (%)
|
CD4 count cells/µl
|
< 200
|
10 (47.62)
|
11 (52.38)
|
21
|
0.02
|
200-499
|
56 (60.22)
|
37 (39.78)
|
93
|
>500
|
130 (87.25)
|
19 (12.75)
|
149
|
Total
|
196 (74.52)
|
67 (25.48)
|
263
|
|
Smoking habit
|
Non-smoker
|
117 (77.48)
|
34 (22.52)
|
151
|
> 0.05
|
Smoker
|
35 (70)
|
15 (30.0)
|
50
|
Previous smoker
|
44 (70.97)
|
18 (29.03)
|
62
|
Total
|
196 (74.52)
|
67 (25.48)
|
263
|
|
History of PTB
|
No cases
|
149 (77.20)
|
44 (22.80)
|
193
|
> 0.05
|
Cases
|
47 (67.14)
|
23 (32.86)
|
70
|
Total
|
196 (74.52)
|
67 (25.48)
|
263
|
|
Bacterial infection among HIV people based on their literacy and occupation
Most of the samples (43.3%) were from HIV people completing primary level education. Very least (1.1%) samples were from highly educated ones. The rate of infection was found to be higher among literate people as compared to illiterate people. Likewise, bacterial infection was higher (30%) in the individuals involving their business followed by official workers (26.6%) (Table 3).
Table 3
Microbial growth pattern and literacy
Literacy
|
Number of sample
|
Bacterial growth (%)
|
Occupation
|
Number of sample
|
Bacterial growth (%)
|
Illiterate
|
85
|
26 (30.59)
|
Households
|
82
|
20 (24.39)
|
Primary
|
114
|
28 (24.56)
|
Farmer
|
36
|
10 (27.78)
|
Secondary
|
52
|
8 (15.38)
|
Business
|
50
|
15 (30)
|
Higher secondary
|
9
|
3 (33.33)
|
Driving
|
13
|
2 (15.38)
|
Bachelors
|
3
|
2 (66.67)
|
Social work
|
10
|
2 (20)
|
Total
|
263
|
67 (25.48)
|
Labor
|
9
|
2 (22.22)
|
|
|
|
Official work
|
38
|
10 (26.32)
|
|
|
|
Others
|
25
|
6 (24)
|
|
|
|
Total
|
263
|
67 (25.48)
|
Frequency of bacterial pathogens from LRT infections: Out of 67-gram negative bacterial isolates, K. pneumoniae was the most predominant bacteria followed by H. influenzae. Acinetobacter spp was the least isolated one (Figure 2).
Antibiotic susceptibility pattern: All isolated strains of K. pneumoniae and K. oxytoca were resistant to Amoxicillin whereas all of them were sensitive to Colistin and Polymyxin B. Of 12 isolates of E. coli, 10 (83.33%) were resistant to Amoxicillin and 9 (75%) were resistant to third-generation cephalosporins. Similarly, the highest number of E. aerogenes; 8/9 (88.89%) were resistant to Amoxicillin. All isolates of C. frundii were also resistant to Amoxicillin (Table 4).
Table 4
Antibiogram of bacterial isolates of Enterobacteriaceae family
Antibiotics used
|
Number of resistant pathogens (%)
|
K. pneumoniae (n=17)
|
K. oxytoca (n=4)
|
E. coli (n=12)
|
E. aerogenes (n=9)
|
C. frundii (n=6)
|
Amoxicillin
|
17 (100)
|
4 (100)
|
10 (83.33)
|
8 (88.89)
|
6 (100)
|
Cotrimoxazole
|
10 (58.82)
|
2 (50)
|
8 (66.67)
|
1 (11.11)
|
0
|
Ceftriaxone
|
9 (52.94)
|
2 (50)
|
9 (75)
|
1 (11.11)
|
0
|
Ciprofloxacin
|
4 (23.53)
|
1 (25)
|
7 (58.33)
|
1 (11.11)
|
0
|
Chloramphenicol
|
3 (17.65)
|
0
|
3 (25)
|
1 (11.11)
|
0
|
Gentamycin
|
2 (11.76)
|
0
|
1 (8.33)
|
1 (11.11)
|
0
|
Tetracycline
|
14 (82.35)
|
3 (75)
|
7 (58.33)
|
3 (33.33)
|
3 (50)
|
Ceftazidime
|
9 (52.94)
|
2 (50)
|
9 (75)
|
1 (11.11)
|
0
|
Amoxicillin-clavulanic acid
|
10 (58.82)
|
2 (50)
|
9 (75)
|
2 (22.22)
|
0
|
Piperacillin tazobactam
|
5 (29.41)
|
1 (25)
|
7 (58.33)
|
1 (11.11)
|
0
|
Cefepime
|
5 (29.41)
|
1 (25)
|
5 (41.67)
|
1 (11.11)
|
0
|
Imipenem
|
2 (11.76)
|
0
|
1 (8.33)
|
1 (11.11)
|
0
|
Polymyxin B
|
0
|
0
|
0
|
0
|
0
|
Colistin
|
0
|
0
|
0
|
0
|
0
|
All strains of P. aeruginosa were resistant to Amoxicillin, Cotrimoxazole, Ceftriaxone, Ceftazidime, Chloramphenicol, Tetracycline, Amoxicillin-clavulanic acid, Piperacillin-tazobactam and 3/4 (75%) of strains were resistant to Ofloxacin and Cefepime. However, all strains were sensitive to Gentamycin, Ciprofloxacin, Imipenem, Amikacin, Colistin. Likewise, all isolates of Acinetobacter spp were resistant to Amoxicillin, Cotrimoxazole, Ceftriaxone, Chloramphenicol, Tetracycline, Ceftazidime, Piperacillin and Amoxicillin-clavulanic acid and all were susceptible to Gentamycin, Imipenem, Polymyxin B and Colistin.
Multidrug-resistant (MDR) and extended-spectrum β-lactamase (ESBL) producing strains
Out of 53 bacterial isolates, 28 (52.83%) were found multidrug-resistant. All strains of P. aeruginosa and Acinetobacter spp were found MDR strains whereas no strain of C. frundii was observed to be MDR. Similarly, 75% (9/12) of E. coli, 64.71% (11/17) of K. pneumoniae and 50% (2/4) of K. oxytoca were also MDR strains.
A total of 23 (43.4%) isolates were found to be ESBL producers including 75% (9/12) E. coli and all isolates of P. aeruginosa and Acinetobacter spp.
Out of total MDR strains, 72.73% (8/11) of K. pneumoniae and 50% (1/2) of K. oxytoca were ESBL producers. One strain of P. aeruginosa was also found to produce MBL.
Detection of ESBL genes: Of 53 isolates, 23 (43.4%) possessed ESBL genes. Among them, 11 (47.83%) harbored the blaCTX-M gene (Figure 3) and 2 (8.69%) contained the blaTEM gene only (Figure 4). Similarly, 10 isolates (43.48%) possess both blaTEM and blaCTX-M genes in their plasmid DNA (Table 5).
Table 5
Detection of blaCTX−M and blaTEM ESBL genes among the isolates
Isolates
|
n
|
Phenotypic ESBL
|
Genotypic ESBL
|
Number of amplified genes
|
blaCTX−M (%)
|
blaTEM (%)
|
blaCTX−M + blaTEM (%)
|
K. pneumoniae
|
17
|
8 (47.06)
|
7 (41.18)
|
3 (42.86)
|
0
|
4 (57.14)
|
K. oxytoca
|
4
|
1 (25)
|
2 (50)
|
1 (50)
|
0
|
1 (50)
|
E. coli
|
12
|
9 (75)
|
9 (75)
|
3 (33.33)
|
2 (22.22)
|
4 (44.45)
|
P. aeruginosa
|
4
|
4 (100)
|
3 (75)
|
3 (100)
|
0
|
0
|
Acinetobacter spp
|
1
|
1 (100)
|
1 (100)
|
1 (100)
|
0
|
0
|
E. aerogenes
|
9
|
0
|
1 (11.11)
|
0
|
0
|
1 (100)
|
C. frundii
|
6
|
0
|
0
|
0
|
0
|
0
|
Total
|
53
|
23 (43.4)
|
23 (43.4)
|
11 (47.83)
|
2 (8.69)
|
10 (43.48)
|