Bacteria and Antimicrobial Resistance in Children at Damascus Hospital


 Background

Antimicrobial resistance is the third top-ranking global causative of death.
Aims

The aim is to evaluate antimicrobial resistance and sensitivity to aid the assessment of the efficacy in Syrian management protocols.
Methods

A retrospective study was conducted to analyze children with positive culture results presenting with nosocomial or community-acquired infections in Damascus Hospital, Damascus, Syria.
Results

117 patients with 183 positive culture results were included in the study. The most antibiotic-resistant bacterium was Pseudomonas aeruginosa. The highest bacterial antibiotic resistance occurred with Ceftriaxone, Pseudomonas aeruginosa (89%), Escherichia coli (77%), Enterobacter (74%), and Proteus (42%). Staphylococcus sensitivity towards vancomycin was only 3%. The mortality was 19(16%), nosocomial infection 11(55%) and community infections 9(45%).
Conclusion

The efficacy of the remaining antibiotics to which the bacteria are sensitive must be maintained through rationalization of its use. Strict precautionary measures must be implemented to ban the illegal dispensation of antibiotics.


Introduction
The third top-ranking worldwide cause of death is due to antibiotic resistance. Antibiotic resistance is highly related to both high mortality rates and high medical costs in the healthcare system. New predictions show there were 4.95 million deaths in 2019 due to bacterial antibiotic resistance. Projections revealed that death will soar to an estimated 10 million deaths by 2050 as a result of antibiotic resistance. [1] In Syria, self-diagnosing and self-medicating is a common ritual among Syrians, seeking advice from local pharmacists is customary to avoid doctor visit expenses with a prevalence of 57%. [2,3] Over-thecounter sales of antibiotics have been reported in various countries of the Middle East; the prevalence of antibiotic self-medication ranged between 19 and 82%. [4] A study carried out on pharmacists in the capital, Damascus, found that 87% of pharmacists sold antibiotics without prescription, 10% sold with prescription, and 3% refused to sell antibiotics without prescription; [5] despite the law issued by the Ministry of Health in 1988 that speci ed that antibiotics were not among the drugs that could be sold without a prescription. [6] This has resulted in the emergence of antimicrobial resistance in both nosocomial and community infections in Syria. Also, with the increased number of Syrian immigrants, this local problem evolved into a global issue as several studies conducted in Europe on Syrian immigrants have revealed many multidrug-resistant pathogens (MDR) bacteria. The presence of MDR gram-negative microbes was found in 60% of the immigrants who underwent the microbiological tests. [7,8] This study aims to provide an insight into the Syrian paediatric population at Damascus hospital during the current Syrian crisis and the Covid-19 pandemic. This study aims to describe the epidemiology, culture results, bacterial antibiotic resistance and sensitivity, and outcomes of children with positive culture results presenting with nosocomial or community-acquired infections. Evaluating antimicrobial resistance and sensitivity is an integral part of assessing e cacy in our management protocols.

Methods
A cross-sectional descriptive retrospective study was conducted at the Pediatric Division in Damascus Hospital (Al Mujtahid Hospital), Damascus, Syria, between 7/31/2020 and 7/31/2021. 117 patients with 183 positive culture results were included in the study. The inclusion criteria for evaluation were medical records of children admitted to the pediatric division ≤13 with positive culture results. Cases with positive culture results attending the pediatric accident and emergency department were excluded (70 cases). Of 123 records found, 6 patients were admitted with positive culture results on 2 separate occasions. Data extracted from medical records in the pediatric archive included: gender, age, diagnosis, outcome (recovery or death), culture result, type of infection acquired (community or nosocomial), and types of antibiotics administered before and after culture results. Culture reports included information on the type of sample (Urine, blood, sputum, cerebral spinal uid, cutaneous swabs, lower respiratory tract secretions, respiratory tract swabs, ascites uid, pleural uid, pus, swabs from central and venous catheters, swabs from urinary catheter, swabs from intubation tubes, and swabs from ICU ventilators), bacteria cultured, and bacteria's sensitivity and resistance towards antibiotics. When culture reports were missing from medical records in the pediatric archive, the culture report was found among the archives of the histopathology laboratory. Ethical approval was obtained from Damascus Hospital Institutional Review Board (IRB). Data frequencies, percentages, and means were calculated via SPSS (Statistical package for social sciences) 25.0 program for Windows.
The following 3 antibiotics were used as pretreatments: Ceftriaxone 67%, and was appropriate in 50% of the cases; Vancomycin 55%, and was appropriate in 56% of the cases; Azithromycin 22%, and was appropriate in 53% of the cases.

Discussion
This rst study describes the outcomes of children with positive culture results presenting with nosocomial or community-acquired infections.
The percentage of nosocomial infections in our study was 35%, which is very high compared with a Chinese study, 2.56% in 2019, and decreased to 1.39% in 2020. [9] A similar study in Iran reported the incidence of nosocomial infections as 3%. [10] Staphylococcus aureus was the most common in both nosocomial and community-acquired infections. Escherichia coli was the most common in a Chinese study. [11] Staphylococcus was the most cultured bacteria (75%) from cerebrospinal uid (CSF). This is likely to be high due to the presence of only 8 CSF-positive bacterial cultures. Staphylococcus was also the most common causative of meningitis in a study conducted in China, the number of few positive CST bacterial cultures re ects the effect of pretreatments with antibiotics before the CSF sample collection. [12] There is an extremely high bacterial resistance to most of the mentioned antibiotics, especially: ceftriaxone, cefepime, cefotaxime, trimethoprim, gentamycin, levo oxacin, piperacillin with tazobactam.
We acknowledge that there are some limitations to this study mainly with the retrospective aspect of data collection. Struggles with data collection included: disorganized medical records, subjective aspects, and illegible handwriting.

Conclusion
There is an extreme increase in bacterial resistance to most antibiotics. Pretreatment with antibiotics seems inappropriate before receiving the culture results due to the low bacterial sensitivity and high resistance. Also, unwanted side effects of antibiotic use, and incurring nancial expenses without any bene t. The e cacy of the remaining antibiotics to which the bacteria are sensitive must be maintained through rationalization of its use. Educational programs targeting doctors, pharmacists, and the community will aid rational use of antimicrobials; similar programs have been implemented in various countries. Positive culture results by age incidence