Sociodemographic characteristics
A total of 406 LRTI suspected adult patients were enrolled in this study. Of them, 246(60.6 %) were male. The mean age of patients was 36.75 ±14.84. More than half of the participants live in urban 225(55.4%) [Table1].
Clinical characteristics
Among 406 study participants, twenty six (6.4%) of participants have previous tuberculosis disease exposures before two years and 34(8.4%) of participants have heart disease and 26(6.4%) were HIV positive [Table2].
Table 1 Sociodemographic characteristics of adult patients with lower respiratory tract infection at HUCSH, 2019
Variables
|
Frequency
|
Percent (%)
|
Sex
|
Male
Female
|
246
160
|
60.6
39.4
|
Age(year)
|
18-35
36-49
50-64
>65
|
235
93
51
27
|
57.9
22.9
12.6
6.7
|
Residence
|
Rural
Urban
|
181
225
|
44.6
55.4
|
Education status
|
No formal education
1-8 grade
9-12 grade
Diploma & above
|
142
141
70
53
|
35.0
34.7
17.2
13.1
|
Marital status
|
Single
Married
|
104
302
|
25.6
74.4
|
Occupation
|
Farmer
Government
Private
Housewife
Student
Jobless
|
89
43
93
112
52
17
|
21.9
10.6
22.9
27.6
12.8
4.2
|
Monthly income
(Ethiopian birr)
|
<1000
1000-2000
2001-3000
3001-5000
>5000
No monthly income
|
126
79
118
52
19
12
|
31.0
19.5
29.1
12.8
4.7
3.0
|
Table 2 Clinical characteristics of adult patients with lower respiratory tract infection at HUCSH, 2019
Variables
|
Frequency
|
Percent (%)
|
Cigarette smoking
|
Smoker
No smoker
|
33
373
|
8.1
91.9
|
Alcohol drinking
|
Yes
No
|
55
351
|
13.5
86.5
|
Crowded living condition
|
Yes
No
|
52
354
|
12.8
87.2
|
History of the previous TB
|
Yes
No
|
26
380
|
6.4
93.6
|
Heart disease
|
Yes
No
|
34
372
|
8.4
91.6
|
Previous HIV screening
|
Positive
Negative
Unscreened
|
26
167
213
|
6.4
42.1
52.5
|
Bacterial profile of LRTIs
The overall culture-positive sputum sample from a patient with LRTI in this study were 136/406(33.5%), 95% CI (28.8%-40%) with a total bacterial isolate of 142/406 (35.0%). Single bacterial pathogens were isolated from 130(32.0%) patients, while mixed infections were isolated from 6(1.4%) patients. Among mixed infection isolate, E. coli and S. aureus were isolated from 1(0.2%) patient, E. coli and Pseudomonas spp from 1(0.2%) patient and K. pneumoniae and E. coli from 4(1.0%) patients. The gram-negative bacteria 108(76.0%) predominated over gram-positive bacteria. In this study, K. pneumoniae 36(25.4%) was the frequently isolated bacteria followed by Pseudomonas spp 25(17.6%), E. coli 22(15.5%) and S. aureus 21(14.8%) [Table3].
Table 3 Frequency of bacterial isolates identified from sputum specimen of an adult patient with community acquired LRTI at HUCSH 2019
Isolates
|
Frequency
|
Percent (%)
|
K. pneumoniae
|
36
|
25.4
|
Pseudomonas spp
|
25
|
17.6
|
E. coli
|
22
|
15.5
|
S. aureus
|
21
|
14.8
|
Acinetobacter spp
|
19
|
13.4
|
S.pneumoniae
|
9
|
6.3
|
Enterobacter spp
|
4
|
2.8
|
Others*
|
6
|
4.2
|
* Citrobacter spp, S.pyogene and Enterococcus spp
The bacterial pathogens were more predominant in male 87(64.0%) than female as the study result shows. The age group 18-35 years was more susceptible to bacterial pathogens of LRTI 64(47.1%) than other age groups. Of 302 married study participants enrolled in this study, 112(82.4%) were positive for sputum culture. Among 43(10.6%) government workers participated in study 11(8.1%) were positive for bacterial pathogens of LRTI.
In bivariate analysis the variables; age range of 18-35 years (COR =3.886, 95% CI, 1.712-8.821, p=.001) and 36-49 years (COR=2.773, 95% CI, 1.151-6.677, p =.023); educational status who were 1-8 grade students (COR=.596, 95% CI, .296-1.199, P =.147), marital status those were married (COR=.509, 95% CI, .305-.850, P=.010), monthly income with 2001-3000 (COR=.336, 95% CI, .070-1.606, P=.172) and >5000 (COR=.222, 95%(.038-1.298, P=.095). In addition those who were non-cigarette smoker (COR= 1.984, 95% CI, .969-4.062, P=.061), non-alcohol drinker (COR=1.652, 95%CI, .927-2.945, P=.089), had no chronic heart disease (COR=1.638, 95% CI, .804-3.334, P=.174) and HIV result of negative (COR=.749, 95% CI, .486-1.154, P=.190), participants who were unscreened for HIV at all (COR=.420, 95 %CI, .184-.957, P=.039) were candidate variable for multivariate analysis with p-value < .250.
However, in multivariate analysis the age range 18-35 years (AOR=3.856, 95% CI, 1.584-9.387, P=.003), 36-49 years (AOR=3.136, 95% CI, 1.247-7.888, P=.015), marital status those who are married (AOR= .450, 95% CI, .207-.980, p= .044), occupation in government (AOR=6.303, 95% CI, 1.508-26.341, P=.012) and monthly income >5000 (AOR=.060, 95% CI, .007-.526, P=.011) were the only statically significant associated risk factors for LRTI [Table4].
Table 4 Associated factors of culture-positive sputum sample of a patient with community acquired LRTI at HUCSH, 2019 (n=406).
Variables
|
Growth
|
COR(95%CI)
|
p-value
|
AOR(95%CI)
|
P-value
|
Yes (%)
|
No (%)
|
Sex
|
Male
Female
|
87(64.0)
49(36.0)
|
159(58.9)
111(41.1)
|
.807(.527-1.235)
1
|
0.323
|
|
|
Age(year)
|
18-35
36-49
50-64
>65
|
64(47.1)
32(23.5)
24(17.6)
16(11.6)
|
171(63.3)
61(22.6)
27(10.0)
11(4.1)
|
3.886(1.712-8.821)
2.773(1.151-6.677)
1.636(.636-4.207)
1
|
0.001
0.023
0.307
|
3.856(1.584-9.387)
3.136(1.247-7.888)
1.717(.637-4.631)
|
0.003*
0.015*
0.285
|
Residence
|
Rural
Urban
|
62(45.6)
74(54.4)
|
119(44.1)
151(55.9)
|
1
.772(.703-1.609)
|
0.772
|
|
|
Educational status
|
No formal education
1-8 grade
9-12 grade
Diploma & above
|
48(35.3)
53(39.0)
21(15.4)
14(10.3)
|
94(34.8)
88(32.6)
49(18.1)
39(14.4)
|
.703(.348-1.419)
.596(.296-1.199)
.838(.378-1.857)
1
|
0.326
0.147
0.663
|
.613(.194-1.931)
.427(.146-1.248)
.556(.188-1.646)
|
0.403
0.120
0.289
|
Marital status
|
Single
Married
|
24(17.6)
112(82.4)
|
80(29.6)
190(70.4)
|
1
.509(.305-.850)
|
0.010
|
.450(.207-.980)
|
0.044*
|
Occupation
|
Farmer
Government
Private
Housewife
Student
Jobless
|
31(22.8)
11(8.1)
34(25.0)
41(30.1)
14(10.3)
5(3.7)
|
58(21.5)
32(11.9)
59(21.9)
71(26.3)
38(14.1)
12(4.4)
|
.689(.325-1.462
1.072(.428-2.687)
.639(.304-1.345)
.638(.309-1.315)
.884(.264-2.965)
1
|
0.332
0.882
0.239
0.223
0.842
|
2.661(.841-8.413)
6.303(1.508-26.341)
2.425(.882-6.668)
2.048(.656-6.392)
3.192(.709-14.365)
|
0.096
0.012*
0.086
0.217
0.131
|
Monthly income
|
<1000
1000-2000
2001-3000
3001-5000
>5000
No monthly income
|
38(27.9)
26(19.1)
44(32.4)
17(12.5)
9(6.6)
2(1.5)
|
88(32.6)
53(19.6)
74(27.4)
35(13.0)
10(3.7)
10(3.7)
|
.463(.097-2.215)
.408(.083-1.997)
.336(.070-1.606)
.412(.081-2.091)
.222(.038-1.298)
1
|
0.335
0.268
0.172
0.285
0.095
|
.461(.083-2.551)
.443(.076-2.578)
.310(.055-1.752)
.265(.043-1.61 )
.060(.007-.526)
|
0.375
0.365
0.185
0.150
0.011
|
Cigarette Smoking
|
Smoker
No smoker
|
16(11.8)
120(88.4)
|
17(6.3)
253(93.7)
|
1
1.984(.969-4.062)
|
0.061
|
2.274(.810-6.385)
|
0.119
|
Alcohol drinking
|
Yes
No
|
24(17.6)
112(82.4)
|
31(11.5)
239(88.5)
|
1
1.652(.927-2.945)
|
0.089
|
1.112(.468-2.642)
|
0.809
|
Crowded living condition
|
Yes
No
|
16(11.8)
120(88.2)
|
36(13.3)
234(86.7)
|
1
1.154(.615-2.164)
|
0.655
|
|
|
History of previous TB
|
Yes
No
|
9(6.6)
127(93.4)
|
17(6.3)
253(93.7)
|
1
1.055(.457-2.432)
|
0.901
|
|
|
Chronic heart disease
|
Yes
No
|
15(11.0)
121(89.0)
|
19(7.0)
251(93.0)
|
1
1.638(.804-3.334)
|
0.174
|
1.530(.688-3.401)
|
0.297
|
Previous HIV screening
|
Positive
Negative
Unscreened
|
13(9.6)
60(44.1)
63(46.3)
|
13(4.8)
107(39.6)
150(55.6)
|
1
.749(.486-1.154)
.420(.184-.957)
|
0.190
0.039
|
.524(.202-1.358)
1.301(.803-2.110)
|
0.183
0.285
|
CI=Confidence Interval, OR=Odds Ratio
Antimicrobial susceptibility patterns of bacterial isolates
Gram positive bacteria
In this study, Gram-positive were sensitive to clindamycin 26(76.5%) and erythromycin 18(55.9%) however, they showed resistant to tetracycline 20(58.8%). S. aureus was sensitive to cefoxitin 19(90.6%), gentamycin 16(76.2%) and ciprofloxacin 15(71.4%). S. aureus was resistant to tetracycline 13(61.9%) and cotrimoxazole 10(47.6%). S. pneumoniae were sensitive to clindamycin 8(88.9%), penicillin 7(77.8%), erythromycin 6(66.7%), but S. pneumoniae was resistant to tetracycline 6(66.7%). All S. pyogenes isolates were 3(100%) sensitive to tetracycline, ampicillin, clindamycin, erythromycin and penicillin [Table5].
Gram negative bacteria
Gram-negative bacteria were sensitive to cefepime 93(86.0%), ciprofloxacin 84(77.8%), ampicillin 13(20.3%), augmentin 18(28.1%) and ceftazidime 49(45.4%). K. pneumoniae was sensitive to ciprofloxacin 33(91.7%), cefepime 30(83.3%) and cefoxitin 30(83.3%) and K. pneumoniae was resistant
to augmentin 20(56.6%), ceftazidime 19(52.8%) and ampicillin 19(52.8%) . Pseudomonas spp was sensitive to cefepime 23(92.0%), ciprofloxacin 17(68.0%), gentamycin 17(68.0%), imipenem 16(64.0%) while Pseudomonas spp was resistant to ceftazidime 17(68.0%). E. coli were susceptible to cefoxitin 18(81.1%), cefepime 17(77.3%) and show resistant to ampicillin 19(86.4%). Acinetobacter spp was sensitive to cefepime 17(89.5%), ceftriaxone 16(84.2%), gentamycin 16 (84.2%) but resistant to cotrimoxazole 10(52.6%). All Enterobacter spp and Citrobacter spp were 100% sensitive to cefepime, tetracycline, ceftriaxone and ciprofloxacin antibiotics [Table6].
Multiple drug resistance (MDR) patterns of the isolates
In this study, the overall multidrug resistance (MDR) bacteria were 47/142(33.1%). E. coli was the most isolate that showed MDR 13(59.1%) followed by S. aureus 12(57.1%) and K. pneumoniae 12(33.3%). Majority of bacterial isolates were resistant to three classes of antibiotics 25(17.6%)[Table7].
Table 5 Antibiotic susceptibility patterns of gram-positive bacterial isolates from lower respiratory tract infection at HUCSH, 2019
|
|
Antibiotics (%)
|
Isolates
|
Pattern
|
CXT
|
TAT
|
AMP
|
CPR
|
COT
|
CLD
|
ERY
|
GN
|
PEN
|
CFP
|
CAF
|
S. aureus (N=21)
|
S
|
19(90.6)
|
3(14.3)
|
|
15(71.4)
|
9(42.9)
|
14(66.7)
|
10(47.6)
|
16(76.2)
|
9(45.0)
|
|
|
I
|
1(4.7)
|
5(23.8)
|
NR
|
1(4.8)
|
2(9.5)
|
0
|
0
|
3(14.3)
|
2(10.0)
|
NR
|
NR
|
R
|
1(4.7)
|
13(61.9)
|
|
5(23.8)
|
10(47.6)
|
7(33.3)
|
11(52.4)
|
2(9.5)
|
9(45.0)
|
|
|
S. pneumoniae (N=9)
|
S
|
|
2(22.2)
|
|
|
|
8(88.9)
|
6(66.7)
|
NR
|
7(77.8)
|
|
|
I
|
NR
|
1(11.1)
|
NR
|
NR
|
NR
|
0
|
2(22.2)
|
|
0
|
NR
|
NR
|
R
|
|
6(66.7)
|
|
|
|
1(11.1)
|
1(11.1)
|
|
2(22.2)
|
|
|
S. pyogene (N=3)
|
S
|
|
3(100)
|
3(100)
|
|
|
3(100)
|
3(100)
|
NR
|
3(100)
|
2(66.7)
|
|
I
|
NR
|
0
|
0
|
NR
|
NR
|
0
|
0
|
|
0
|
0
|
NR
|
R
|
|
0
|
0
|
|
|
0
|
0
|
|
0
|
1(33.3)
|
|
Enterococcus spp (N=1)
|
S
|
NR
|
0
|
NR
|
1(100)
|
0
|
1(100)
|
0
|
|
|
|
0
|
I
|
|
0
|
|
0
|
0
|
0
|
0
|
NR
|
NR
|
NR
|
0
|
R
|
|
1(100)
|
|
0
|
1(100)
|
0
|
1(100)
|
|
|
|
1(100)
|
Total (34)
|
S
|
19(90.6)
|
8(23.5)
|
3(100)
|
16(72.0)
|
9(40.0)
|
26(76.5)
|
19(55.9)
|
16(76.2)
|
19(57.6)
|
3(100)
|
0
|
I
|
1(4.7)
|
6(17.6)
|
0
|
1(4.5)
|
2(10.0)
|
0
|
1(2.9)
|
3(14.3)
|
2(6.0)
|
0
|
0
|
R
|
1(4.7)
|
20(58.8)
|
0
|
5(22.7)
|
11(50.0)
|
8(23.5)
|
14(41.2)
|
2(9.5)
|
11(33.3)
|
0
|
1(100)
|
NR-not recommended, CXT-cefoxitin, AMP-ampicillin, CEF-cefepime, TAT-tetracycline, CPR-ciprofloxacin, COT-cotrimoxazole- erythromycin, PEN-penicillin, CAF- chloramphenicol, CLD-clindamycin, GN-gentamycin, S- sensitivity, I-intermediate, R-resistance
Table 6 Antibiotic susceptibility pattern of gram-negative bacterial isolates of an adult patient with lower respiratory tract infection at HUCSH, 2019
Isolates
|
|
Antibiotics (%)
|
Pattern
|
CFP
|
CAZ
|
CXT
|
TAT
|
CTR
|
AMP
|
AUG
|
CPR
|
COT
|
GN
|
IMP
|
K. pneumoniae
(N=36)
|
S
|
30(83.3)
|
13(36.1)
|
30(83.3)
|
15(41.7)
|
24(66.7)
|
9(25.0)
|
12(33.3)
|
33(91.7)
|
19(52.8)
|
|
|
I
|
0
|
4(11.1)
|
0
|
4(11.1)
|
4(11.1)
|
8(22.2)
|
4(11.1)
|
0
|
1(2.8)
|
NA
|
NR
|
R
|
6(16.7)
|
19(52.8)
|
6(16.7)
|
17(47.2)
|
8(22.2)
|
19(52.8)
|
20(56.6)
|
3(8.3)
|
16(44.4)
|
|
|
Pseudomonas spp (N=25)
|
S
|
23(92.0)
|
6(24.0)
|
|
|
|
|
|
17(68.0)
|
|
17(68.0)
|
16(64.0)
|
I
|
0
|
2(8.0)
|
NR
|
NR
|
NR
|
NR
|
NR
|
0
|
NR
|
4(16.0)
|
2(8.0)
|
R
|
2(8.0)
|
17(68.0)
|
|
|
|
|
|
8(32.0)
|
|
4(16.0)
|
7(28.0)
|
E.coli (N=22)
|
S
|
17(77.3)
|
11(50.0)
|
18(81.1)
|
3(13.6)
|
14(63.6)
|
3(13.6)
|
5(22.7)
|
13(59.1)
|
10(40.9)
|
|
|
I
|
1(4.5)
|
2(9.1)
|
2(9.1)
|
5(22.7)
|
0
|
0
|
1(4.5)
|
0
|
1(45.5)
|
NA
|
NR
|
R
|
4(18.2)
|
9(40.9)
|
2(9.1)
|
14(63.6)
|
8(36.4)
|
19(86.4)
|
16(72.7)
|
9(40.9)
|
11(4.5)
|
|
|
Acinetobacter
(N=19)
|
S
|
17(89.5)
|
13(68.4)
|
|
|
16(84.2)
|
|
|
15(78.9)
|
6(31.6)
|
16(84.2)
|
12(63.2)
|
I
|
0
|
1(5.3)
|
NR
|
NR
|
2(10.5)
|
NR
|
NR
|
1(5.3)
|
3(15.8)
|
2(10.5)
|
2(10.5)
|
R
|
2(10.5)
|
5(26.3)
|
|
|
1(5.3)
|
|
|
3(15.3)
|
10(52.6)
|
1(5.3)
|
5(26.3)
|
Enterobacter spp (N=4)
|
S
|
4(100.0)
|
4(100)
|
3(75.0)
|
4(100)
|
4(100)
|
1(25)
|
1(25)
|
4(100)
|
2(50)
|
|
|
I
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
NA
|
NR
|
R
|
0
|
0
|
1(25.0)
|
0
|
0
|
3(75)
|
3(75)
|
0
|
2(50)
|
|
|
Citrobacter spp (N=2)
|
S
|
2(100.0)
|
0
|
1(50.0)
|
2(100.0)
|
2(100.0)
|
0
|
0
|
2(100.0)
|
1(50)
|
|
|
I
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
NA
|
NR
|
R
|
0
|
2(100.0)
|
1(50.0)
|
0
|
0
|
2(100.0
|
2(100.0)
|
0
|
1(50)
|
|
|
Total
(N=108)
|
S
|
93(86.0)
|
49(45.4)
|
52(81.3)
|
23(35.9)
|
60(72.3)
|
13(20.3)
|
18(28.1)
|
84(77.8)
|
38(45.8)
|
33(75.0)
|
28(63.6)
|
I
|
1(0.9)
|
9(8.3)
|
2(3.1)
|
10(15.6)
|
6(7.2)
|
8(12.5)
|
5(7.8)
|
1(0.9)
|
5(6.0)
|
6(13.6)
|
4(9.1)
|
R
|
14(13.0)
|
50(46.3)
|
9(15.6)
|
31(48.4)
|
17(20.5)
|
43(67.2)
|
41(64.0)
|
23(21.3)
|
40(48.2)
|
5(11.4)
|
12(27.3)
|
NA-not applied, NR-not recommended, AUG-augmentin, CAZ- ceftazidime, CXT-cefoxitin, AMP- ampicillin, CEF-cefepime, TAT-tetracycline, CTR-ceftriaxone, CPR- ciprofloxacin, GN- gentamycin, IMP- imipenem, S- sensitivity, I- intermediate, R- resistance
Table 7 multi-drug resistant rates of bacterial isolates among adult patient with lower respiratory tract infection at HUCSH, 2019
Isolate
|
R0(%)
|
R1(%)
|
R2(%)
|
R3(%)
|
R4(%)
|
R5(%)
|
≥R6(%)
|
Total (%)
|
K. pneumoniae (N=36)
|
3(8.3)
|
7(19.4)
|
13(36.1)
|
7(19.4)
|
3(8.3)
|
2(5.6)
|
0
|
12(33.3)
|
S. aureus (N=21)
|
3(14)
|
2(9.5)
|
4(19.0)
|
6(28.6)
|
3(14.3)
|
2(9.5)
|
1(4.7)
|
12(57.1)
|
E. coli (N=22)
|
3(13.6)
|
3(13.6)
|
4(18.2)
|
3(13.6)
|
3(16.6)
|
0
|
6(27.3)
|
12(54.5)
|
Pseudomonas spp (N=25)
|
4(16.0)
|
7(28.0)
|
10(40.0)
|
4(16.0)
|
0
|
0
|
0
|
4(16.0)
|
Acinetobacter spp (N=19)
|
6(31.6)
|
5(26.3)
|
6(31.6)
|
2(10.5)
|
0
|
0
|
0
|
2(10.5)
|
S. pneumoniae (N=9)
|
2(22.2)
|
5(55.5)
|
1(11.1)
|
1(11.1)
|
0
|
0
|
|
1(11.1)
|
Enterobacter spp (N=4)
|
0
|
1(25.0)
|
2(50.0)
|
1(25.0)
|
0
|
0
|
0
|
1(25.0)
|
S. pyogene (N=3)
|
3(100)
|
0
|
0
|
0
|
0
|
0
|
|
0
|
Citrobacter spp(N=2)
|
0
|
0
|
1(50.0)
|
1(50.0)
|
0
|
0
|
0
|
1(50.0)
|
Enterococcus spp (N=1)
|
0
|
0
|
0
|
0
|
1(100)
|
0
|
0
|
1(100)
|
Total (N=142)
|
24(17.0)
|
30(21.1)
|
41(28.9)
|
25(17.6)
|
10(7.0)
|
4(2.8)
|
7(4.9)
|
46/142(32.4)
|
Key: R0- no antibiotic resistance, R1- resistance to one, R2-resistance to two, R3-resistance to three, R4-resistance to four, R5-resistance to five, and ≥R6- resistance to six and more than six antibiotics families.