Etiologic diagnosis and antimicrobial resistance pattern of nosocomial infection in Pediatric Intensive Care Unit of a Tertiary Hospital, Tigray, Ethiopia

doi:10.21203/rs.3.rs-2986361/v1

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Etiologic diagnosis and antimicrobial resistance pattern of nosocomial infection in Pediatric Intensive Care Unit of a Tertiary Hospital, Tigray, Ethiopia

https://doi.org/10.21203/rs.3.rs-2986361/v1

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Background

Antimicrobial resistance in the pediatric population is emerging and becoming a global threat. Data from the WHO found that infections caused by multidrug-resistant bacteria were found to have a higher death rate across all ages. This study assesses nosocomial infection's etiologic cause and antimicrobial resistance pattern in the Pediatric Intensive Care Unit (PICU).

Result

Forty-five (20.2%) patients admitted to pediatric ICU acquired nosocomial infection (NI). The median age of the patients was one year (IQR 0.5–5.5), with an M: F ratio of 1:1.4. Etiology diagnosis was confirmed in 21 (42.9%) patients. Gram-negative bacteria were the major contributor to NI. Klebsiella pneumonia was the most common isolate, accounting for 34.6%, followed by Acinetobacter (19.2%), Staphylococcus species (11.5%), and Escherichia coli (11.5%). Third-generation cephalosporins (Ceftriaxone, cefotaxime, and ceftazidime) had a 100% resistance against all organisms tested. About 96% of the pathogens had a multidrug-resistant pattern. Methicillin-resistant (MRSA) staphylococcus aureus was also identified in one patient.

Conclusion

Antimicrobial resistance

Nosocomial infection

Pediatric Intensive Care Unit

Nosocomial infection is a significant public health problem that increases morbidity and mortality, hospitalization length, and healthcare-related costs. (1). The prevalence of Hospital-acquired infection (HAI) in pediatric intensive care units (PICU) is substantially higher in developing countries than in industrialized countries. According to the World Health Organization (WHO) recent data, the incidence of HAI in ICU is 2–3 times greater in low and middle-income countries than in high-income countries (2). Antimicrobial resistance, especially multidrug-resistant pathogens, is among the most critical global and public threats.

WHO estimates that multidrug-resistant bacteria result in 700,000 deaths across all ages (3).

A study conducted in the US found that organisms responsible for PICU nosocomial infections were 40.2% Gram-negative, 57.0% Gram-positive, and 2.8% Candida spp. Staphylococcus aureus and coagulase-negative staphylococci (CoNS) were the first and third most common organisms across all age groups, respectively. (4). Recent data from southern Ethiopia shows a predominant Gram-positive organism, Staphylococcus aureus (32.2%), coagulase-negative Staphylococci (25%), and Klebsiella pneumoniae (14.3%). The isolated bacteria showed high resistance to amoxicillin, ceftriaxone, streptomycin, and Ampicillin. Multidrug resistance (MDR) was observed in 82.1% of the isolates (5).

An Egyptian study from two pediatric ICU hospitals revealed gram-negative bacteria as the most commonly identified etiology of HAI, with significant microorganisms identified being Staphylococcus aureus, Acinetobacter, and Klebsiella. According to cultural sensitivity, Amikacin and Imipenem were the most sensitive antibiotics, whatever the type of organism (6). Another study which was done in 2015 in Pediatrics Unit in Rwanda showed the main bacteria causing HAI were Klebsiella pneumoniae, followed by E. coli and Staphylococcus aureus, with the percentage of (51.66%), (20%), and (18.33%) respectively. (7). It is assumed that infections caused by MDR bacteria will have a worse prognosis because of the delay in administering appropriate therapy (8).

In most patients with suspected NI, Empirical treatment is started to reduce the associated mortality and morbidity due to the delay in blood culture. Due to a lack of knowledge regarding the cause of infection and the pattern of antibiotic resistance, the international guidelines on antibiotic use that are currently in place are only suitable for some regions and need to take into account the local susceptibility patterns of developing countries. Changing antimicrobial resistance rates, pathogen distribution, demographics, and medical care delivery may all affect the epidemiology of nosocomial infection. Therefore, updated trends in the microbiology of HAI pathogens and antibiotic susceptibility are required to support therapeutic guidelines for appropriate therapies and potential strategies to overcome challenges. Furthermore, a study of the pathogens' relative frequency and microbiological traits in HAI patients in our intensive care units (ICU) still needs to be done. It is imperative to catalog antimicrobial stewardship and stop the abuse of antibiotics in all fields. Therefore, this study aims to evaluate Microbial distribution and Antibiotic Susceptibility patterns, including multidrug resistance in the Pediatric Intensive Care unit.

A two-year retrospective follow-up study was conducted in the pediatric intensive care unit of Ayder tertiary Hospital. Six hundred thirty patients were admitted to the PICU during the study period, and 223 were selected after calculating the sample size. A total of 49 samples were taken from the patients with hospital-acquired infection (HAI). In order to evaluate equal patients in each month of the study period, every third chart was recruited by excluding incomplete charts and those who stayed less than 48 hours in the pediatric intensive care unit.

Investigated parameters were the age, gender, residence, source of admission, underlying disease, Nutritional status, culture, antimicrobial sensitivity, resistant pattern, and organisms, including multidrug resistance (MDR) pattern.

Antimicrobial resistance to at least one antibiotic drug in three or more antimicrobial classes (extended-spectrum penicillins, cephalosporins, fluoroquinolones, carbapenems, and aminoglycosides) was considered a multidrug-resistant pathogen (9).

Under the aseptic technique, body fluids (i.e., blood, urine, pus, and CSF) were collected and transported to the microbiology unit. Semi-quantitative culture technique was used for urine samples. After a loop full of well-mixed and centrifuged urine was inoculated onto Blood agar (BA) and MacConkey agar (MA), they were aerobically incubated at 37°C for 24 h. Regarding blood samples, they were initially enriched on Brain Heart infusion broth for 48h and subsequently cultured on both MA and BA every 24h for three days. Next to the isolation of pathogens with colony characteristics, gram staining was performed to categorize isolates as gram-positive and gram-negative. Catalase, oxidase, coagulase, and optochin sensitivity tests were carried out to further identify Gram positives. Gram-negatives were also further identified using catalase, oxidase, motility, H2S, indole production, citrate utilization, triple sugar iron utilization, urea hydrolysis, and other biochemical tests.

The antimicrobial susceptibility of all isolates was determined using the Kirby-Bauer disk diffusion method according to Clinical Laboratory Standard Institute (CLSI) (9). For gram-positive bacteria, the following discs were included: Penicillin G, Ampicillin, Erythromycin, Vancomycin, Ciprofloxacin, Chloramphenicol, Ceftriaxone, Sulphamethaxazole/trimethoprim, Meropenem, and Tetracycline. For gram negatives, Ampicillin, Amoxicillin /Clavulanic acid, Ciprofloxacin, Gentamycin, Sulphamethaxazole/trimethoprim, Chloramphenicol, Ceftazidime, Meropenem, Cephalosporin, Amikacin, Piperacillin, and Tobramycin were used. After measuring and interpreting the zone of inhibition using a standard chart, the bacteria were labeled as susceptible (S), intermediate (I), or resistant (R).

Ethical clearance was obtained from the institution's ethical committee with a reference number of [1853/21].

Data were coded, cleaned, and entered into EPI Info version 3.5.1 and analyzed by SPSS version 24. Descriptive analysis was used for frequency distribution; percentage, ratios, and the measure of dispersion were used to describe findings.

Socio-demographic profile

The median age of the patients was one year (IQR 0.5–5.5), with an M: F ratio of 1:1.4. Emergency department was the leading source of admitted patients in PICU (53.3%, 24/45), followed by pediatric ward transfer (40%, 18/45). Infectious patients accounted for (22.2%, 10/45) of admitted PICU cases, followed by neurology and GI (20%, 9/45 each). Severe and moderate acute malnutrition were reported in (26.9%, 12/45) and (22%, 10/45), respectively. Over half (60%, 27/45) of HAI patients had an associated comorbid illness (Table 1).

A total of 45patients (20.2%, 45/223) were diagnosed with hospital-acquired infection (HAI). Culture was taken in 95.6% (42/45) of patients, of which17 (40.5%) of them had a culture-proven infection. Forty-nine samples were analyzed from different body sites, of which the majority (83.7%, 41/49) were from blood, followed by urine (8.2%, 4/49) and pus (4.1%, 2/49), respectively (Fig. 1). Of 49 specimens subjected to microbiological tests, 21 (42.9%) showed growth to different bacteria. Most patients with HAI were bloodstream infections (71.4%), while Urinary tract infections accounted for 6.1%.

Microbiology and drug-susceptibility results

A total of 26 bacteria were isolated from 21 specimen subjected to culture. Gram-negative bacteria were the dominant organisms identified in this study. Klebsiella pneumoniae was the most common isolated organism accounting for 34.6% (9/26), followed by Acinetobacter (19.2%, 5/26), Escherichia coli, and Staphylococcus aureus, accounting for 11.5% (3/26) each (Fig. 2). Three strains produced extended-spectrum-beta lactamase (ESBL) from the cultured etiologies: one of 2 isolates of Enterobacter, one of 3 isolates of E.coli, and one of 9 isolates of Klebsiella pneumoniae.

Regarding antimicrobial susceptibility patterns, third-generation cephalosporins (Ceftriaxone, cefotaxime, and ceftazidime) revealed 100% resistance against all pathogens tested. Other resistant antibiotics identified were Ampicillin (96.2%), Doxycyclin/tetracyclin (94.7%), Amoxicillin/ Clavulanic acid (90.5%), and Cotrimoxazole (85.7%). Both gram-positive and gram-negative isolated organisms revealed multiple drug resistance to a commonly used antibiotic. Still, they had good susceptibility to antibiotics such as Amikacin, Nitrofurantoin, meropenem, Vancomycin, cloxacillin, and Ciprofloxacin (Fig. 3).

Sensitivity and resistance of specific antibiotics to different bacterial etiologies found that almost all isolates found multidrug resistant except Streptococcus spp. Methicillin resistance Staphylococcus Aureus (MRSA) were identified in (33.3%, 1/3) of patients.

Klebsiella pneumoniae was the leading bacterial cause of nosocomial infection and was resistant to most antibiotics except Amikacin, ciprofloxacin, and meropenem (Fig. 4).

Nosocomial infection is a significant public health matter, particularly in low-income countries like Ethiopia, due to increased hospital stays, morbidity, mortality, and healthcare expenditures (10). Antimicrobial resistance is one of the utmost concerns in global health nowadays. The World Health Organization (WHO) stated in its most recent report from September 2017 that the world is running out of antibiotics (11).

The present study is the initial report concerning NI rates in pediatric ICUs in the region. Despite the differences between studies regarding causative organisms, Gram-Negatives showed the commonest pathogens identified in this study, consistent with other studies done in Tunisian PICU and Egypt (8, 12).

An incidence of 1.34% HAI was observed in a three-year retrospective study of pediatric ICU. Pneumonia accounted for 58% of NI, followed by urinary tract infection (31%). All hospital-acquired pneumonia (HAP) cases were associated with endotracheal intubation, and almost all UTI cases had urinary catheters. Among patients with HAI, a wide variety of organisms were found, of which 16 (61.5%) were Gram-negative, and 10 (38.5%) were Gram-positive (13).

The yield of microbiological growth in this study was 42.9% samples. Klebsiella pneumoniae and Acinetobacter were the dominant organisms found. This finding was parallel to the study done in the adult intensive care unit of the same hospital (14). Cross-contamination of the same microorganisms between the ICUs could be the potential explanation.

In contrast, a study conducted in five PICUs in Lithuania analyzed 157 samples and found a growth of 134(85.4%) samples. H.influenzae (20.1%) and S.aureus (17.6%) were the commonest organisms identified. There were also two cases of MRSA (15). This may be explained by the difference in the number of ICUs, sample site, and empiric initiation of antibiotics. Another study done PICU of a large teaching hospital in Mumbai, India, from a total of 298 samples, showed a growth of 120 (40.26%) samples, similar to our finding. Another study done by el-nawawy et al. and his colleagues revealed that gram-negative bacteria were more prevalent in PICU, especially Klebsiella pneumoniae (30.5%), Acinetobacter baumanii (22.22%), and Pseudomonas aeruginosa (16.67%). Almost all PICU-acquired episodes were caused by MDR bacteria (35/36 episodes), which coheres with our findings which showed that nearly all bacterial isolates demonstrated a multidrug resistance pattern (16).

Deep A and associates from India conducted a study regarding the Clinical and Microbiological Profile of Nosocomial Infections in the Pediatric Intensive Care Unit (PICU); The most common causes of NI in their study were Klebsiella pneumoniae (33.3%) followed by E.coli (16.7%) (17). These findings cohere with our result, which was 34.6% for Klebsiella pneumoniae and 11.3% for E.coli. In their study, Klebsiella pneumoniae and E. coli were most sensitive to Amikacin and maintained nearly 25% sensitivity to cephalosporins (ceftriaxone and cefotaxime) but 100% resistant to ciprofloxacin (17). Though the sensitivity of these microorganisms to Amikacin is similar to our study, the other sensitivity tests have quite the opposite results. In our study, cephalosporins (ceftriaxone, cefotaxime, and ceftazidime) had 100% resistance to every bacteria tested. Ciprofloxacin resistance was observed in more than half (57.1%) of the isolates. Another retrospective study assessing organisms causing HIA and antibiotic susceptibility in pediatric ICU showed a prevalence of (25.5%). Coagulase-negative staph (CONS) was the dominant organism 20/39 (51.2%), followed by Klebsiella pneumoniae 6/39 (15.3%) and Pseudomonas 4/39 (10.2%). CONS were sensitive to Oxacillin, vancomycin, Linezolid, ciprofloxacin, and gentamicin. Klebsiella were sensitive to Imipenem, Amikacin, Gentamicin, Norfloxacin, Oxacillin, Vancomycin, Linezolid, Ciprofloxacin, and Cotrimoxazole. On the other hand, CONS were resistant to cotrimoxazole, erythromycin, cefixime, cefoxitin, and clindamycin (18).

The variations in results may be attributed to the available antibiotics and the rationality of prescription. These results are alarming and show a high resistance rate to most of our routine antimicrobials. The significant clinical effects of the drug-resistant present may be attributed to the empiric utilization of broad-spectrum antibiotics during hospital admissions and subsequent modifications. It is possible to recognize the disparities in the effectiveness of antibiotics in distinct areas, and it is essential to illustrate how regional protocols cannot be employed in areas where the sensitivity test is unknown. The knowledge of common organisms and their antibiotic susceptibility is critical to initiating the most appropriate antimicrobial therapy, thus restricting empiric broad-spectrum antibiotics, which predispose to colonization.

Strength and Limitation

Though the culture yield was low, we have complete data about the etiologic description and the drug sensitivity tests based on availability. The fact that our study was retrospectively made it challenging to examine other lab-related investigations to correlate the clinical profile and outcome of the patients. Sample sites and culture Media are limited, which may underestimate the positivity rate of culture.

The findings of the study revealed that nearly all bacterial isolates demonstrated a multidrug resistance pattern, which is associated with increased morbidity and mortality, despite the delay in administering appropriate therapy. Gram-negative bacteria were the predominant organisms identified. A strategy to decline nosocomial infection and the spread of antimicrobial resistance is crucially essential in critically ill patients admitted to ICU. Therefore, priority should be given to implementing an effective infection control team, and a comprehensive Guideline is in need, including infection control measures.

CDC -Center for Disease Control

WHO-World Health Organization

HAI- Hospital Acquired Infection

NI-Nosocomial Infection

PICU-Pediatric Intensive Care Unit

SSPS-Statistical Package for Social Science

Ethics statement

Ethical clearance was obtained from the Institutional Review Board (IRB) of the College of Health Sciences of Mekelle University with IRB number of 1853/21. Permission from Ayder Comprehensive Specialized Hospital clinical director offices, support letter from chief clinical director was obtained before the commencement of the study.

Informed Consent

Consent was taken from the care givers after they were told about the objective and purpose of the study. They were also told about their right to refuse to participate in the study at any time.

Moreover, it confirms that this study compiles all the requirements of the latest 2013 version of the Declaration of Helsinki.

Consent for publication

Competing interests

No conflict of interest in all the authors.

Acknowledgements

Funding

No funding

Availability of data and material

The original contributions presented in the study are comprised in the article, further inquiries can be contacted to the corresponding author.

Authors’ contribution

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Saleem Z, Hassali MA, Godman B, Hashmi FK, Saleem F. A multicenter point prevalence survey of healthcare-associated infections in Pakistan: Findings and implications. Am J Infect Control. 2019;47:421–4.
Iwuafor A, Ogunsola T, Oladele RO. Incidence, clinical outcome and risk factors of intensive care unit infections in the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. PLoS ONE. 2016;11(10):e0165242. 10.1371/journal.pone.0165242.
Duan N, Sun L, et al. Microbial Distribution and Antibiotic Susceptibility of Bloodstream Infections in Different Intensive Care Units. Front. Microbiol; 2021.
Sader HS et al. / Frequency and antimicrobial susceptibility of bacteria causing bloodstream infections in pediatric patients (2020) https://doi.org/10.1016/j.diagmicrobio.2020.115108.
Ameya et al. Antimicrobial Susceptibility Pattern and Associated Factors of Pediatric Septicemia in Southern Ethiopia, Infect Drug Resist 2020:133895–3905.
Gomaa HE, Helmy NA, El-Sahrigy SAF, Shouman MG, Ibrahim HM, Abdel Rahman AMO, Habib SA, Khattab AA. Prevalence and Anti-Microbial Susceptibility of Hospital Acquired Infections in Two Pediatric Intensive Care Units in Egypt.
Rwanda. Journal of Medicine and Health Sciences, 2019:2 (3).
Folgori L, Bernaschi P, et al. Healthcare-Associated Infections in Pediatric and Neonatal Intensive Care Units: Impact of Underlying Risk Factors and Antimicrobial Resistance on 30-Day Case-Fatality in Italy and Brazil. Infect Control Hosp Epidemiol. 2016;37(11):1302–9.
Mohamed AH, Mohamud HA, Arslan E. Epidemiological characteristics and predisposing factors for surgical site infections caused by bacterial pathogens exhibiting multidrug-resistant patterns. Antibiotics. 2021 May 24;10(6):622.
Saleem Z, Hassali MA, Godman B, Hashmi FK, Saleem F. A multicenter point prevalence survey of healthcare-associated infections in Pakistan: Findings and implications. Am J Infect Control. 2019;47:421–4.
World Health Organization. 2017. Antimicrobial Resistance— Global Report on Surveillance. Available at (accessed December 2017).
Ben, Jaballah et al. Epidemiology of hospital-acquired blood stream infection in a Tunisian pediatric intensive care unit: America journal of infectious control online.
Akinkugbe O, Cooke FJ. Healthcare-associated bacterial infections in the paediatric ICU. JAC-Antimicrobial Resist. 2020;2(3):dlaa066.
Dawit et al. Nosocomial sepsis and drug susceptibility pattern among patients admitted to adult intensive care unit of Ayder Comprehensive Specialized Hospital, Northern Ethiopia: BMC Infect Dis (2021) 21:824.
Ašembergienė J, Gurskis V. Nosocomial infections in the pediatric intensive care units in Lithuania. Med (Kaunas). 2009;45(1):29–36.
el-nawawy et al. Incidence of Multidrug-Resistant Organism among Children Admitted to Pediatric Intensive Care Unit in a Developing Country: DOI: 10.1089/mdr.2017.0414.
Deep A, Ghildiyal R, et al. Clinical and Microbiological Profile of Nosocomial Infections in the Pediatric Intensive Care Unit (PICU). Indian Pediatr. 2004;42:1238–46.
Sharad Agarkhedkar S, Chavan, Aditya Shelke. Study of organisms causing healthcare associated infection in paediatric intensive care unit and their antibiotic susceptibility. MedPulse Int J Pediatr November. 2019;12(2):46–52. http://medpulse.in/Pediatrics/index.php.

Tables 1 is available in the Supplementary Files section.

No competing interests reported.

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Etiologic diagnosis and antimicrobial resistance pattern of nosocomial infection in Pediatric Intensive Care Unit of a Tertiary Hospital, Tigray, Ethiopia

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Abstract

Background

Result

Conclusion

Figures

Introduction

Methodology

Results

Socio-demographic profile

Microbiology and drug-susceptibility results

Discussion

Strength and Limitation

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

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