The article presents assessment of antibiotic resistance of gram-negative bacteria causing nosocomial pneumonia in stroke patients at 103 Military hospital.
Journal of military pharmaco-medicine no2-2018 STUDY OF GRAM-NEGATIVE BACTERIA RESISTANCE TO ANTIBIOTICS CAUSING NOSOCOMIAL PNEUMONIA IN PATIENTS WITH STROKE AT MILITARY HOSPITAL 103 Dang Phuc Duc*; Nguyen Minh Hien* Mai Xuan Khan*; Nguyen Thai Son* SUMMARY Objectives: To evaluate the antibiotic resistance of Gram-negative bacteria causing pneumonia in stroke patients Methods: Descriptive study Results: P aeruginosa resistance > 80% was observed in most antibiotics (14/20 patients), 100% was resistant to imipenem, norfloxacin; sensitivity to polymycin (100%) K pneumoniae strains 100% with 8/20 antibiotics, including ciprofloxacin, cefpirome, cefuroxime K pneumoniae strains were sensitivity 100% to doxycylins and carbapenem antibiotics A baumannii strains resist 100% to antibiotics, including piperacillin + tazobactam; 50% of A baumannii strains resist to the carbapenem group * Keywords: Nosocomial pneumonia; Antibiotic resistance; Stroke INTRODUCTION Stroke patients have many potential risk factors for nosocomial pneumonia such as: poor mobility due to paralysis, swallowing disorders, immuno-depression, mechanical ventilation Most causes of pneumonia are Gram-negative bacteria Antibiotic resistance of bacteria, especially Gram-negative bacteria is increasing and causing difficulties in treatment We conducted this study aiming at: Assessment of antibiotic resistance of Gram-negative bacteria causing nosocomial pneumonia in stroke patients at 103 Military Hospital SUBJECTS AND METHODS Subjects 215 patients were diagnosed with stroke at Department of Stroke, 103 Military Hospital, divided into two groups: pneumonia and non-pneumonia * Inclusion criteria: - American Thoracic Society's 2005 nosocomial pneumonia diagnostic criteria: - Pneumonia appears after hospitalization > 48 hours - The presence of a new or progressive radiographic infiltrate plus at least two of three clinical features - Fever greater than 38oC - Leukocytosis or leukopenia - Purulent secretions - For patients who not meet new pulmonary radiographic criteria, clinical signs and sputum cultures are pathogenic, we also classify pneumonia * 103 Military Hospital Corresponding author: Dang Phuc Duc (dangphucduc103@gmail.com) Date received: 08/12/2017 Date accepted: 18/01/2018 128 Journal of military pharmaco-medicine no2-2018 * Exclusion criteria: - Patients died or discharged within 48 hours after hospitalization - Pneumonia within 48 hours after admission - Tuberculosis, lung tumors Method Descriptive research with analysis Statistical processing using SPSS 15.0 software RESULTS AND DISCUSSION We studied 215 stroke patients who were divided into two groups: pneumonia group (n = 29); non pneumonia group (n = 186), we obtained the following results: Patients’ characteristics Table 1: Stroke characteristics Stroke type Pneumonia (n = 186) Non pneumonia (n = 29) Total (n = 215) n % n % n % Ischemia 125 67.2% 11 37.9% 136 63.3% Hemorrhage 61 32.8% 18 62.1% 79 36.7% Total 186 29 p < 0.05 215 Out of 215 stroke patients, 136 patients (63.3%) suffered from ischemia and 79 patients had hemorrhage (36.7%) 29 patients (13.5%) caught pneumonia According to the research by Phan Nhut Tri, the proportion of stroke patients accquired pneumonia was 19.1% [9] The bacteria that cause nosocomial pneumonia in stroke patients Table 2: Types of bacteria in pneumonia group Bacteria Do not grow bacteria Gram negative Gram positive Pseudomonas aeruginosa n = 29 % 17.2 24.1 Klebsiella pneumoniae 13.8 Acinetobacter baumannii 6.9 Klebsiella oxytoca 3.4 Klebsiella ozaenae 3.4 Staphylococcus aureus 10.3 Streptococcus.d 3.4 Streptococcus viridans 17.2 Of 29 patients with nosocomial pneumonia, patients had sputum culture without bacterial growth (17.2%) Of the 24 samples cultured with bacteria, 15 samples had Gram-negative bacteria (62.5%), only 37.5% had Gram-positive bacteria 129 Journal of military pharmaco-medicine no2-2018 According to data from the Vietnamese Ministry of Health, the leading cause of hospital-acquired pneumonia is Gram-negative bacteria [1] In our study, the most common bacterial cause of nosocomial pneumonia was S aeruginosa (24.1%) The results were consistent with those by Huynh Thi Ngoc Chi et al (2012) [2]; Doan Ngoc Duy et al [3]: P aeruginosa accounted for the highest rate (16.7%) Antibiotic resistance characteristics of some Gram-negative bacteria cause nosocomial pneumonia in stroke patients Table 3: Antibiotic resistant characteristics of Pseudomonas aeruginosa Sensitive Antibiotics Resistant Intermediate Total n % n % n % Gatifloxacin 0.0% 100% 0.0% Gentamycin 0.0% 100% 0.0% Imipenem 0.0% 100% 0.0% Netilmycin 0.0% 100% 0.0% Norfloxacin 0.0% 100% 0.0% Ofloxacin 0.0% 100% 0.0% Ticar/clavulanic 0.0% 100% 0.0% Ticarcillin 0.0% 100% 0.0% Tobramycin 0.0% 100% 0.0% Trime/sulfamethoxazole 0.0% 100% 0.0% Cefepime 14.3% 85.7% 0.0% Levofloxacin 0.0% 83.3% 16.7% Meropenem 16.7% 83.3% 0.0% Ceftazindin 20.0% 80.0% 0.0% Ciprofloxacine 33.3% 66.7% 0.0% Aztreonam 0.0% 50.0% 50.0% Piperacillin 25.0% 25.0% 50.0% Pipe/tazobactam 83.3% 16.7% 0.0% Amikacine 50.0% 0.0% 50.0% Polymycin 100% 0.0% 0.0% 15 19.0% 57 72.2% 8.9% 79 Total P aeruginosa was resistant to > 80% with most antibiotics (14/20), 100% was resistant to imipenem, norfloxacin P aeruginosa was sensitive to polymycin (100%), piperacillin/tazobactam (83.3%) and amikacine (50%) 130 Journal of military pharmaco-medicine no2-2018 Multidrug resistant P aeruginosa is common in both domestic and international studies [1, 3, 8, 12] The carbapenem resistance leads to a return to colistin, an antibiotics of the polymicin family Many domestic and international studies have shown that P aeruginosa are highly susceptible to colistin: Tran Thi Thanh Nga (2010), Labarca et al (2016) [11], Yayan (Germany, 2015) Table 4: Characteristics of Klebsiella pneumoniae antibiotic resistant Antibiotics Sensitive Resistant Intermediate Total n % n % n % Cefepime 0.0% 100% 0.0% Cefpirome 0.0% 100% 0.0% Cefurocime 0.0% 100% 0.0% Ciprofloxacine 0.0% 100% 0.0% Chloramphenicol 0.0% 100% 0.0% Fosfomycin 0.0% 100% 0.0% Tobramycin 0.0% 100% 0.0% Amo + clavulanic acid 0.0% 75.0% 25.0% Ceftriaxone 25.0% 75.0% 0.0% Gatifloxacin 25.0% 75.0% 0.0% Levofloxacin 33.3% 66.7% 0.0% Cefotaxim 50.0% 50.0% 0.0% Ceftazindin 25.0% 50.0% 25.0% Ofloxacin 50.0% 50.0% 0.0% Amikacine 66.7% 33.3% 0.0% Aztreonam 33.3% 33.3% 33.3% Doxyxylin 100% 0.0% 0.0% Ertapenem 100% 0.0% 0.0% Imipenem 100% 0.0% 0.0% Meropenem 100% 0.0% 0.0% Total 17 35.4% 28 58.3% 6.3% 48 In our study, K pneumoniae was 100% resistant to 8/28 antibiotics, including ciprofloxacin, cefpirome, cefuroxime The bacterial had sensitivity 100% to doxycylin and carbapenem antibiotics The antibiotic resistance of K pneumoniae in our study was higher than in previous studies Le Thi Kim Nhung (Thong Nhat Hospital, 2008 - 2010) [7]: K pneumoniae was resistant to empiric antibiotics, including third generation cephalosporins, with levels of resistance ranging from 18 - 38% Ngo The Hoang (2012) studied the resistance of 131 Journal of military pharmaco-medicine no2-2018 K pneumoniae in nosocomial pneumonia indicating that P pneumoniae was resistant to most quinolones generation I - II and third generation cephalosporine 54.8 - 64.3%; sensitivity to carbapenem antibiotics (imipenem sensitivity 90.5%; meropenem sensitivity 97.6%) [5] Many studies also show that K pneumoniae is relatively sensitive to carbapenem antibiotics [5, 7, 8] Table 5: Antibiotic resistant characteristics of Acinetobacter baumannii Antibiotics Sensitive Resistant Intermediate Total n % n % n % Aztreonam 0.0% 100% 0.0% Doxyxylin 0.0% 100% 0.0% Gentamycin 0.0% 100% 0.0% Pipe/tazobactam 0.0% 100% 0.0% Ticarcillin 0.0% 100% 0.0% Cefepime 50.0% 50.0% 0.0% Ceftazindin 50.0% 50.0% 0.0% Ciprofloxacine 50.0% 50.0% 0.0% Imipenem 50.0% 50.0% 0.0% Levofloxacin 50.0% 50.0% 0.0% Amikacine 100% 0.0% 0.0% Cefotaxim 0.0% 0.0% 100% Ceftriaxone 0.0% 0.0% 100% Meropenem 50.0% 0.0% 50.0% Piperacillin 0.0% 0.0% 100% Rifampin 0.0% 0.0% 100% Tobramycin 100% 0.0% 0.0% Trime/sulfamethoxazole 100% 0.0% 0.0% 10 40.0% 10 40.0% 20.0% 25 Total A baumannii was resistant 100% to antibiotics, including piperacillin/tazobactam For carbapenem antibiotics, A baumannii was resistant 50% The rapid emergence of multidrug-resistant A baumannii strains is becoming a challenge for treatment Multidrug-resistant status of this bacterium has been reported in several studies [4, 12] A baumannii was resistant to the carbapenem group, which is one of the widest spectrum of antibiotics currently available [4, 6, 8] Not only in Vietnam, there are many international reports about A baumannii resistance to carbapenem [10, 11] 132 Journal of military pharmaco-medicine no2-2018 CONCLUSION In our study on 215 patients with stroke at Department of Stroke, 103 Military Hospital, we drew some conclusions: - The incidence pneumonia was 13.5% of nosocomial - Of 24 bacterial strains, 62.5% of Gram-negative bacteria were cultured - P aeruginosa was resistant to > 80% with most antibiotics (14/20), resistance 100% to imipenem, norfloxacin P aeruginosa was sensitive to polymycin (100%); piperacillin/ tazobactam (83.3%) and amikacine (50%) - K pneumoniae was resistant 100% to 8/21 antibiotics, including ciprofloxacin, cefpirome, cefuroxime K pneumonia sensitivity 100% to doxycylins and carbapenem antibiotics A baumannii was resistant 100% to antibiotics, including piperacillin + tazobactam For carbapenem antibiotics, A baumannii was resistant to 50% REFERENCES Bộ Y tế Hướng dẫn phòng ngừa viêm phổi Bệnh viện sở khám bệnh, chữa bệnh Ban hành kèm Quyết định số 3671/QĐ-BYT Bộ Y tế Huỳnh Thị Ngọc Chi, Bùi Thị Hằng Tỷ lệ viêm phổi bệnh viện bệnh nhân đột quỵ não bệnh nhân có di chứng đột quỵ não Y học TP HCM 2012, 16 (phụ số 1) tr.276-279 Đoàn Ngọc Duy, Trần Văn Ngọc Đặc điểm viêm phổi bệnh viện pseudomonas aeruginosa Bệnh viện Chợ Rẫy từ - 2009 đến - 1010 Y học TP HCM 2012, 16 (phụ số 1, tr.87-90 Trần Minh Anh Đào, Nguyễn Thanh Bảo Khảo sát tác nhân tính đề kháng kháng sinh trực khuẩn Gram âm không lên men đường Bệnh viện Đại học Y dược TP HCM Y học TP HCM 2015, 19 (1), tr.473-479 Ngơ Thế Hồng, Quế Lan Hương, Nguyễn Bá Lương Tính kháng thuốc klebsiella pneumoniae viêm phổi bệnh viện Bệnh viện Thống Nhất Y học TP HCM 2012, 16 (phụ số 1), tr.264-270 Nguyễn Phú Hương Lan, Nguyễn Văn Vĩnh Châu, Đinh Hữu Huy Mẫn CS Khảo sát mức độ đề kháng kháng sinh Acinetobacter Pseudomonas phân lập Bệnh viện Nhiệt đới năm 2010 Thời Y học 2012, 68, tr.9-12 Lê Thị Kim Nhung Gia tăng kháng kháng sinh vi khuẩn Gram âm gây bệnh Bệnh viện Thống Nhất năm 2008 2010 Y học TP HCM 2011, 15 (phụ số 2), tr.42-49 Lê Thị Kim Nhung, Vũ Thị Kim Cương Tính kháng kháng sinh vi khuẩn gây bệnh đường hô hấp Bệnh viện Thống Nhất Y học TP HCM 2012, 16 (phụ số 2), tr.89-93 Phan Nhựt Trí, Nguyễn Thị Thu Hương Nghiên cứu rối loạn nuốt theo GUSS bệnh nhân đột quỵ não cấp Bệnh viện Cà Mau năm 2010 - 2011 Nghiên cứu Y học 2011, (tháng 6) (74) tr.167-170 10 Chaari A, Mnif B, Bahloul M et al Acinetobacter baumannii ventilator-associated pneumonia: Eidemiology, clinical characteristics and prognosis factors International Journal of Infectious Diseases 2013, 17 (12), pp.e1225e1228 11 Labarca J.A, Salles M.J.C, Seas C et al Carbapenem resistance in Pseudomonas aeruginosa and Acinetobacter baumannii in the nosocomial setting in Latin America Critical reviews in microbiology 2016, 42 (2), pp.276-292 12 World Health Organization Guidelines for the prevention and control of carbapenemresistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities pp.1-76 133 ... patients with stroke at Department of Stroke, 103 Military Hospital, we drew some conclusions: - The incidence pneumonia was 13.5% of nosocomial - Of 24 bacterial strains, 62.5% of Gram-negative. .. Nhut Tri, the proportion of stroke patients accquired pneumonia was 19.1% [9] The bacteria that cause nosocomial pneumonia in stroke patients Table 2: Types of bacteria in pneumonia group Bacteria... generation cephalosporins, with levels of resistance ranging from 18 - 38% Ngo The Hoang (2012) studied the resistance of 131 Journal of military pharmaco-medicine no2-2018 K pneumoniae in nosocomial