Introduction
Bacterial respiratory infections are most commonly causes of illness for all age group patients, which cured with invasive mechanical ventilation in ICU.1 It is systemic pathway via which body acquired fresh oxygen and remove carbon dioxide. The respiratory tract system are classified in the following parts upper and lower respiratory tracts. 2
Upper respiratory tract structure consist of nose, nasal passages, paranasal sinuses, the pharynx and the part of larynx above the vocal folds. The commonly occurring URTI are common cold, tonsillitis, pharyngitis, laryngitis, rhino sinusitis and otitis media. 3
Lower respiratory tract structure includes larynx, vocal folds, trachea, bronchi, bronchioles and alveoli. The most commonly occurring respiratory tract infection are tracheitis, bronchiolitis and pneumonia. It can have severe effects which may lead to hospitalization and loss of life. 4
In ICU’s nosocomial infection have been included as a severe problem among intubated patients leading to major mortality and morbidity. Most of the patients suffer from urosepsis, postoperative disease and lower respiratory infection when admitted in ICU’s. 5
Respiratory tract infection are generally caused by Acinetobacter baumannii, P. aeruginosa, K. pneumoniae, Citrobacter koseri, Enterobacter spp., Staph. aureus, Staph. epidermidis, E. coli, Proteus spp., Serratia , Burkholderia are the most common organisms isolated from BAL and endotracheal sample in the patients of ICU who were affected by lower respiratory infection. 6
Materials and Methods
The study was carried out in the department of microbiology, in TMU hospital Moradabad. Total numbers of 123 clinical samples were processed in which 68 pathogenic isolates were found. The samples were collected properly taken in clean, leak proof sterile container & tubes from various ICU’s in our hospital. All sample received in the microbiology lab, smears were examined after performing gram staining to see the character of exudates, number and type of organisms. Culture of ET secretion, BAL fluid & trans-tracheal aspirates was done on Blood agar plates and Mac-Conkey agar plates and incubated at 370C for overnight in the incubator. After 12 hours colonies appear (if growth) were processed for subsequent identification. Colonies have been identified on the basis of colony morphology and culture characteristics and After gram’s staining speciation and do biochemical’s & Antimicrobial Sensitivity pattern was by Kirby-Bauer disc diffusion method. 7, 8
Identification & antimicrobial sensitivity testing
The Kirby-Bauer disc diffusion method used in this research, according with the CLSI guidelines, using antibiotic discs, all isolates were tested for antimicrobial susceptibility in Muller Hinton agar. 9, 10
Screening and confirmation for MRSA, ESBL, MBL producers
CLSI has developed disk diffusion tests for the possible MRSA, ESBL, MBL production. CLSI has proposed disk screening for MRSA production by Staphylococcus aureus and for ESBL, MBL, production by E.coli, Klebsiella spp., Pseudomonas spp., Enterobacter spp., Citrobacter spp., Acinetobacter spp. 11, 10
Confirmatory test for MRSA All microorganisms were isolated and tested for methicillin resistance using a Cefoxitin disc (30mcg) and incubated overnight at 350C according to the CLSI guidelines. The zone of inhibition was studied under reflected light on a non-reflected backdrop on Petri plates. According to CLSI guidelines isolated organisms demonstration an inhibition of <14 mm were considered MRSA.9, 11, 12, 10
Confirmatory test for ESBL production all microorganisms were isolated and using a Cephalosporins/clavulanate combination Disk. The CLSI advocates the use of Ceftazidime (30mcg) disks with or without clavulanate (10mcg) for confirmation of the presence of ESBLs. A difference of >5 mm between the zone diameters of either of the Ceftazidime disks and their respective Ceftazidime/clavulanate disk is taken to be phenotypic confirmation of ESBL production, and were using to imipenum (10mcg) disk for testing MBL production.12, 10
Results
The samples were obtained from the patients admitted in ICU’s of our hospital. Out of 123 total suspected cases of BAL fluid and endotracheal aspirate were included in this study among in which 68 (55.3%) positive samples were found.
Table 1
Showing sex wise distribution, Out of 123 total samples size.
|
Gender |
Number |
Percentage |
|
Male |
79 |
64.2% |
|
Female |
44 |
35.8% |
|
Total |
123 |
100% |
Table 2
Showing isolated organisms out of 123 samples.
|
Organisms isolated |
Number |
Percentage |
|
Pathogenic isolates |
68 |
55.3% |
|
Non pathogenic isolates |
5 |
4.1% |
|
No growth |
50 |
40.6% |
|
Total |
123 |
100% |
Figure 1
Pie chart showing Isolation of pathogenic organism shows most prevalent organism Pseudomonas 23(33.82%), Acinetobacter 21(30.88%), Klebsiella 11(16.17%), E.coli 6(8.82%), Enterobacter 3(4.41%), Citrobacter 2(2.94%), Staphylococcus aureus 2(2.94%).
Table 3
Showing antibiotic sensitivity pattern of isolated organisms.
Discussion
The current study done in TMMC & RC, Moradabad, U.P. Respiratory tract disease are one of the major public health issues, affecting both children and adults; they appear to be more serious when located in the LRT. The most common infections seen in the community and among hospitalized patients remains pneumonia. Out of the 123 endotracheal and BAL fluid sample were collected after receiving written consent from the patient 64.22% (79) constitutes male population, the remaining 35.78% (44) being the female population.
In our study 55.28% (68/123) organisms were isolated in BAL and endotracheal aspirate samples. In which 67.6% (46) male and 32.4% (22) female patients. Older population falling in the 40-50 years of age group contributes the majority (27.64%) of the infection undergoing treatment for LRT infection in ICU patients in TMMC & RC, Moradabad. And in 70-80 years of age group (4.06%) was less contributes of this infection. A study conducted in Siriraj hospital from Thailland was highly comparable to our study. In this study done by Werarak P and Kiratisin P et al. 13 who reported 24.7% HAP and 75.3% VAP patients. In this study 70% constitute male population and 30% female population with the mean age of 70 years respectively. The study was also based on parameters of age and gender. It was found that in our study both in male were more affected due to various reasons.
Out of the total 68 positive samples was Analysis of our study Pseudomonas33.82% as the most common pathogen then Acinetobacter 30.88%, Klebsiella 16.17%, E.coli 8.82%, Enterobacter 4.41%, Citrobacter 2.94% and Staphylococcus aureus 2.94%. A resembling study was done by Khatun Mst and Shamsuzzaman S.M. et al. 5 percentage of Acinetobacter baumanni were 34.21%, Pseudomonas aeruginosa 15.79%, Klebsiella spp. 23.68%, Citrobacter spp. 2.63%, Enterobacter spp. 2.63%, Staphylococcus aureus 7.89%, Staphylococcus epidermidis 2.63%, Moraxella catarrhalis 5.26%, Proteus spp. 5.26%.
Our study also revealed about the antibiogram that in lower respiratory tract infection in ICU’s patients. The most resistant antibiotics in gram positive bacteria Ciprofloxacin, Erythromycin, Levofloxacin and more sensitive antibiotics were Vancomycin, Linezolid, Teicoplanin, and Gentamicin, and the gram negative bacteria most resistant antibiotics Ofloxacin, Cefepime, Cefoperazone, Ciprofloxacin, Ceftriaxone, Meropenem, Levofloxacin, Piperacillin/ tazobactum and more sensitive antibiotics Amikacin, Gentamicin, Colistin, Tigecycline A correlated with the study done by Shahrokhi E. et al. 14 having similar results alike Piperacillin/tazobactum was resistant antibiotic and Ceftazidime, Amikacin being the most sensitive antibiotics.
In this study we conclude that Gram-negative bacilli were the predominant of BAL fluid and endotracheal aspirates of ICU patients. Out of 68 multidrug resistance isolates, 1.47% were MRSA, 77.94% were ESBL and 55.88% were MBL isolates. Higher rate of ESBL production seen in Pseudomonas spp, and higher rate of MBL production in Acinetobacter spp. A correlated with the done by Santosh khanal et al. 15 having similar results alike 5.4% were MRSA, 41.1% were ESBL and 53.4% were MBL isolates. Higher rate of ESBL production was seen in Pseudomonas spp., and higher rate of MBL production in Acinetobacter Spp.
Conclusion
The goal of our study was bacteriological profile and their antibiogram from endotracheal aspirate and BAL fluid samples in our hospital. In our study LRTI are the most common causes of nosocomial pathogens and that are responsible for causing variety of human illness. The emergence of multi-drug resistant organisms is more common in the current age of antibiotic resistance.
In our study total 123 patients included in which pathogenic isolates were obtained in 55.3% of cases. Most common pathogenic organism found to be Pseudomonas, Acinetobacter, Klebsiella, E.coli and Enterobacter, Citrobacter, Staphylococcus aureus. Since bacterial isolation may vary in different geographical regions and even over time in the same location and population. In this study we found 40.6% were no growth and 4.1% were non pathogenic isolates (may be S. pneumoniae, Candida spp.) in ICU patients. Higher prevalence of LRTIs observed in the age group 41-50 years, as well as LRTIs still a major health threat in old age group.
In our study most common antibiotic sensitivity pattern for Gram positive cocci more sensitive were Gentamicin, Vancomycin, Teicoplanin, Linezolid and for Gram negative bacteria more sensitive were Amikacin, Gentamicine, Colistin, Tigecycline.
In this study we conclude that Gram-negative bacilli were predominant in BAL fluid and endotracheal aspirates of ICU patients. Out of 68 multidrug resistance isolates, 1.47% were MRSA, 41.17% were ESBL and 57.36% were MBL isolates. Higher rate of ESBL production was seen in Pseudomonas spp., and higher rate of MBL production in Acinetobacter spp. In the main purpose of this study is control in ICU infections, to determine the common bacterial isolates and their antibiotic sensitivity pattern for better treatment of patients.
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