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ISSN 1027-0299Recognised and registered with thePakistan Medical
& Dental CouncilNO.PF.11-F-96 (Infectious Diseases) 2560College
of Physicians & Surgeons, PakistanIndexed - WHO EMRO
69
73
68
October - December 2019 Volume 28 Issue 04
INFECTIOUSDISEASESJOURNALPublished by the Medical Microbiology
& Infectious Diseases Society of Pakistan
of Pakistan
IDJ
Oct - Dec 2019. 67Volume 28 Issue 04Volume 28 Issue 04
CONTENTS PAGE #
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Infectious Diseases Journal of PakistanOfficial Organ of the
Medical Microbiology & Infectious Diseases Society of
Pakistan
President Bushra JamilInternal Medicine, Infectious DiseasesAga
Khan University Hospital,Karachi. Pakistan
Gen. Secretary Summiya NizamuddinSection of MicrobiologyShaukat
Khanum Memorial Cancer Hsopitaland Research Centre, Lahore,
Pakistan.
Treasurer Sunil DodaniDepartment of Infectious Diseases,Sindh
Institute of Urology & TransplantationKarachi, Pakistan
Editorial Office
Editor: Ali Faisal Saleem
Associate Editors: Iffat KhanumKiran HabibMuhammad Idris
MazharSunil DodaniNosheen Nasir
Editorial Board: Aamer Ikram Naseem SalahuddinAltaf Ahmed Ejaz
A. KhanShehla Baqi Luqman SettiM. Asim Beg Naila Baig Ansari
Rana Muzaffar
78
Manager MMIDSP: Luqman Mahmood85
87
EDITORIAL
Role of Digital Health for Ceftriaxone-Resistant
SalmonellaOutbreak Investigation and Control in Sindh Province,
PakistanAbdul Momin Kazi
ORIGINAL ARTICLES
Does Abnormal Serum Glucose Level Compromise the Outcomein
Neonatal Sepsis?Muhammad Usman Khalid, Farah Haroon, Sikandar
Hayat, Rafia Gul,Khawaja Ahmad Irfan Waheed, Javaria Younus
Socioeconomic Status of Father and Vaccination Status of
Children:A Community Based Household SurveyNaureen Omar, Shamaila
Hassnain, Umbreen Navied, Iram Manzoor
Emergence of Multidrug Resistant Gram-negative Pathogens inan
Intensive Care Unit of a Tertiary Care HospitalZehra NM, Hanif F,
Khursheed U, Jaffer SR, Yousuf S, Nadeem S
CASE REPORT
Extremely Drug Resistant Pseudomonas in Qazi Hussain
AhmedMedical Complex, Nowshera, Pakistan.Hamzullah Khan, Fazli
Bari
INSTRUCTIONS FOR AUTHORS
Courtesy : Ali Faisal Saleem, Assistant professor, Paediatric
InfectiousDiseases, Aga Khan University, Karachi, Pakistan
A 13-year-old girl with fever, weight loss, poor intake
andlethargies. Family of Pulmonary tuberculosis s present
Upper lung infiltrates are identified in anterior segment of
leftupper lobe showing calcifications. Left apical infiltrates
alsonoted. A tiny calcified granuloma is identified involving
theposterior segment of the left lower lobe. No evidence of
pleuraleffusion or pneumothorax identified bilaterally.
Centraltracheobronchial tree appears unremarkable. Left upper
lobeinfiltrates with calcifications. Findings could
representgranulomatous infection likely tuberculosis.
a b c
-
68 . Infectious Diseases Journal of Pakistan
GUEST EDITORIAL
Role of Digital Health for Ceftriaxone-Resistant Salmonella
Outbreak Investigation and Control inSindh Province, Pakistan
In Nov 2016 the Clinical laboratory of Aga Khan
UniversityHospital started reporting cases admitted at Aga Khan
Maternal& Child Center Hyderabad with ceftriaxone resistant S.
Typhi.This was the largest outbreak of ceftriaxone-resistant S
Typhireported in Hyderabad, Pakistan. Given the urgency of
theoutbreak and to understand attributable factors for the mode
oftransmission it was decided to initiate an outbreak
investigationwith epidemiological and technological support.
With the leapfrog in mobile phone use, there has been a
drasticincrease in access and acceptability of technology in
bothdeveloped as well as developing countries. There is a
greatpotential for digital health interventions to improve
servicequality, provide information and decision support to
healthprofessionals and improve visualization of data and
therebyhaving a positive public health impact even in
resourceconstrained settings.
As part of an outbreak investigation an age-matched case-control
(1:4) study was conducted from 1st December 2016 to15th September
2017. Further it was decided to use technologyat two fronts to
support this study.1 To collect the participant’sinformation
through eQuestionnaire and geotagging theirlocation.2 To conduct
geospatial analysis in order to map outcases and understand mode of
transmission. An open streetview map of Hyderabad was integrated in
the Esri ArcGIS,version 10·5 to identify famous points and
localities inHyderabad, using geospatial mapping technique. A
paper-basedmap of Hyderabad sewerage line network was also
acquiredfrom Hyderabad water board which was scanned
andgeoreferenced in the ArcGIS software. In addition,
co-ordinatesof the households for both cases and controls and
importantrelevant landmarks including water supply were
incorporated. Color coding of serum positive and negative cases, as
well aswater positive cases, were also conducted.
The geospatial analysis revealed a clustering of the cases
aroundsewage lines both in Qasimabad and Latifabad areas
inHyderabad indicating mixing of sewage water with municipalwater
supply. Electronic mapping and microbiological analysisof community
water supply samples from the drinking sourcealso indicated E-Coli
contamination supporting our hypothesisof broken sewerage lines and
mixing of sewerage water withthe drinking water; this was confirmed
by molecular detectionof S. Typhi DNA by PCR. Data collected
through mobilephone/tablet supported in generating geospatial maps
andincorporation of information with Google maps and paper-based
maps. This helped in identifying the specific distributionof the
outbreak and in prediction of water born origin of bacteriathat was
causing infection.
Simultaneously spread of cases in Karachi from Hyderabadwere
also identified and an algorithm was developed to
extractgeographical location of the XDR typhi cases from AKU
centrallaboratory data base according to towns in Karachi. This
aidedin identifying clustering of XDR cases in Karachi and
pointingout high burden areas. The geospatial data of Karachi
alsoreinforced the evidence of spread to other cities of
Sindhprovince. Our technique highlights the importance of
usingdigital technology in a resource-constrained settings to
improveroutine immunization coverage among Pakistani children
andworldwide. One major limitation of the strategy used was thatthe
culture positive cases were only from Aga Khan UniversityHospital
main and satellite labs.
In conclusion this was a unique digital health strategy which
wasused for an outbreak investigation, following John Snow
mappingtechnique for the Cholera epidemic but including latest
informationand technology techniques. This study facilitated in
formingCDC recommendations to travel to Pakistan and
recommendationfor inclusion of TCV vaccine in the Expanded Program
ofImmunization (EPI). This data aided in guiding the policy
makersin understanding the reason of XDR spread through water
born,direction of spread and identifying high burden areas for
TCVvaccination campaigns and catch up doses. Future
strategiesshould include adding culture positive XDR cases
locationinformation from other major laboratories in Pakistan in
the database and generating prediction models for spread of
ceftriaxone-resistant Salmonella in Pakistan using geospatial,
genomic,environmental and sero-prevalence data.
AcknowledgementDr. Farah Qamar and Tahir Yousufzai.
References1. Qamar FN, Yousafzai MT, Khalid M, Kazi AM,
Lohana
H, Karim S, Khan A, Hotwani A, Qureshi S, Kabir F, AzizF, Memon
NM, Domki MH, Hasan R. Outbreak investigation
ofceftriaxone-resistant Salmonella enterica serotype Typhi and its
riskfactors among the general population in Hyderabad, Pakistan: a
matchedcase-control study. Lancet Infect Dis. 2018
Dec;18(12):1368-1376.
2. Yousafzai MT, Qamar FN, Shakoor S, Saleem K, LohanaH, Karim
S, Hotwani A, Qureshi S, Masood N, Rauf M,Khanzada JA, Kazi M,
Hasan R. Ceftr iaxone-resistantSalmonella Typhi Outbreak in
Hyderabad City of Sindh,Pakistan: High Time for the Introduction of
Typhoid Conjugate Vaccine.Clin Infect Dis. 2019 Feb 15;68
(Suppl1):S16-S21.
Dr. Abdul Momin KaziAssistant Professor,Department of
PaediatricsThe Aga Khan University, Karachi, PakistanEmail:
[email protected]
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Oct - Dec 2019. 69Volume 28 Issue 04
ORIGINAL ARTICLE
contributes 47% to U5MR.1 Its rate is 19 per 1,000 live
birthsworldwide whereas in Pakistan it is 42 per 1,000 live
births.2
Neonatal sepsis is a significant cause of morbidity and
mortalityand contributes up to 13% - 15% of deaths in developed,
30%- 50% deaths in developing countries and 28% neonatal deathsin
Pakistan.3-5
Neonatal sepsis is defined as the clinical syndrome with
presenceof both infection and systemic inflammatory response.6
Clinicalvariables suggestive of sepsis are lethargy, feed
intolerance,apnea, prolonged capillary refill time and hypotension
alongwith variability in temperature, heart rate and respiratory
rate.Laboratory parameters suggestive of sepsis include
leukocytosis,leukopenia, raised C-reactive protein, Immature: Total
neutrophilratio, thrombocytopenia, raised plasma lactate,
raisedprocalcitonin, increase in IL-6 or IL-8, 16S PCR
positive.7
Whereas, blood culture is the gold standard for its
diagnosis.8
Sepsis has variable impact on neonatal glucose level leadingto
hypoglycemia (blood sugar level 125 mg/dl).9,10 Septic neonates
experiencehypoglycemia because of reluctance to feed, increased
metabolicdemand, hypothermia and defective gluconeogenesis.
Differentstudies have shown its variable association with brain
injury,epilepsy and neurocognitive outcome in later
childhood.11,12
Whereas, hyperglycemia is due to increased production of
stresshormone like glucagon, growth hormone,
catecholamines,glucocorticoids and an increase in
proinflammatorycytokines.12,16 Complications associated with
neonatalhyperglycemia are intra-ventricular hemorrhage, late
onsetinfections and necrotizing enterocolitis.13
Incidence of altered blood glucose in septic neonates varies
indifferent studies showing 7.63% to 13.5% of septic
neonatesexperiencing hypoglycemia.14,15 While, 23.8%16 to 50%13
ofseptic neonates observed to have hyperglycemia. Reportedmortality
in hypoglycemic septic neonates is 42.8%, whereasit is 11.8% to
32.4 % in septic neonates with hyperglycemia.15,18,19
There is paucity of local data regarding impact of serum
glucoselevels on outcome of septic babies. The current study
wasdesigned with an aim to fill in this gap. The information
obtainedwill help in identifying those septic babies that
requirepreferential attention and channelizing resources and
willultimately lead to improvement in their morbidity and
mortality.
Abstract
BackgroundIn Pakistan, neonatal mortality rate is 42 per 1,000
live birthsand sepsis contributes up to 28% neonatal deaths.2,3,5
Sepsishas variable impact on neonatal glucose level. This study
wasconducted to determine if abnormal glucose levels compromisethe
outcome in neonatal sepsis.
MethodsThis study was conducted in the Neonatology Department
ofThe Children’s Hospital, Lahore from September 2017 toFebruary
2018. Two hundred and twenty septic neonates withpositive blood
culture were included in this descriptive crosssectional study.
Blood glucose estimation was done using bloodglucose strips, later
confirmed with spectrophotometer technique.Statistical analysis was
performed using SPSS v19.
ResultsAmong 220 blood culture proven septic neonates, there
were128 (58.2%) males and 92 (41.8%) females. There were 71(32.27%)
low birth weight babies and 36 (16.4%) large forgestational age
babies. Blood sugar level monitoring showedthat hypoglycemia and
hyperglycemia was noted in 35(15.9%)and 52(23.63%) neonates,
respectively, while 133 (60.5%) hadnormal glucose level. Among all
neonates, 145 (65.9%) survivedwhile 75 (34.1%) expired. Among total
75 expiries,hypoglycemia, euglycemia and hyperglycemia were
documentedin 12(16%), 39 (52%) and 24 (32%) babies,
respectively.Hyperglycemic neonates had significantly increased
mortality(p=0.036) and prolonged hospital stay (p=0.02).
ConclusionAbnormal serum glucose level compromises the outcome
inneonatal sepsis. Hyperglycemia leads to significant increase
inmortality in neonatal sepsis and prolonged hospital stay.
Key wordsabnormal serum glucose, neonatal sepsis, neonatal
mortality.
IntroductionNeonatal mortality is a major health issue globally
and
Corresponding Author: Muhammad Usman Khalid,Senior Registrar
Neonatology,The Children’s Hospital & the Institute of Child
Health,Lahore,Pakistan.Email: [email protected]
Muhammad Usman Khalid, Farah Haroon, Sikandar Hayat, Rafia Gul,
Khawaja Ahmad Irfan Waheed, Javaria Younus
The Children’s Hospital & the Institute of Child Health,
Lahore, Pakistan.
Does Abnormal Serum Glucose Level Compromise the Outcome in
Neonatal Sepsis?
-
70 . Infectious Diseases Journal of Pakistan
Material & MethodsThis descriptive cross sectional study was
conducted fromSeptember 2017 to February 2018 in the Neonatology
Unit ofThe Children’s Hospital & the Institute of Child Health,
Lahore.It was initiated after obtaining permission from the
InstitutionalReview Board of the hospital. Informed written consent
wasobtained from parents or guardians. Sample size was
calculatedwith 80% power of test and 5 % level of significance by
usingformula:
n=Z^2(p) (1-p)/d^2
Blood glucose estimation of every neonates with probablesepsis
was performed at the time of admission by glucose teststrips
(hexokinase method) later confirmed withspectrophotometer
technique. Neonates with blood cultureproven sepsis were included
in study and neonates with surgicalproblems, malformations,
syndromes, infant of diabetic motherand those who received
intravenous glucose within 6 hoursbefore or after admission before
checking of glucose level wereexcluded. Incomplete data and left
against medical advice(LAMA) before completion of data were also
excluded.
Each septic neonate was managed as per standard
institutionalguidelines. On the basis of blood sugar, babies were
classifiedinto groups as hypoglycemia (blood sugar level 125
mg/dl).9,10 Information including demographic data,outcome and
duration of hospital stay were recorded on dataform. Duration of
stay more than 14days was labeled asprolonged hospital stay.
Statistical analysis was performed using Statistical Package
forSocial Sciences (SPSS) 19. The studied variables were
describedby numbers and percentages. Chi-square test was applied
tostudy differences in the various categories and group. P-value3.5
12(33.33%) 19(52.77%) 05(13.88%) 36(16.36%)
Total 35(15.90%) 133(60.45%) 52(23.63%) 220 (100%)
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Volume 28 Issue 04 Oct - Dec 2019. 71
euglycemic neonates, 39(29.3%) died while 94(70.7%) survivedwith
(p value =0.06). Among 52 hyperglycemic neonates,24(46.1%) died
while 28(53.9%) survived (p-value = 0.036)(figure 1).
Among 35 hypoglycemic neonates, 14(40%) had prolongedhospital
stay ( p=0.31) and in euglycemic neonates, 59(44.36%)
had prolonged hospital stay (p=0.21). Among 52
hyperglycemicneonates, 32(61.5%) had prolonged hospital stay
(p=0.023)(figure 2).
DiscussionNeonatal sepsis is one of the major contributing
factors amongthe numerous risk factors for neonatal morbidity and
mortality.
Fig 1. Outcome of septic neonates in relation to blood glucose
level
Fig 2. Length Hospital stay
Abnormal glucose metabolism in neonatal sepsis may worsenthe
outcome in neonates. This descriptive cross sectional studywas
carried out with an objective to find the effect of bloodglucose
level on outcome in confirmed neonatal sepsis.
In our study, males were 1.4 times more as compared to
femaleneonates. Similar demographic patterns were observed in
studies
carried out in various NICUs.13,16 Low birth weight is
animportant risk factor for neonatal sepsis.20 Septic low
birthweight babies are more prone to have altered blood
glucoselevel because of intricate multifaceted mechanism
involvingaltered endogenous glucose production, insulin
response,catecholamine and their antagonists along with reduced
oralintake and hypothermia.13 Sultan11 has shown in study that15.3%
septic low birth weight neonates have hypoglycemia.Similarly in our
study, 19.71 % septic low birth weight neonateswere hypoglycemic.
On the other hand, fifty percent of theseptic low birth weight
babies experienced hyperglycemia.Whereas, reported incidences of
hyperglycemia in VLBWbabies vary a lot between 20 and 80% due to
different cut offvalues used to define hyperglycemia in different
studies.21
In a study conducted by Swain15 7.63% of all septic neonateshad
hypoglycemia while in a study from Bangladesh,14
documented prevalence of hypoglycemia was 13.5% in
neonatalsepsis. Studies by Sabzehei et al16, Islam17 and Gul13
reportedthat 29%, 23.8%, and 50% of all septic neonates
hadhyperglycemia, respectively. In our study 15% septic
neonates
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72 . Infectious Diseases Journal of Pakistan
were hypoglycemic, 23.6% hyperglycemic and 61.4%euglycemic. The
difference in results is because of differencein study design,
including birth weight and different levels tobe considered as
hyperglycemia or hypoglycemia.
Reported mortality in hypoglycemic neonates with probablesepsis
is 32%, by Ahmed and Khalid.11 The results arecomparable to our
study as 34.3% hypoglycemic septic neonatesdied. This similarity
could be due to similarity in studypopulation. In a study from
Thailand and Sudan, 32.4% and11.8% of septic neonates with
hyperglycemia died.18,19 However,reported mortality was quite high
(46.1%) in our septichyperglycemic neonates. This difference can be
due to differentcomorbidities with hyperglycemia leading to high
mortality.
Prolonged hospital stay was observed in hyperglycemic
neonateswhich is attributed to complications related to high
bloodglucose level requiring interventions including
intraventricularhemorrhage and necrotizing enterocolitis.. Sabzehei
et al22
found that hyperglycemic neonates had prolonged hospital stayas
compared to non-hyperglycemic neonates. This is comparableto our
study where prolonged hospital stay was statisticallysignificant in
hyperglycemic septic neonates.
For the babies with confirmed neonatal sepsis, there must bea
meticulous monitoring of glucose level as they are at risk
ofdeveloping hyperglycemia which, if managed early may leadto
better outcome otherwise lead to an adverse outcome andprolonged
hospital stay. Further, research work needed by thetorch bearers in
neonatology field to make a consensus statementregarding the target
blood glucose levels in neonatal sepsis toimprove the outcome.
ConclusionAbnormal serum glucose level compromises the outcome
inneonatal sepsis. Hyperglycemia leads to significant increase
inmortality in neonatal sepsis and prolonged hospital stay.
References1. World Health Organization. (2017). Neonatal
mortality. [online] Available
at: http://www.who.int/gho/child_health/mortality/neonatal/en/
[Accessed4 Oct. 2017].
2. National Institute of Population Studies (NIPS) [Pakistan]
and ICF. 2018.Pakistan Demographic and Health Survey 2017-18.
Islamabad, Pakistan,and Rockville, Maryland, USA: NIPS and ICF.
3. Committing to Child Survival: A Promise Renewed – Progress
Report
2015 [Internet]. UNICEF. 2015 [cited 21 October 2017]. Available
from:h t t p s : / /www.un i ce f . o rg /pub l i c a t i ons / i
ndex_83078 .h tml .
4. World Health Organization. World Health Statistics
2015.www.who.int/gho/publications/world_health_statistics/2015/en/.
5. Khan A, Kinney M, Hazir T, Hafeez A, Wall S, Ali N et al.
Newbornsurvival in Pakistan: a decade of change and future
implications. HealthPolicy and Planning. 2012;
27(suppl_3):iii72-iii87.
6. Javaid S, Waheed K, Sheikh M, Gul R, Nizami N. Is
ThrombocytopeniaConsistent with Specific Bacterial/Fungal Neonatal
Sepsis?. Infec Dis JPak 2016; 25(2):27-30.
7. Bentlin M, de Souza Rugolo L. Late-onset Sepsis:
Epidemiology,Evaluation, and Outcome. Neo Reviews 2010;
11(8):e426-e435.
8. Camacho-Gonzalez A, Spearman PW, Stoll BJ. Neonatal
infectiousdiseases: evaluation of neonatal sepsis. Pediatr Clin
North Am 2013;60:367–89.
9. Harris D, Weston P, Harding J. Incidence of Neonatal
Hypoglycemia inBabies Identified as at Risk. The J Pediatr 2012;
161(5):787-791.
10. Jain V, Chen M, Menon K. Disorders of carbohydrate
metabolism. GleasonC A, Devaskar S U. Avery’s Diseases of the
Newborn. 9th Ed: USA;Saunders 2012; 1327-9.
11. Ahmad S, Khalid R. Blood Glucose Levels in Neonatal Sepsis
andProbable Sepsis and its Association with Mortality. 2012 Jan;
22(1):15-18.
12. Branco RG, Tasker RC, Garcia PCR, Piva JP, Xavier LD.
GlycemicControl and Insulin Therapy in Sepsis and Critical Illness.
Jornal dePediatria 2007; 83: 128-36.
13. Gul R, Waheed KAI, Sheikh M, Javaid S, Haroon F, Fatima ST.
Ishyperglycemia a risk factor for neonatal morbidity and mortality?
PakArmed Forces Med J 2017; 67 (4): 621-26
14. Islam Z, et al. Evaluation of hypoglycemic status and
causative factorsin neonatal sepsis. Int J Contemp Pediatr 2017
Nov; 4(6):1927-1933.
15. Swain A, Das K , Tripathy SK , Behera S, Satpath SK. Study
of morbiditypattern of hypoglycemia in neonates admitted to a
tertiary care centeran experience of two years. ejpmr 2017;
4(7):497-502.
16. Islam MF, Mia MAH, Akhter KR, Haque M, Malik M. Glycemic
Statusand its Effect in Neonatal Sepsis in a Tertiary Care
Hospital. BangladeshJ Child Health 2016; 40(1):21.
17. Sabzehei M K, Afjeh S A, Shakiba M, Alizadeh P, Shamshiri
AR, EsmailiF. Hyperglycemia in VLBW Infants; Incidence, Risk
Factors and Outcome.Arch Iran Med 2014; 17(6): 429-34.
18. Tareen Z, Jirapradittha J, Sirivichayakul C, Chokejindachai
W. FactorsAssociated with Mortality Outcomes in Neonatal Septicemia
in SrinagarindHospital, Thailand. Neonat Pediatr Med 2017; 3:131.
doi:10.4172/25724983.1000131.
19. Mohammed MMM, Abdel Rahman SMK. Frequency of
neonatalhyperglycaemia at Gaafar Ibnauf Children’s Hospital:
Clinical aspectsand short term outcome. Sudan J Paediatr 2016; 16
(1):45 - 52.
20. Schrag SJ, et al. Risk factors for neonatal sepsis and
perinatal deathamong infants enrolled in the prevention of
perinatal sepsis trial, Soweto,South Africa. 2012 Aug;
31(8):821-6.
21. Decaro M, Vain N. Hyperglycaemia in preterm neonates: What
to know,what to do. Early Human Development. 2011; 87:S19-S22.
22. Sabzehei M K, Afjeh S A, Shakiba M, Alizadeh P, Shamshiri
AR, EsmailiF. Hyperglycemia in VLBW Infants; Incidence, Risk
Factors and Outcome.Arch Iran Med 2014; 17(6): 429-34.
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Volume 28 Issue 04 Oct - Dec 2019. 73
ORIGINAL ARTICLE
Corresponding Author: Naureen Omar,Assistant
Professor,Department of Community Health SciencesFatima Memorial
College of Medicine and Dentistry,Lahore, Pakistan.Email:
[email protected]
Socioeconomic Status of Father and Vaccination Status of
Children: A Community Based HouseholdSurvey
Naureen Omar*, Shamaila Hassnain*, Umbreen Navied*, Iram
Manzoor**
*Department of Community Health Sciences, Fatima Memorial
College of Medicine and Dentistry,Lahore, Pakistan
** Department of Community Health Sciences, Akhtar Saeed Medical
College. Lahore, Pakistan
Abstract
BackgroundPakistan, being a developing country faces the
challenge ofcompromised maternal and child health, as a state it is
laggingbehind with poor child health status and extremely high
mortalityrates for the past many years. Immunization can be
consideredto be the keystone factor to help combat with this
situation.
ObjectiveTo assess the influence of fathers’ socioeconomic
status on thevaccination status of children aged less than five
years in theNorthern Peri-Urban areas of Lahore.
DesignCommunity based household survey
MethodologyCommunity based household survey was conducted in
NorthernPeri-urban areas of Lahore within a period of three months.
Atotal of 939 households were visited, married couples havingat
least one child were enrolled in the study after informedconsent. A
pretested structured questionnaire translated in locallanguage was
used to collect data pertaining to socio-demographic profile,
paternal education, occupational statusand immunization status of
under five children.
ResultSurvey was conducted on a total of 939 households
inhabitedby 5,356 members,836 household had male heads, mean
age45+14 years and 153 were headed by females, mean age 52+15years.
Children under 5 years of age, 617 (74%) were fullyvaccinated, 111
(13%) partially vaccinated and 108 (13%)unvaccinated. Income of 541
(65%) was less than 15,000 and295 (35%) more than 15,000. Majority
fathers were uneducatedor had attended madrasah/Quran literate 550
(66%). Nosignificant relationships were exhibited between
vaccinationstatus of children, income and father’s educational
status
ConclusionAs observed father’s educational status was pertinent
indetermining the vaccination status of their children in
additionto the socioeconomic status. Majority fathers were
illiteratethus highlighting the need of educational services in
additionto better EPI coverage within this particular area.
KeywordsImmunization, Father Education, Household Survey
IntroductionPakistan, being a developing country faces the
challenge ofcompromised maternal and child health, as a state it is
laggingbehind with poor child health status and extremely high
mortalityrates for the past many years. In 2017 the under –five
mortalitieshave been reported to be 74.9/ 1000 live births.1
Appropriate,acceptable and implementable steps need to be taken to
identify,improve and reduce the factors responsible for
thesecircumstances. Immunization can be considered to be
thekeystone factor to help combat with this situation.2
The Expanded Program on Immunization was launched in 1979by
UNICEF and WHO, with the objective of prevention ofchildhood
diseases. This program still faces a number of hurdlesin provision
of complete immunization. According to thePakistan Demographic and
Health Survey 2017-2018 80% ofchildren are fully vaccinated in
Punjab and only 1% are notvaccinated.3 Punjab Health Survey (PDHS)
2016 over 81% ofchildren aged 12-23 months are fully vaccinated in
Punjab.3
According to the Pakistan Demographic Health Survey
(PDHS)2017-2018 the total vaccination coverage in Pakistan
hasimproved from 54% to 66%.3
Education inculcates moral and ethical values, positive
thinkingand attitudes within an individual. Education helps to
strengthenone’s mind enabling to perceive to deal with specific
challengesin life. Parental education plays a significant role in
decisionmaking and comprehending different preventive health
servicesconcerned with their children, especially immunization.
Manystudies, emphasize and support that educated parents play
adominant role in regards to immunization of their children.
Thecomprehensive involvement of both parents is fruitful.4,5 It
was
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74 . Infectious Diseases Journal of Pakistan
observed that lowest immunization coverage was noticed
inchildren with lesser educated fathers, thus parental educationhad
a positive effect in promoting immunization coverage.6
Gaps have been identified in the knowledge of parents
regardingprevention of infectious diseases thus highlighting the
importanceof awareness of parents especially fathers regarding
relevantinformation related to these diseases.7 It has been noted
that theavailability of relevant information with respect to
children’shealth is important for parents as it influences them in
decisionmaking, especially in relation to immunization.8
Anothermisleading factor responsible for prevention of
immunizationare the associated risks which may occur due to
immunization.Misconceptions regarding immunizations need to be
reviewedto reduce chances of non-immunization.9 It has been
distinguishedthat the immunization status of children is related to
the socio-economic status of the household. In India it has been
observedthat children belonging to the poorest economic
householdshowed an increase trend in non-immunization.10 Low
andmiddle income countries also exhibit missed opportunities
inimmunization.11 Studies reported different issues responsiblefor
low immunization coverage in Pakistan. Researches inPakistan have
also highlighted different issues responsible forthe low
vaccination coverage.
These included distant vaccination centers, improper knowledgeof
Expanded Program on Immunization (EPI) schedule andparental
education.12
It is imperative that we understand the relationship of
parentalespecially father’s education and socioeconomic status
indeciding the vaccination status of their children. The
parent’sawareness especially fathers in relation to the
understandingof the significance of vaccination requires
interventions toaddress this domain, as decision making of
children’s healthis dependent on the parents. Pakistan is in dire
need to improveits EPI vaccination coverage to overcome and
eliminate theprevailing communicable diseases in children. Research
targetingthis domain is essential as it would help us identify
areas wherewe could use interventions to enhance the awareness of
parentsespecially fathers regarding the importance of vaccination
asthey play a major role in decision making. In addition,
Pakistanis in dire need to improve its EPI vaccination coverage so
asto target the elimination of targeted communicable diseases.
This study was conducted with the aim to assess the influenceof
father’s socioeconomic status on the immunization status ofchildren
aged less than five years in the Northern Peri Urbanareas of
Lahore. This study was conducted with the aim toassess the
influence of father’s socioeconomic status on thevaccination status
of children aged less than five years in theNorthern Peri Urban
areas of Lahore.
MethodologyIn the Northern Peri urban areas of Lahore including
the townsof Malikpur, Bheni, Talwara, Jandiala, Icho Gill and Awan
Dhai
Wala, Union Council 176 a community based household surveywas
conducted within a period of three months. Each townapproximately
has 2500 households, every 15th house (calculatedby systematic
random sampling/kth fraction) was visitedamounting to a total of
939 households. Married couples havingat least one child were
enrolled in the study after informedconsent. Investigators
conducted personal interviews collectingdata pertaining to
socio-demographic profile, paternaleducational, occupational status
and EPI vaccination status ofunder five children. Children up to
five years of age receivingcomplete course of EPI vaccination were
considered fullyvaccinated, unvaccinated were children up to five
years of agereceiving no dose of any EPI vaccination and partially
vaccinatedwere children up to five years of age missing even one
dose ofany EPI vaccination. A non-response rate of less than 3%
wasencountered. A pretested structured questionnaire translated
inlocal language was used. Pilot study was conducted on
tenhouseholds before using the instrument. Consent was takenfrom
all of the participants and Institutional Review Boardclearance was
sought before collection of data. Analysis wasdone on SPSS version
20 with chi square being the test ofsignificance at 95% confidence
interval p value of 0.05 hasbeen considered significant. Chi Square
was calculated.
ResultsThis survey was conducted on a total of 939 households
inhabitedby 5,356 members, out of whom 836 household had male
heads,mean age 45.5+ 14.6 years and 153 were headed by females,mean
age 52.6+ 14.9 years.
Households with male heads were evaluated for further
results.Children under 5 years of age, 617 (74%) were fully
vaccinated,111 (13%) partially vaccinated and 108 (13%)
unvaccinated.The questionnaire was based on categories of income
definedon the basis of previous surveys done in the community
ofNainsukh. So, the mean income cannot be generated. The
crosstabulation between the education of fathers and
vaccinationstatus shows that there was no significant relationship
betweeneducation status and vaccination based on our results.
Therelationship of income with vaccination status exhibited a
non-significant relationship with a p value of 0.060, indicating
thathouseholds with income more than 15,000 rupees had only 6%more
vaccination coverage than households with low income.
DiscussionDespite many strategies Pakistan faces the dilemma of
lowvaccination coverage of children which can be attributed tomany
factors. It is utmost importance that these factors behighlighted.
This study was conducted to highlight the influenceof father’s
socioeconomic status on the vaccination status oftheir children.
Majority children of the Northern Peri urbanareas of Lahore were
vaccinated as witnessed in the currentstudy depicting the overall
picture of Punjab especially Lahore.More than half of the children
were fully vaccinated supportingthe fact that majority parents were
aware of the importance of
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Volume 28 Issue 04 Oct - Dec 2019. 75
vaccination in addition to proper coverage of all areas
withinthe province.13
Various studies support the fact that maternal education
isessential for the well-being of children, but on the other
handfather’s education cannot be denied as being head of
thehouseholds they are the decision makers.14, 15, 16 Analysis of
sixlow income countries including Pakistan reported that
countrieswith low paternal educational status had less
vaccinationcoverage.17 In a Nigerian study similar results were
reportedin addition lack of approval of father towards vaccination,
poorpaternal educational and socioeconomic statue were
emphasizedupon.18 Contrarily in the current study although majority
fatherswere illiterate or had a low educational status the
vaccination
Cross Tab I: Relationship between Educational Status ofFather
and Vaccination Status
Children Vaccination Status(n = 836)
Educational Status Yes No
Illiterate/ Quran /Madrassah 459 91
(83.5%) (16.5%)
Primary to Matric 206 34(85.9%) (14.1%)
Intermediate 31 3(91.2%) (8.8%)
Bachelor & Above 12 0(100%) (0%)
Total 708 128(84.7%) (15.3%) p=0.38
Cross Tab II. Relationship between Income and
VaccinationStatus
Children Vaccination Status(n = 836)
Income /months Yes No Total(household)
Less than 15,000 447 94(82.6%) (17.3%)
More than 15,000 261 34(88.4%) (11.6%)
Total 708 128(84.7%) (15.3%) p=0.06
Table 1: Socio-demographic data
Frequency (%)
Income/monthLess than 15,000 541 (65%)More than 15,000 295
(35%)
Educational status of FatherIlliterate/Quran/Madrasah 550
(68%)Primary to Matric 240 (29%)Intermediate 34 (4%)Bachelors &
above 12 (1%)
Immunization Status of Last Born ChildPartially vaccinated 111
(13%)Unvaccinated 108 (13%)Fully Vaccinated 617 (74%)
Total 37,560 Households Enrolled
Less than 3%Non-response rate
After systematicrandom samplingevery 15th house
was visited
836 Householdshad male heads
153 Householdshad female heads
Total 939Households
assessed
36,621 Householdsagreed for survey
Flow Diagram:
The reasons for non-response rate among the households were:1.
Not willing to be a part of the study.2. Non-availability of the
household members on the particular
day of pre-survey.
-
76 . Infectious Diseases Journal of Pakistan
coverage was high and a significant relationship was
notestablished (p value 0.382). This can be attributed to the
factthat this study was conducted in a Peri urban area
whereawareness levels were high as vaccination camps were
beingconducted in addition during surveys importance of
EPIvaccination was being emphasized upon parents as was doneduring
our data collection too.
The current study witnessed most of the households to have
anincome of less than 15,000 PKR in accordance with theeducational
status of fathers and low vaccination status of theirchildren (p
value 0.008), as was observed in a study conductedin Africa
majority households belonged to the lower class withnon- educated
father’s thus less vaccinated children.19
A study conducted in Sindh, Pakistan highlighted that
poorsocioeconomic status of parents can be considered to be
animportant predictor of the vaccination status of their
childrenmajority having a monthly income of less than 3000
PKR.20,21
The irony being that free vaccination programs are not the
onlysolution for adequate vaccination we need to take into
accountmany factors.
This study emphasizes on the fact that we still need to
investigateand identify various factors associated with
immunization statusof children. Limitations encountered were
minimal sample sizewas enrolled in lieu of the feasibility.
Vaccination evidence wasbased on responses as in most of the houses
vaccination cardswere not available so the element of recall bias
cannot be denied,but data was collected under the supervision of
the principalinvestigator after training of the data
collectors.
ConclusionVaccination coverage in the Northern Peri Urban areas
ofLahore is 85%. As observed father’s educational status wasa
pertinent in determining the immunization status of theirchildren
in addition to the socioeconomic status. Majorityfathers were
illiterate thus highlighting the need of educationalservices in
addition to better EPI coverage within this particulararea. Surveys
in different geographical areas need to beconducted so as to have a
broader overview of the vaccinationcoverage, status and factors
associated with it throughout thecountry.
AcknowledgementsThe authors are thankful to the Department of
CommunityHealth Sciences, FMHCM&D and students of 4th year
MBBSfor their contribution in the data collection. Worth
mentioningare the contributions of Mr Tipu Sultan in the analysis
of thedata. We would like to thank the people of the communities
wevisited.
References1. Unicef: Under Five Mortality. Sept 2019
https://data.
unicef.org/topic/child-survival/under-five-mortality/ Cited
25 August 2017.2. Shoukat M, Khurmi MS, Faheem MU. Child Health
Status
in Pakistan. Student JAMC. 2015; Sep 15:1(1).3. PDHS – 2017-18
Key indicator report Aug 2018.
http://www.nips.org.pk/abstract_files/PDHS. Cited 25August
2017
4. Brugha RF, Kevany JP, Swan AV. An investigation of therole of
fathers in immunization uptake. Int J
Epidemiol1996;25(4):840-5.
5. Garfield CF, Isacco A. Fathers and the well-child
visit.Pediatrics 2006;117(4):637-45.
6. Rammohan A, Awofeso N, Fernandez RC. Paternaleducation status
significantly influences infants’ measlesvaccination uptake,
independent of maternal educationstatus. BMC public health
2012;12(1):336.
7. Hilton S, Hunt K, Petticrew M. Gaps in parentalunderstandings
and experiences of vaccine-preventablediseases: a qualitative
study. Child Care HLTH DEV 2007;33(2):170-9.
8. Sporton RK, Francis SA. Choosing not to immunize: areparents
making informed decisions? Fam Pract2001;18(2):181-8.
9. Raithatha N, Holland R, Gerrard S, Harvey I. A
qualitativeinvestigation of vaccine risk perception amongst
parentswho immunize their children: a matter of public
healthconcern. J Public Health 2003;25(2):161-4.
10. Devasenapathy N, Jerath SG, Sharma S, Allen E, ShankarAH,
Zodpey S. Determinants of childhood immunisationcoverage in urban
poor settlements of Delhi, India: a cross-sectional study. BMJ open
2016;6(8):013015.
11. Sridhar S, Maleq N, Guillermet E, Colombini A, GessnerBD. A
systematic literature review of missed opportunitiesfor
immunization in low-and middle-income countries.Vaccine
2014;32(51):6870-9.
12. Siddiqi N, Khan A, Nisar N, Siddiqi AE. Assessment ofEPI
(expanded program of immunization) vaccine coveragein a peri-urban
area. JPMA 2007;57(8):391-5.
13. Shaheen A, Batool S, Mahmood MA. Coverage ofImmunization
among Poor Children. PJMHS 2012;(1):195-197
14. Babatsikou F, Vorou R, Vardaki Z, Galani S, Ktenas E,Koutis
C. Childhood vaccination uptake and factors affectingthis in
Athens, Greece. Health Sci J 2010;4(4):237.
15. Aslam M, Kingdon GG. Parental education and
childhealth—understanding the pathways of impact in Pakistan.World
Dev 2012;40(10):2014-32.
16. Cochrane SH, Leslie J, O'Hara DJ. Parental education
andchild health: intracountry evidence. Health Policy
Educ1982;2(3-4):213-50.
17. Ilah B, Sakajiki A, Musa A, Edem B, Adelakun M, AdenijiA,
Kaura N. Immunization and socioeconomic status ofchildren 12-59
months attending a specialist hospital,Gusau, Nigeria. ATMPH
2015;8(2):23.
18. Al-lela OQ, Bahari MB, Salih MR, Al-abbassi MG, ElkalmiRM,
Jamshed SQ. Factors underlying inadequate parents’
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awareness regarding pediatrics immunization: findings
ofcross-sectional study in Mosul-Iraq. BMC
Pediatrics2014;14(1):29.
19. Sanou A, Simboro S, Kouyaté B, Dugas M, Graham J,Bibeau G.
Assessment of factors associated with completeimmunization coverage
in children aged 12-23 months: across-sectional study in Nouna
district, Burkina Faso. BMCInt health human rights
2009;9(1):S10.
20. Shaikh S, Taj TM, Kazi A, Ahmed J, Fatmi Z. Coverageand
predictors of vaccination among children of 1–4 yearsof age in a
rural sub-district of Sindh. JCPSP 2010;20(12):806-10.
21. Tikmani SS, Soomro T, Ali SA. Vaccination Status andFactors
for Non-Vaccination in Children at a Tertiary CareHospital. Int J
Vacc Res 2017;2(1):1.
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ORIGINAL ARTICLE
78 . Infectious Diseases Journal of Pakistan
Emergence of Multidrug Resistant Gram-negative Pathogens in an
Intensive Care Unit of a TertiaryCare Hospital
Zehra NM, Hanif F, Khursheed U, Jaffer SR, Yousuf S, Nadeem
S
PNS Shifa Hospital, Karachi, Pakistan
Correspondence Author: Nadia Midhat Zehra,Resident Microbiology,
Department of Pathology,PNS Shifa Hospital, Karachi, PakistanEmail:
[email protected]
Abstract
ObjectivesTo determine the antimicrobial resistance pattern
amongpathogenic gram-negative bacilli isolated from patients
withnosocomial infections at PNS Shifa hospital, Karachi.
Study designDescriptive cross sectional study
Place and Duration of studyThe study was carried out at the
Department of Microbiology,PNS Shifa hospital from Jan 2015 - Dec
2016.
MethodologyAll samples received from surgical and medical
intensive careunit were included in the study. Samples from
patients withinsufficient medical history were excluded. Initially,
gram stainfrom fresh sample was made followed by inoculation on
Bloodagar, Mac Conkey agar and Chocolate media (Biomeurx) for24-48
hours. Pus samples were inoculated additionally onanaerobic media,
as per CLSI 2016 guidelines. Positive cultureswere tested for
antimicrobial susceptibilities by Kirby-Bauertechnique according to
CLSI guidelines. The results were furtherconfirmed by minimum
inhibitory concentration.
ResultsIn 900 patients, a total of 248 gram negative bacilli
were isolatedin either mono-microbial or poly-microbial cultures.
The mostfrequent pathogens were Klebsiella pnemoniae 88(
32%)followed by Acinetobacter baumanii 63 (23%),
Pseudomonasaeruginosa 36 (14%), and E.coli 31(11%), and less
frequentlyisolated organisms, Enterobacter aerogenes ,
Enterobactercloacae and Stenotrophomonas maltophilia , Salmonella
typhi,Proteus mirabilis, Proteus vulgaris, Citrobacter
freundii,Burkhorderia cepacia ,Serratia marcesens and Serratia
odoriferacomprises 12% of the isolates. The tested antimicrobials
wereampicillin, amoxicillin-clavulanate, ceftriaxone,
cefepime,ceftazidime, doxycycline, Co-trimoxazole, gentamicin,
amikacin,ciprofloxacin, levofloxacin, tazobactum-piperacillin,
imipenem,meropenem and, polymyxin. The antimicrobial
susceptibility
was high for polymyxin (100%), imipenem (44.6%),
meropenem(44.5%), sulbactam-cefoperazone (42.75%)
tazobactum-piperacillin (40%), amikacin (29%), gentamicin
(31%),doxycycline (28%), ciprofloxacin (12%). Carbapenem
resistancewas highest amongst Pseudomonas aeruginosa ,
Klebsiellapnemoniae. and Acinetobacter baumanii (76%), followed
by,and Enterobacter aerogenes (69%) E.coli (30%). All
carbapenemresistant isolates were tested for susceptibility
topolymyxin, susceptibility to which was 100%.
ConclusionAntimicrobial susceptibility of the three most common
isolatesin our study has been restricted to carbapenems and
colistin.Even carbapenem resistance is significantly higher, that
makesit unsuitable to be used as an empirical antibiotic. The
decreasingsensitivity of MDR gram negative bacteria to third
generationcephalosporins and carbapenems leaves us with colistin as
theonly option.
Use of colistin has become a unlikeable necessity in spite ofthe
cost and side effects pose by them.
Key WordsAntibiotic, Antimicrobial resistance, Gram-negative
Isolates,Intensive care unit
IntroductionGram negative bacilli causing significant numbers of
infectionsin intensive care units (ICU)1 are a great threat as most
of themexist as multidrug resistant isolates.
They are responsible for 45–70% of
ventilator-associatedpneumonia (VAP), 20–30% of catheter-related
bloodstreaminfections and generally are involved in ICU-acquired
sepsissuch as surgical site or urinary tract infections (UTI).2
Nevertheless, alarming resistance rates are now
beingincreasingly reported worldwide, and rising trends may
elicitconcerns for the coming years.3
Exclusively restricted to the hospital setting, this
issueincreasingly applies for patients with
healthcare-associated.4,5
and even community-acquired infections.6 Patients are
usuallyfound to be on prolonged exposure to broad spectrum
antibiotics,invasive procedures and suffer from an
immunocompromisedstatus.7 Enterobacteriaceae and non-fermenting
GNB
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Volume 28 Issue 04 Oct - Dec 2019. 79
(Pseudomonas aeruginosa, Acinetobacter baumannii
andStenotrophomonas maltophilia) account for the major part ofthe
troublesome situation.8
A high prevalence of extended spectrum beta lactamaseproducing
E.coli and Klebsiella pnemoniae has been reportedmany times in
blood stream infections. 9, 10
A hoard of antibiotic-inactivating enzymes and
non-enzymaticmechanisms have contributed to antimicrobial
resistance ingram negative bacteria (GNB).11 Both may be
intrinsicallyexpressed by a given species of bacteria (chromosomal
genes),or acquired by a subset of strains within the same specie as
aconsequence of mutations in chromosomal genes or
horizontaltransfer mechanisms incorporated in mobile genetic
elements.2
The reasons for development of resistance are multiple and
areattributed to antibiotic overuse and misuse together with
failinginfection control practices in health care setting.12
Multidrug resistant gram-negative infections are
beingincreasingly reported from our critical care unit. In order
toguide a clinicians in reforming a better treatment plan
formultidrug resistant gram negative infections, we
haveinvestigated the antimicrobial resistance patterns among gram-
negative bacteria isolated from ICU patients at PNS Shifahospital
Karachi and devise a plan to curb antibiotic resistance.
Material & MethodsThis study was carried out at PNS Shifa
hospital in Karachifrom January 2014 to December 2016. The study
protocol wasapproved by Ethical Review Committee of PNS Shifa
hospital.This was descriptive cross-sectional study. Sampling was
doneby non-probability consecutive sampling technique.
Patients belonging to adult ICU, pediatric ICU and neonatalICU
were included in the study.Out of 900 culture positive specimens,
248 specimens that yieldnon-lactose fermenting and lactose
fermenting gram negativerods were included in our study. The
remaining 652 specimenscomprising of gram positive pathogens and
fungal isolates wereexcluded from our study.
Three sets of samples were taken in the ICU. First set
consistedof diagnostic samples that were taken at the time of
ICUadmission. These samples were not included in our study.
Theremaining two sets were surveillance samples that were
takenweekly and then followed twice weekly in order to
monitorhospital acquired infections and identify carrier state of
thepatient. Surveillance samples were included in our study.
Specimens received for culture and sensitivity comprised
ofBlood, Bronchi alveolar lavage, tracheal aspirates, sputum,body
fluids, pus specimens, central venous catheter tips andurine
specimens. Specimens were then inoculated on bloodagar, MacConkey
agar and chocolate agar (Biomeurx) for 24-
48 hours. Organism was identified up to species level usingAPI
20E and API 20NE.
Sepsis in terms of microbiology was defined as one or
morepositive blood culture collected during stay in the ICU. In
anindividual patient, positive cultures from each site were
countedas separate samples. All information was documented on
aresearch questionnaire. The information collected
includeddemographic characteristics of patients, site of infection,
andantibiotic sensitivity of the isolate. MDR isolate was definedas
resistance to 3 or more than three categories of
antimicrobialagainst which it has been tested.13
The isolates were identified using standard
microbiologicaltechniques, on the basis of colony morphology and
biochemicaltests using API 20E and 20NE (Biomeurx, France).
Antimicrobialsusceptibility was determined by the Kirby-Bauer disc
diffusionmethod on Muller-Hinton agar (Oxoid, UK).
Antimicrobialdiscs used were: ampicillin amoxicillin –clavulanate,
ceftriaxone,cefepime, ceftazidime, doxycycline, co-trimoxazole,
gentamicin,amikacin, ciprofloxacin, levofloxacin,
tazobactum-piperacillin,imipenem, meropenem, polymxin.
The Muller-Hinton agar plates were incubated aerobically at35
±2°C for 18-24 hours in ambient air. E. coli ATCC 25922was used for
QC of discs. The interpretation of zone diameterswas done according
to clinical and laboratory standards institute(CLSI) guidelines
(2016). Isolates showing resistance toantimicrobial agents were
confirmed by minimum inhibitoryconcentration using Etest method.
The interpretation of minimuminhibitory concentration was done
according to clinical andlaboratory standards institute (CLSI)
guidelines (2016).14 Thedata was analyzed using SPSS 17.0.
Descriptive statistics wereused to calculate frequencies and
percentages of the qualitativevariables.
As per definition, MDR organisms are those which showresistance
to at least 3 different antibiotic groups.13 Antibioticsfor which
susceptibility testing has been done and were foundto be
susceptible to more than 80% isolates are included in thestudy.
Multidrug resistant (MDR) has been defined for
clinicallysignificant major gram negative bacteria such as
Acinetobacterbaumanii, Pseudomonas aeruginosa, Escherichia coli,
andKlebsiella pnemoniae. Antibiotics tested for gram
negativepathogens were Aminoglycosides (AMG), Cephalosporins(CEPH),
Carbapenems (CARB), Tetracyclines (TETRA) andFluroquinolones
(FQ).
Class 1: This class includes organism that pose resistance
tofive classes of antimicrobials such as aminoglycosides,
thirdgeneration cephalosporins, fluoroquinolones, carbapenems,and
tetracyclines. Acinetobacter baumanii are labelled as class1 MDR
organism as tetracyclines are tested only forAcinetobacter baumanii
among MDR GNB.Class 2: Organism included in this class demonstrate
resistance
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80 . Infectious Diseases Journal of Pakistan
against four classes of antimicrobials such as
aminoglycosides,third generation cephalosporins, fluoroquinolones
andcarbapenems.Class 3: This class is further divided in 3a, 3b, 3c
and 3d3(a): Resistance against three classes of antimicrobials such
asaminoglycosides, third generation cephalosporins
andfluoroquinolones but sensi t ive to carbapenems. 3(b):
Resistance demonstrated against three classes ofantimicrobials such
as third generation cephalosporins,fluoroquinolones and carbapenems
but sensitive toaminoglycosides. 3(c): Resistant to three classes
of antimicrobials such asaminoglycosides, fluoroquinolones and
carbapenems, butsensitive to third generation cephalosporins. 3(d):
Resistant to three classes of antimicrobials such
asaminoglycosides, third generation cephalosporins andcarbapenems,
but sensit ive to fluoroquinolones.
Note: For general gram negative bacilli; ceftriaxone
andceftazidime were used in third generation cephalosporins
exceptfor Acinetobacter and Pseudomonas species, where
onlyceftazidime was used. In category of carbapenems, meropenemwas
used; aminoglycosides were represented by gentamicinand amikacin,
and for fluoroquinolones, ciprofloxacin was themodel drug.
ResultsAmong 900 culture positive patients selected for study,
gramnegative rods were isolated from 248 (28%) patients.Most common
clinical specimen yielding gram negativepathogens during the
present study were respiratory specimens131 (47.9%) followed by
blood 41 (15%) and pus 50 (18.3%).Distribution of pathogens among
different clinical specimensreceived from the ICUs during the study
period is shown in(table1). It was observed that Klebsiella
pnemoniae 88 (32.2%)was the most common organism isolated from
various clinicalspecimens in our study followed by Acinetobacter
baumanii63(23%) (Figure1). Other common organisms isolated
indecreasing order were Pseudomonas aeruginosa 36 and E.coli31
(12%).
Frequency of pathogens in neonatal, pediatric and adult
ICUs(table 2). Klebsiella pnemoniae N=11, Citrobacter species
N=8and Enterobacter species N= 4 were recurrently reported fromthe
pediatric ICUs. In Adult ICUs, Klebsiella pnemoniae,
N=65Acinetobacter baumanii, N=60 and Pseudomonas aeruginosaN=33
were more common.
The gram-negative bacilli in our study belong to
familyEnterobacteracae and some isolates of non-
enterobacteracaefamily. Antimicrobial resistance pattern is
depicted in (table3). In our study we noted that Klebsiella
pnemoniae of familyenterobacteracae ranks top in the gram negative
bacilli isolatedfrom ICU. Most of the Klebsiella isolates were
multi drugresistant organisms showing resistance against three or
more
than three groups of antimicrobials. High resistance was
shownagainst carbapenems and aminoglycosides. Among
non-enterobacteracae family, Acinetobacter baumanii andPseudomonas
aeruginosa were most common clinical isolatesin this family. Both
of these gram negative bacteria turned outto be, highly
non-susceptible to quinolones, cephalosporinsand beta lactam
inhibitor group of drugs. Resistance tocarbapenems was high and
does not show any significantdifference when compared to isolates
of enterobacteracae family.
When we study co resistance pattern among significant
gramnegative bacilli [tab-4], we find that out of 218 gram
negativebacilli isolates recovered, 105(48.1%) isolates were
multidrugresistant i.e., resistant to at least three or more than
three classesof antimicrobial agents. About 14.6% of isolates are
resistantto four groups of antimicrobials and 2.2% of isolates
wereresistant to three classes of antimicrobial drugs. It was
observedthat 34.09% of Klebsiella pnemoniae, 35% of
Acinetobacterbaumanii and 38.8% of Pseudomonas aeruginosa
showedcomplete resistance to aminoglycosides, quinolones,
macrolides,tetracyclines and carbapenems.
DiscussionAntimicrobial resistance among pathogens is a serious
threatto mankind that is difficult to overcome. Multi-drug
resistantinfections by gram negative bacilli are some of the key
causesof deaths, morbidity and economic setback amongst
hospitalizedpatients. Through this study we identify major
organisms andtheir antimicrobial resistance patterns. We tend to
find out theshortage of antimicrobials that we will be facing in
near future.
Klebsiella pnemoniae (35.4%) was the most common
organismisolated from our intensive care unit. Jamil et al., in
aretrospective study conducted at a tertiary care hospital15
hasnarrated similar findings where Klebsiella pnemoniae was themost
common infective agent isolated. In a study by Siddiquiet al,
Acinetobacter species was often isolated infective agentfollowed by
Klebsiella pnemoniae.16 Different members of theenterobacteracae
family isolated less often consists E.coli(12.5%), Enterobacter and
Citrobacter species (4%). Thesemultidrug resistant isolates are a
challenge to the treatingmedical practitioner and cause of economic
burden for thehospital.
Among members of non-enterobacteracae family, gram
negativebacilli like Acinetobacter baummanii (25.4%) followed
byPseudomonas aeruginosa (14.5%) were the ensuing commonclass of
microorganisms isolated from clinical specimen. Theseisolates are
reported from pus and respiratory specimens. Theyare next common to
Klebsiella pnemoniae in their occurrencefrom respiratory specimens.
All the three isolates havesignificantly different mechanisms which
lead to theirp redominance in r e sp i r a to ry spec imens f
romimmunocompromised patients of ICU. Klebsiella pnemoniae,have
capsular antigens that resist complement mediated killing
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Volume 28 Issue 04 Oct - Dec 2019. 81
Table 1: Shows number of different clinical specimens received
from ICU patients. Total specimens =273
Blood(41) Respiratory Urine(32) Pus(50) Body fluids(10) CVP
tip(9)15% specimens 11.7% 18.3% 3.6% 3.2%
(131) 47.9%
Acinetobacter Klebsiella E.coli(15) Klebsiella Klebsiella
Klebsiellabaumanii (4) pnemoniae(59) 46.8% pnemoniae(6)
pnemoniae(2) pnemoniae (4)9.7% 45% 12% 20% 44%
Klebsiella Acinetobacter Klebsiella E.coli(3) Pseudomonas
Enterobacterpnemoniae(14) baumanii(24) oxytoca(2) 6% aeruginosa (4)
cloacae(1)34.1% 18.3% 6.2% 40% 11%
Burkhorderia Pseudomonas Enterobacter Pseudomonas Acinetobacter
Citrobactercepacia(1) aeruginosa(19) aerogenes(1) aeruginosa(5)
baumanii(1) koseri(1)2.4% 14.5% 3.1% 10% 10% 11%
Enterobacter E.coli(7) Citrobacter Acinetobacter
Proteuscloacae(3) 5.3% freundii(1) baumanii(29) mirabilis(1)7.3%
3.1% 58% 10%
Citrobacter Enterobacter Pseudomonas Proteuskoseri(2)
aerogenes(1) aeruginosa(2) mirabilis(1)4.8% 0.76% 6.2% 2%
Citrobacter Enterobacter Acinetobacter Citrobacterfreundii(4)
cloacae(5) baumanii(5) freundii(1)9.7% 3.8% 15.6% 2%
Pseudomonas Proteus Proteus Klebsiellaaeruginosa(5) mirabilis(1)
mirabilis(1) oxytoca(1)12.1% 0.76% 3.1% 2%
E.coli(6) Providencia Serratia14.6% rettgeri(1) odorifera(1)
0.76% 2%
S.typhi(1) Proteus2.4% vulgaris(1)
0.76%
Citrobacterkoseri(1)0.76%
Citrobacterfreundii(1)0.76%
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82 . Infectious Diseases Journal of Pakistan
whereas Acinetobacter baumanii and Pseudomonas
aeruginosacolonize respiratory tract of patients on prolonged
mechanicalventilation1 7 resulting in nosocomial infections.
Antimicrobial resistance varies in two commonly
occurringisolates of enterobacteracae family. Among, 34.9%(30/88)
ofKlebsiella pnemoniae isolates were found to be resistant to
5categories of antimicrobials consisting of third
generationcephalosporins, aminoglycosides, quinolones,
carbapenemsand tetracyclines. Only 18.8 %( 16/88) of Klebsiella
pnemoniaeisolates are found come underneath the class of 4MDR
i.e.resistant to four categories of antimicrobials together with
thirdgeneration cephalosporins, aminoglycosides,
quinolones,carbapenems. As compared to Klebsiella isolates, a
significantlyless degree of resistance is shown by E.coli. Among
E.coli,only 6.45% (2/31) isolates are classified as five MDR
i.e.resistant to cephalosporins, aminoglycosides,
quinolones,carbapenems and tetracyclines and 3.22% (1/31) are
classifiedas four MDR i.e. resistant to cephalosporins,
aminoglycosides,quinolones, and Carbapenum.
Members of non-enterobacteracae, show consistently
higherresistance patterns against all major classes of
antimicrobialsused in our study. This data is supported by Kaushal
V Shethet al18 and Cai B et al.19 A 60 %(38/63) of
Acinetobacterbaumanii were found to be resistant to be meropenem;
whereas100 % (63/63) isolates are resistant to ceftriaxone
.Resistanceis reduced to 57 % (36/63) once
combinations(sulbactam/cefoperazone) were used. A 52% (34/63)
isolatesdemonstrate resistance to amikacin and 60 % (38/63)
isolatesare resistant to ciprofloxacin. Similar concordance
patterns arementioned by Kaushal V Sheth at al.18 Only 36.5%
(23/63)isolates of Acinetobacter baumanii are resistant to
doxycycline.It can be assumed that doxycycline was found to be
moreeffective against Acinetobacter baumanii compared to the
otherantimicrobials, hence it can be a promising agent for
thetreatment of Acinetobacter baumanii infections.
Multidrug resistant Pseudomonas aeruginosa isolated frommultiple
specimens of ICU patients is alarming, Resistance ofisolates of
pseudomonas to class A category drugs includingceftazidime was
found to be 72%(23/36), while 52.7 %(19/36)isolates showed
resistance to cefoperazone/ sulbactam.Resistance to carbapenems and
aminoglycosides was found tobe 69.4%(25/36) and 50%(18/36)
respectively. Our isolatesrevealed 64% (23/36) resistance to
ciprofloxacin. These resultsare in agreement with many alternative
studies.20
On comparison of co-resistance among multidrug
resistantgram-negative bacilli, we discover lactose- non
fermentinggram-negative bacilli superseding lactose -fermenting
gramnegative isolates. It is evident that 30/88 (34.09%)
Klebsiellapnemoniae isolates have ceased responding to five
majorcategories of antimicrobials i .e.
Cephalosporins,aminoglycosides, quinolones, carbapenem and
tetracyclines.
Fig 1. Pattern of gram negative Bacteria in percentages
Table 2: Distribution of pathogens in neonatal, pediatricand
adult Intensive care unit
Neonatal ICU Pediatric ICU Adult ICU
Klebsiella Klebsiella Klebsiellapnemoniae pnemoniae
pnemoniaeN=12 N=11 N=65
Enterobacter Citrobacter E.colicloacae freundii N=28N=4 N=8
E.coli Citrobacter AcinetobacterN=1 koseri baumanii
N=3 N=60
Pseudomonas Pseudomonasaeruginosa aeruginosaN=3 N=33
Acinetobacter Enterobacterbaumanii cloacaeN=3 N=6
E.coli EnterobacterN=2 aerogenes
N=1
Serratia Burkhorderiaodorifera cepaciaN=1 N=1
Salmonella typhi Proteus mirabilisN=1 N=4
Providencia rettgeriN=1
Proteus vulgarisN=1
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Volume 28 Issue 04 Oct - Dec 2019. 83
Table 3. Antimicrobial resistance pattern of gram negative
isolates. % indicates resistance pattern of a clinical isolate
tocorresponding antimicrobial agent
Antimicrobial Klebsiella Acinetobacter Pseudomonas E.coli Other
gramagent pnemoniae baumanii aeruginosa (N=31) negative rods
(N=88) (N=63) (N=36) N=30
Ceftriaxone/ 81 (92%) 63 (100%) 23 (72%) 29 (93.5%) 30
(100%)Ceftazidime
Sulbactam- 66 (75%) 36 (57%) 19 (52.7%) 11 (35.4%) 14
(46.6%)Cefoperazone
Meropenem 53 (60.2%) 38 (60%) 25 (69.4%) 6 (19.3%) 14
(46.6%)
Gentamicin 69 (78.4%) 35 (55%) 21 (58.3%) 18 (58%) 17(56.6%)
Amikacin 66 (75%) 34 (52%) 18 (50%) 10 (32.2%) 14 (46.6%)
Ciprofloxacin 79 (89.7%) 38 (60%) 23 (64%) 25 (80.6%) 20
(66.6%)
Doxycycline 61 (69.3%) 23 (36%) - 17 (54.8%) 21 (70%)
Aztreonam - - 28 (78%) - -
Table 4. Multidrug resistant pattern among significant clinical
isolates of gram-negative bacilli.
Combination of antibiotic Acinetobacter Pseudomonas Escherichia
Klebsiella Total MDRbaumanii aeruginosa* coli Pnemoniae gram
negative
N=63 N=36 N=31 N=88 N=218
5MDR(AMG+CEFT/FEP*/CAZ*+FQ+CARB+TETRA/TZP*) 22(35%) 14(38.8%)
2(6.45%) 30(34.09%) 68(31.1%)
4MDR(AMG+CEFT/FEP*/CAZ*+FQ+CARB) 13(20.6%) 2(5.5%) 1(3.22%)
16(18.8%) 32(14.6%)
3MDR(AMG+CEFT/FEP*/CAZ*+FQ) 0 0 3(9.6%) 0 0
3MDR(CARB+CEFT/FEP*/CAZ*+FQ) 4(6.3%) 1(2.7%) 0 0 5(2.2%)
3MDR(AMG+FQ+CARB) 0 0 0 0 0
3MDR(AMG+CEFT/FEP*/CAZ*+CARB) 0 0 0 0 0
Total MDR (%) 39(61.9%) 17(47.2%) 6(19.35%) 46(52.2%)
105(48.1%)
MDR=Multidrug resistant, AMG=aminoglycosides, CEFT=Ceftriaxone,
FQ=Fluoroquinolone, CARB=Carbapenum,TZP=Tazobactum-piperacillin,
FEP=Cefepime, CAZ=Ceftazidime, *drugs for pseudomona
-
84 . Infectious Diseases Journal of Pakistan
patients. World J Crit Care Med 2016; 5(2):111-202. Ruppe E,
Woerther P-L, Barbier. Mechanism of antimicrobial resistance
in Gram negative bacilli. Ann.Intensive Care (2015); 5:213.
REA-Raisin Network (2012) Surveillance of nosocomial infections
in
critically ill adult patients, France, 20124. Aliberti S et al.
Multidrug-resistant pathogens in hospitalized patients
coming from the community with pneumonia: a European
perspective.Thorax 2013; 68:997–9
5. Razazi K et al. Clinical impact and risk factors for
colonization withextended spectrum beta-lactamase-producing
bacteria in the intensivecare unit. Intensive Care Med 2012;
38(11):1769–78
6. Torres A et al. Bacteremia and antibiotic-resistant pathogens
in communityacquired pneumonia: risk and prognosis. Eur Respir J
2015; 45(5):1353–63
7. Choi J.Y. et al.Trends in the distribution and antimicrobial
susceptibilityof causative pathogens of device-associated infection
in Korean intensivecare units from 2006 to 2013: results from the
Korean NosocomialInfections Surveillance System (KONIS) .J Hosp
Infection 2013; 92(4):363 – 71
8. Center for Diseases Control and Prevention (2013) Threat
report2013.http://www.cdc.gov. Accessed 13 Mar 2015
9. Bassetti M, Righi E, Carnelutti A. Bloodstream infections in
the IntensiveCare Unit. Virulence. 2016; 7(3):267-79
10. Parajuli NP, Acharya SP, Mishra SK, Parajuli K, Rijal BP,
Pokhrel BM.High burden of antimicrobial resistance among gram
negative bacteriacausing healthcare associated infections in a
critical care unit of Nepal.Antimicrobial Resistance and Infection
Control. 2017; 6:67.
11. Alekshun MN, Levy SB Molecular mechanisms of antibacterial
multidrugresistance. Cell. 2007; 128(6):1037–50
12. Wasswa P, Nalwadda CK, Buregyeya E, Gitta SN, Anguzu P,
Nuwaha F.Implementation of infection control in health facilities
in Arua district,Uganda: a cross-sectional study. BMC Infectious
Diseases. 2015; 15:268.
13. Magiorakos AP et al. Multidrug-resistant, extensively
drug-resistant andpan drug-resistant bacteria: an international
expert proposal for interimstandard definitions for acquired
resistance. Clin Microbiol Infect. 2012;18 (3): 268-81
14. Patel JB. Performance standards for antimicrobial
susceptibility testing.Wayne, PA: Clinical and Laboratory Standards
Institute; 2016.
15. Bushra et al. Bacteremia: Prevalence and antimicrobial
resistance profilingin chronic kidney diseases and renal transplant
patients. Pak Med Assoc.2016; 66(6):705-9
16. Siddiqui N-R, Qamar FN, Jurair H, Haque A. Multi-drug
resistant gramnegative infections and use of intravenous polymxin B
in critically illchildren of developing country: retrospective
cohort study. BMC InfectiousDiseases. 2014; 14:626
17. Bennett, J., Dolin, R., Blaser, M., Mandell, G. and Douglas,
R. (2015).Mandell, Douglas, and Bennett's principles and practice
of infectiousdiseases. Philadelphia: Elsevier Saunders.
18. Sheth KV, Patel TK, Malek SS, Tripathi CB. Antibiotic
sensitivity patternof bacterial isolates from the intensive care
unit of a tertiary care hospitalin India. Trop J Pharm Res.
2012;11(6):991-99
19. Bin Cai et al. Prevalence of Carbapenem-Resistant
Gram-NegativeInfections in the United States Predominated by
Acinetobacter baumanniiand Pseudomonas aeruginosa. J Infect
Dis.2017; 4(3):176
20. Yusuf et al. Emergence of antimicrobial resistance to
Pseudomonasaeruginosa in the intensive care unit: association with
the duration ofantibiotic exposure and mode of administration. Ann.
Intensive Care.2017; 7(1):72
21. Decicera Colombo OV et al. Trends of 9,416
multidrug-resistant Gramnegative bacteria. Rev. Assoc. Med. Bras.
2015; 61(3): 244-49.
22. Masgala A, Kostaki K, Ioannnidis I. Multi Drug Resistant
Gram NegativePathogens in Long Term Care Facilities: A Steadily
Arising Problem. JInfect Dis Diagn.2015; 1:101
As compared to Klebsiella, 35%(22/63) isolates of
Acinetobacterbaumanii are multidrug resistant to these five
antimicrobials.E.coli, the second commonest lactose fermenting
gram-negativebacilli showed comparatively lesser degree of
multidrugresistance. Pseudomonas aeruginosa isolates on the
oppositehand are equally multidrug resistant as shown by (14/36)
38%of isolates displaying multi-drug resistance to five
categoriesof antimicrobials. Nearly similar pattern of multidrug
resistancehas been reported in different studies.21, 22
There are certain limitations of this study. First, non-
availabilityof adequate clinical data makes it a retrospective
study.Colonization of surfaces by Pseudomonas and
Acinetobactermakes it difficult to label these organisms as
pathogens especiallywhen they are isolated from blood cultures. We
are unable toexplore the outcome of patients suffering from
hospital acquiredinfections again due to limited data. Third, in
depth analysis oftreatment in cases of MDR infections has not been
done. MDRorganisms defined in this study are subjected to changes
as perupcoming guidelines and clinical efficacy of drugs when
usedby clinicians. We can have entirely different pattern
ofantimicrobial resistance once a different definition is
applied.
ConclusionAntimicrobial susceptibility of the three most common
isolatesin our study has been restricted to carbapenems and
colistin.Even carbapenem resistance is significantly higher, that
makesit unsuitable to be used as an empirical antibiotic. The
decreasingsensitivity of MDR gram negative bacteria to third
generationcephalosporins and carbapenems leaves us with colistin as
theonly option. Use of colistin has become a unlikeable necessityin
spite of the cost and side effects pose by them.
RecommendationsDetrimental effects of antimicrobial resistance
surface asprolonged hospital stays, increased financial burden and
mortalityrate. The main goal of hospital administrators around the
worldshould be focused at making worthy efforts to
reduceantimicrobial resistance and hospital acquired infection.
Practicing antimicrobial surveillance is the need of the hour
asit directs in generating an antibiogram which reflects our
nationaldata. It also guides the clinician in choosing the type
ofantimicrobial drug and appropriate duration of
therapy.Antimicrobial surveillance cannot be achieved without an
effectivehospital infection management policy with frequent
revisions ofantimicrobial policy guideline. Thus, practicing
antimicrobialstewardship can help us in curbing antimicrobial
resistance.
References1. Paramythiotou E,Routsi C. Association between
infections caused by
multidrug- resistant gram negative bacteria and mortality in
critically ill
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Volume 28 Issue 04 Oct - Dec 2019. 85
CASE REPORT
Corresponding Author: Hamzullah Khan,Associate
Professor,Nowshera Medical College,NowsheraEmail:
[email protected]
Extremely Drug Resistant Pseudomonas in Qazi Hussain Ahmed
Medical Complex, Nowshera, Pakistan.
AbstractNosocomial infections are major health issues in
developingas well as developed countries. The most common
pathogensthat cause nosocomial infections are Staphylococcus
aureus,Pseudomonas aeruginosa, and E. coli. Pseudomonas
Aeruginosais an ubiquitous organism because of its extraordinary
survivaland adaptation abilities in various environments like soil,
water,sewage, hospitals etc. Among all gram-negative
bacteria,Pseudomonas is a predominant opportunistic pathogen
whichusually infects persons having some underlying diseases
andcompromised immune status. Increasing multidrug resistanceamong
nosocomial pathogens specially pseudomonas is alarmingand is a
challenge for the health care providers in managementof various
infectious diseases in hospital set up.
Key WordsDrug Resistance, Psuedomonas, Opportunistic
Infections
Case ReportA 3 days old baby presented with Meningomyelocele
with nomotor activities in the lower extremities presented to the
Pediatricsurgery unit of Qazi Hussain Ahmed Medical complex.
Thebaby born in a local private clinic. Child was admitted in
thehospital 17/12/2017 for Meningomyelocele and operated
on18/12/2017. Baby weight was 3 kg and well built otherwise(Figure
1). Daily dressing was in routine protocol along withtreatment of
infection with antibiotics. Child was dischargedon 26/12/2017. The
home take medications were ampicillinand cefuraxime during with vit
A and paracetamol drops. Childwas re-admitted for oozing post
operative wound to the sameunit on 03/01/2018. The child wound was
open with oozing ofpus and was re-started on antibiotic cefuraxime
250mg BD,gentamicine 1-2mg/kg, Inj ampicillin+ cloxacillin 250mg
BD,with local application of polymyxin B and fusidic acid. Pusswab
for culture and sensitivity was sent to microbiology sectionon
03-01-2018.
Grams stain showed Gran Negative Rods that was followedwith
Culture on Macconkey agar. The plate was incubated at35C under
aerobic conduction. After 24 hours growth of colonieswas obtained
(figure 1). A spot Oxidase test was positive.Presumptive diagnosis
made was Pseudomonas auriginosa.
The colonies were inoculated on Mueller Hinton Agar as perCLSI
(Clinical and Laboratory Standards Institutes) Guidelinesfor 24
hours. The accepted zones of sensitivity taken in
Hamzullah Khan, Fazli Bari
Nowshera Medical College, Nowshera, Pakistan.
Figure 2. Figure showing sensitivity of conventional andnon
conventional antibiotics against the Pseudomonasaeruginosa.
Fig 1. Baby general look and growth of isolate on
Macconkeyagar.
-
86 . Infectious Diseases Journal of Pakistan
consideration as per CLSI (Clinical Laboratory
StandardInstitute) Guideline 20151. The pseudomonas bug was
foundresistant to all conventional and non conventional
antibioticsincluding (Ak-Amikacin, Mem-Meropenem,
IPM-imepenum,CAZ-Ceftazadime, CTX-Cefotaxime,
TZP-PiperacillinTazobactum, SCF-Cefperazone Sulbactum,
AMC-AmoxicillinClavolinic acid) Lev- Levofloxacin, CN-Gentamycin
and Cip-ciprofloxacin. Then non conventional drugs like,
E-Erythromycin, Dox-Doxycyclin, SXT-Co-Triamaxazol
andchloramphenicol,. We found that isolate was only sensitive toCT-
Colistin Sulphate.
DiscussionBaby born with congenital meningomylocele and was
broughtto hospital for repair surgery. Various risk factors can
becontributed to growth of multidrug resistant pseudomonas
inhospital set up. Treatment of diseases with multidrug
resistantpseudomonas. P. aeruginosa becomes more challenging
forclinicians. The chromosomally encoded AmpC cephalosporinase,the
outer membrane porin OprD, and the multidrug effluxpumps are
particularly attributed to this therapeutic challengedealing with
pseudomonas.2,3 In the hospital, P. aeruginosa canbe isolated from
a variety of sources, including respiratorytherapy equipment,
antiseptics, soap, sinks, mops, medicines,and physiotherapy and
hydrotherapy pools.4
The risk for acquiring XDR infections may be related to
extrinsic,ecological characteristics of patients, such as the
number ofcarriers in the same ward, the nurse-to-patient ratio,
andcompliance with infection control measures as well as
toindividual risk factors, such as patient characteristics and
in-hospital events, including treatment with antibiotics.5
Rates of antibiotic resistance in Pseudomonas aeruginosa
isreported worldwide as a therapeutic challenge with some casesas
with therapeutic dead end like the case we studied, as wehave no
option/ no molecule to treat such like infections. TheExtremely
drug-resistance (XDR) in P. aeruginosa isattributed/mediated by
several mechanisms including multidrugefflux systems, enzyme
production, outer membrane protein(porin) loss, and target
mutations.6
We observed that pseudomonas bug was resistant to
allconventional antibiotics including (Ampicillin,
Co-Amoxiclav,Cefradine, Cefotaxime, Cefuraxime, Amikacine,
Amipenem,Pipracilline Tazobactum, Cefoperazone sulbactum
andceftazadime) and non conventional drugs like
chloramphenicol,erythromycin, doxycycline, and co-trimoxazole were
also noteffective. However, it was found sensitive to only
CholistineSulphate which can’t be given as monotherapy and the
sametime its availability is an issue.P. aeruginosa exhibits the
highest rates of resistance for the
fluoroquinolones, with resistance to ciprofloxacin
andlevofloxacin ranging from 20 to 35%. Specially in ICU
patients.P. aeruginosa isolates from ICU patients also confers
higherrates of b-lactam resistance than general trends for
hospitalizedpatients. Among the aminoglycosides, most studies have
focusedon gentamicin, with resistance rates ranging from 12 to
22%.7,8
We recommended to the clinician to start on liposomal
cholistinesulphate along with combination of pipracillin tazobactum
ascholistine sulphate is not advised as monotherpay as per
CLSIrecommendation.
After reporting of this isolate, we informed the
hospitaladministration, unit in-charge and OT in-charge about
theemergence of this super bug, with the request to fumigate
theoperation theatre as well as the ward and to isolate the
baby.
We suggest this XDR Pseudomonas infection can be preventedin
hospitals with the following general preventive measure ifproperly
adopted including proper scientific hand washing,fumigation of the
operation theatre and ward, reducing thenumber of visitors to the
ward, minimizing the irrational useof antibiotics and prescribing
antibiotic after culture andsensitivity.
We also planned in departmental meeting to start cultures
onweekly basis from OT and surgical wards and to report it tothe
administration for further necessary actions.
References1. Clinical Laboratory standard institute. M100-S25.
Performance standard
for antimicrobialsusceptablity testing: twenty fifth
informationalsupplement. CLSI, Wayne USA, 2015;35(3):66-72.
2. Lister PD, Wolter DJ, Hanson ND. Antibacterial-Resistant
Pseudomonasaeruginosa: Clinical Impact and Complex Regulation of
ChromosomallyEncoded Resistance Mechanisms. Clin Microbiol Rev
2009; 22(4):582–610.
3. Abdalhamid, B., P. A. Wickman, and N. D. Hanson. Correlation
of ampCinduction with PBP binding in Enterobacter cloacae, abstr.
C1-2211.2005. Abstr. 45th Intersci. Conf. Antimicrob. Agents
Chemother.,Washington, DC
4. Pollack, M. Pseudomonas aeruginosa, p. 1820-2003. In G. L.
Mandell,R. Dolan, and J. E. Bennett (ed.), Principles and practices
of infectiousdiseases. Churchil l Livingstone, New York, NY.
1995.
5. Carmeli, Y., G. M. Eliopoulos, and M. H. Samore. Antecedent
treatmentwith different antibiotic agents as a risk factor for
vancomycin-resistantEnterococcus. Emerg. Infect. Dis 2002.
8:802-807.
6. Tam VH, Hirsch EB. Impact of multidrug-resistant
Pseudomonasaeruginosa infection on patient outcomes. Expert Rev
PharmacoeconOutcomes Res 2010 Aug; 10(4): 441–451.
7. Poirel, L., M. Van De Loo, H. Mammeri, and P. Nordmann.
2005.Association of plasmid-mediated quinolone resistance with
extendedspectrum beta-lactamase VEB-1. Antimicrob. Agents Chemother
49:30913094.
8. Poole, K. 2005. Aminoglycoside resistance in Pseudomonas
aeruginosa.Antimicrob. Agents Chemother 49:479-487.
-
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