Hospital acquired blood-stream infections among intensive care unit (ICU) Patients in Tbilisi, Georgia

Abstract

Since gaining independence in 1991, the ex-Soviet republic of Georgia has suffered severe socio-economic deterioration and civil unrest that has significantly affected the healthcare system [1–3]. For example, blood cultures are rarely used in the standardized care of febrile patients due to: lack of inhospital laboratory facilities, expense of specimen processing, and in the current reimbursement system, cultures are considered non-essential for patient care. Instead, with a lack of microbial susceptibility data, patients are treated empirically with broad spectrum antibiotics. Infection control practices are also underdeveloped and contribute to the risk of antibiotic resistance. The purpose of this study was to determine the microbial spectrum of blood stream infections (BSI) among febrile patients admitted to the intensive care unit (ICU) and the emergency room (ER) at a major, general hospital in Tbilisi. In August 2007, febrile patients admitted to the ICU and the ER of this referral hospital, underwent blood culture testing. Isolates from blood cultures were identified using Analytical Profile Index identification testing, and antibiotic susceptibilities were performed using both ATB testing and disk diffusion methods. A total of 19 febrile patients (14 ICU patients and 5 ER patients) had blood cultures performed. Study patients aged from 20 to 79 (mean 46.5 years); 14 (74%) of 19 patients were male. All patients had recorded temperature C38.0 C. All patients, including those treated in the ER, had received antibiotics prior to the collection of blood culture samples. Trauma was the most common reason for admission to the ICU (9 of 14, 64%) with average pre-culture length of stay of 9 days, and in patients with positive isolates, 14 days. All the ICU patients had a history of central venous catheters. Cultures from all 5 ER patients were sterile. Cultures from 4 of 14 (29%) ICU patients were positive. Two separate bacteria (coagulase negative Staphylococcus [CNS] and Aeromonas hydrophila) were isolated in the same culture from one patient; the CNS was considered to be a contaminant. Isolates from 3 other patients were gram-negative bacteria: Burkholderia cepacia, Klebsiella pneumonia, and Pseudomonas aeruginosa. Both Aeromonas and Pseudomonas isolates were resistant to all antibiotics tested. The Pseudomonas demonstrated intermediate sensitivity to carbapenems alone. The Burkholderia isolate was susceptible to ciprofloxacin, carbapenems, and most aminoglycosides and intermediate to several penicillins. The Klebsiella isolate was susceptible to carbapenems, piperacillin/tazobactam, and ticarcillin/clavulanic acid but resistant to all additional antibiotics. The lack of culture driven antimicrobial therapy and few infection control practices is largely responsible for the resistant gram negative BSI in this study. There is a paucity of data in the medical literature on hospital acquired infections in the former Soviet states. A recent observational study of postoperative infection rates revealed that 17% of operations in Georgia were complicated by infections [4]. Next steps to further evaluate the scope of this problem include more surveillance of hospital acquired infections, C. E. Low (&) K. Walker Department of Internal Medicine, Emory University School of Medicine, Atlanta, USA e-mail: celow@emory.edu