High Prevalence Of Drug Resistance Research Articles

Magnitude and antimicrobial susceptibility profile of bacteria isolated from pediatric sepsis cases at University of Gondar Hospital, Northwest Ethiopia

BackgroundSepsis is one of the major causes of morbidity and mortality among pediatric patients throughout the world. The varying microbiological pattern of sepsis warrants the need for researches on the causative organisms and their antimicrobial susceptibility pattern. The epidemiology of neonatal and pediatric sepsis in Ethiopia is under-research. The objective of this study was to evaluate the burden of bacterial pathogens and their antimicrobial susceptibility patterns among children suspected of sepsis.MethodsAn institutional-based prospective cross-sectional study was conducted on 370 pediatric(age birth-15 years) patients suspected of sepsis at the University of Gondar Comprehensive Specialized hospital from December 2020 to November 2021. Blood samples were collected aseptically and inoculated into Tryptone Soya Broth for culture. The organisms grown were identified by standard microbiological methods and subjected to antibiotic susceptibility testing by modified Kirby-Bauer disk diffusion method recommended by Clinical laboratory and standard institute. Methicillin resistance was confirmed using Cefoxitin disk diffusion method. Data entry and analysis were done using Statistical Package for Social Sciences (SPSS) version 26 software. A p-value less than 0.05 at 95% confidence interval was considered statically significant.ResultsOut of the total 370 study subjects, 21.6% (80/370) of them were culture positive. Of these, 43 (53.8%) and 37 (46.3%) were Gram-positive and Gram-negative bacterial pathogens, respectively. The most prevalent Gram-positive bacterial isolate was Staphylococcus aureus (n = 24; 30%) and coagulase negative staphylococci (n = 7; 8.8%). Among the Gram-negative bacterial isolates, the leading bacteria was Klebsiella pneumoniae (n = 20; 25%) followed by Escherichia coli (n = 7; 8.8%). Clindamycin, Chloramphenicol, Gentamicin and Ciprofloxacin were the most effective antibiotics against Gram-positive bacterial isolates while Amikacin, Meropenem and Chloramphenicol were effective against Gram-negative pathogens. Methicillin resistance was detected in 45.8% of Staphylococcus aureus. Multi-drug resistance (MDR) antimicrobial susceptibility pattern was observed in 76% of the bacterial isolates.ConclusionGram positive bacteria were the predominant isolates among pediatric sepsis cases and most of the bacterial isolates showed MDR. Staphylococcus aureus and Klebsiella pneumoniae were frequently isolated bacteria. The high prevalence of drug resistance warrants rational use of antibiotics and the need for regular antibiotic susceptibility surveillance studies.

Bacteriological Profile and Multidrug Resistance Patterns of Isolates from Sputum of Adults with Community Acquired Pneumonia in Diobu, Port Harcourt, Nigeria: A Retrospective Study

Community acquired pneumonia is a major global public health concern given its substantial contribution to the mortality and morbidity associated with infectious diseases, the huge losses in human and economic resources and the increasing challenges in treatment due to multidrug resistance (MDR). This retrospective cross sectional descriptive study reviewed laboratory records of adults clinically diagnosed with community acquired pneumonia (CAP) between January 1, 2017, and December 31, 2022. A total of 308 sputum specimens meeting the inclusion criteria were reviewed and yielded 135 (43.8%) bacterial strains. The 135 bacterial strains spread across 9 species had Streptococcus pneumoniae as the dominant species with 41(30.4%); followed by Staphylococcus aureus 21(15.6%), Escherichia coli 16(11.9%), Klebsiella pneumoniae 16(11.9%), Pseudomonas aeruginosa 12(8.9%), Streptococcus pyogenes 12(8.9%), Proteus mirabilis 10(7.4%), Enterobacter cloacae 5(3.7%) and Acinetobacter baumannii 2(1.5%). The cumulative resistance profile was 45.7%; the most resistant bacterial specie was Pseudomonas aeruginosa with a resistance profile of 50%; followed by Staphylococcus aureus (48.6%), Enterobacter cloacae (48.0%), Streptococcus pyogenes 47.5%, Streptococcus pneumoniae 47.3%, Klebsiella pneumoniae 45.6%, Proteus mirabilis 42.0%, Escherichia coli 40.0% and Acinetobacter baumannii 35.0%. The MDR prevalence was 85.9% including 36.3% extensively resistant strains; but no pan-drug resistant trains; while 14.1% were non-multidrug resistant. This study has contributed to the data on bacteriological profile and antimicrobial resistance patterns in aetiological agents of community acquired pneumonia in Port Harcourt. The high prevalence of drug resistance implies that many people are likely to be infected, while most of the antibiotics are losing potency against the bacterial pathogens. It is advised that regulatory laws on drug control be revised as it pertains antibiotics, the regulatory agencies should be compelled to perform their statutory duties while there is need to sensitize the populace on the dangers of antibiotic abuse and misuse.

In vitro investigation of relationship between quorum-sensing system genes, biofilm forming ability, and drug resistance in clinical isolates of Pseudomonas aeruginosa

BackgroundPseudomonas aeruginosa is an opportunistic pathogen in the health-care systems and one of the primary causative agents with high mortality in hospitalized patients, particularly immunocompromised. The limitation of effective antibiotic administration in multidrug-resistant and extensively drug-resistant P. aeruginosa isolates leads to the development of nosocomial infections and health problems. Quorum sensing system contributes to biofilm formation, expression of bacterial virulence factors, and development of drug resistance, causing prolonged patient infections. Therefore, due to the significance of the quorum sensing system in increasing the pathogenicity of P. aeruginosa, the primary objective of our study was to investigate the frequency of quorum sensing genes, as well as the biofilm formation and antibiotic resistance pattern among P. aeruginosa strains.MethodsA total of 120 P. aeruginosa isolates were collected from different clinical specimens. The disk diffusion method was applied to detect the antibiotic resistance pattern of P. aeruginosa strains. Also, the microtiter plate method was carried out to evaluate the biofilm-forming ability of isolates. Finally, the frequency of rhlI, rhlR, lasI, and lasR genes was examined by the polymerase chain reaction method.ResultsIn total, 88.3% P. aeruginosa isolates were found to be multidrug-resistant, of which 30.1% had extensively drug-resistant pattern. The highest and lowest resistance rates were found against ceftazidime (75.0%) and ciprofloxacin (46.6%), respectively. Also, 95.8% of isolates were able to produce biofilm, of which 42.5%, 33.3%, and 20.0% had strong, moderate, and weak biofilm patterns, respectively. The frequency of quorum sensing genes among all examined strains was as follows: rhlI (81.6%), rhlR (90.8%), lasI (89.1%), and lasR (78.3%). The most common type of quorum sensing genes among multidrug-resistant isolates were related to rhlR and lasI genes with 94.3%. Furthermore, rhlI, rhlR, and lasI genes were positive for all extensively drug-resistant isolates. However, the lasR gene had the lowest frequency among both multidrug-resistant (83.0%) and extensively drug-resistant (90.6%) isolates. Moreover, rhlR (94.7%) and lasR (81.7%) genes had the highest and lowest prevalence among biofilm-forming isolates, respectively.ConclusionOur findings disclosed the significantly high prevalence of drug resistance among P. aeruginosa isolates. Also, the quorum sensing system had a significant correlation with biofilm formation and drug resistance, indicating the essential role of this system in the emergence of nosocomial infections caused by P. aeruginosa.

Multiproperty Polyethylenimine-Caged Platinum Nanoclusters Promote Apoptosis of Osteosarcoma Cells via Regulating the BAX-Bcl-2/Caspase-3/PARP Axis.

Osteosarcoma, a prevalent primary bone cancer in children, exhibits a poor prognosis due to the high prevalence of drug resistance. The objective of this study was to investigate the potential of fluorescent ultrafine polyethylenimine-coated caged platinum nanoclusters (PEI-Pt NCs) as an antitumor agent in osteosarcoma. The primary focus of this study involved the utilization of osteosarcoma cells (U2-OS and MG-63) and normal control cells (hBMSC) as the primary subjects of investigation. The capacity of PEI-Pt NCs to enter osteosarcoma cells was observed through the implementation of confocal microscopy. The impact of PEI-Pt NCs on migration and proliferation was assessed through the utilization of various methodologies, including the CCK8 assay, Ki-67 immunofluorescence, clone formation assay, transwell assay, and wound healing assay. Furthermore, the influence of PEI-Pt NCs on apoptosis and its underlying mechanism was explored through the implementation of flow cytometry and Western blotting techniques. The PEI-Pt NCs demonstrated the capability to enter osteosarcoma cells, including the nucleus, while also exhibiting fluorescent labeling properties. Furthermore, the PEI-Pt NCs effectively impeded the migration and proliferation of osteosarcoma cells. Additionally, the PEI-Pt NCs facilitated apoptosis by modulating the BAX-Bcl-2/Caspase 3/PARP axis. The novel nanomaterial PEI-Pt NCs possess diverse advantageous capabilities, including the ability to impede cell proliferation and migration, as well as the capacity to modulate the BAX-Bcl-2/Caspase 3/PARP axis, thereby promoting cell apoptosis. Consequently, this nanomaterial exhibits promising potential in addressing the issue of inadequate platinum-based treatment for osteosarcoma.

Assessment of risk factors associated with multi-drug resistant tuberculosis (MDR-TB) in Gulu regional referral hospital.

Multi-drug resistant tuberculosis (MDR-TB) is increasingly recognized as emerging infectious disease of public health concern. Globally, 206030 people were diagnosed with MDR-TB in 2019, representing a 10% increase from 186883people who had it in 2018. In Uganda, the prevalence of MDR among new TB cases is 4.4% and 17.7% among previously treated TB cases. To determine the risk factors associated with MDR-TB among tuberculosis patients in Gulu regional referral hospital. A cross-sectional analytical study using both quantitative and qualitative methods of data collection and analysis was used. Data was collected from 384 TB patients using data extraction form and 6 Key informant interviews conducted. Analysis using Pearson chi-square test was run. HIV positive patients were 2.6 times more likely to be infected with MDR-TB than HIV negative patients [AOR=2.6: 95% CI 1.34- 5.85: P=0.006]. Previously treated TB patients were 2.8 times more likely to be infected with MDR-TB than newly diagnosed TB patients [AOR=2.8: 95% CI 1.33- 5.85: P=0.006]. Defaulting TB patients were 3.1 times more likely to be infected with MDR-TB than the non-defaulting TB patients [AOR=3.1]. There is high prevalence of drug resistance among patients attending TB treatment at the facility.

Outer membrane protein A of Acinetobacter baumannii regulates pulmonary inflammation through the TLR2-NF-κB pathway

Acinetobacter baumannii (A. baumannii) is characterized by a high prevalence of drug resistance; how to effectively treat it is still a major clinical challenge. Our previous experiments confirmed that ompA, which is one of the most well-characterized virulence factors, may be dependent on the caspase-1 pathway-stimulated expression of NLRP3 inflammasome to enhance inflammation. TLRs (i.e., TLR2, etc.) is the initiating signal for NLRP3 inflammasome activation; how it relates to ompA in its underlying pathogenic mechanism is not clear. In this study, we proofed that ompA promoted NLRP3 inflammasome activation while the TLR2-NF-κB pathway was also activated after A. baumannii infection. Additionally, the expression of NLRP3 inflammasome-associated proteins and genes was inhibited by silencing TLR2 and NLRP3. This indicated that ompA might depend on the TLR2-NF-κB pathway to assemble and activate the NLRP3 inflammasome. OmpA promoted the assembly of the NLRP3 inflammasome through the TLR2-NF-κB pathway and inhibited the degradation of caspase-1 by the proteasome so that a large number of mature IL-1β/IL-18 and other proinflammatory factors were released extracellularly to enhance the body’s inflammatory response. Taken together, the results of the joint pre-study confirmed a novel TLR2-NF-κB/NLRP3/caspase-1-modulated mechanism underpinning ompA activity, the NLRP3 inflammasome pathway may be as a potential immunomodulatory target against A. baumannii infections.

Magnitude of Malaria-Typhoid Fever Coinfection in Febrile Patients at Arba Minch General Hospital in Southern Ethiopia.

Coinfection with malaria and typhoid fever is a major public health issue in developing countries. In endemic areas, including Ethiopia, people are at risk of acquiring both malaria and typhoid fever at the same time. Therefore, this study aimed to determine the magnitude of malaria-typhoid fever coinfection in febrile patients attending hospital at Southern Ethiopia. A hospital-based cross-sectional study was carried out on 416 febrile patients attending Arba Minch General Hospital from 1st October to 30th December 2021. The data was collected using a pretested structured questionnaire. Capillary and Venus blood samples were collected for assessing malaria and typhoid fever, respectively. Blood smear, culture, and biochemical tests were performed based on standard parasitological and microbiological methods. The P-value ≤ 0.05 was considered statistically significant. The magnitude of malaria, typhoid fever, and their coinfections was 26.2% (109/416), 6.5% (27/416), and 3.1% (13/416), respectively. Among the confirmed malaria cases, about 66% of infections were Plasmodium falciparum. The malaria-typhoid fever coinfection showed a statistically significant association with a clinical presentation of a continuous pattern of fever (AOR = 5.84; 95% CI: 1.44-23.71, P = 0.014) and chills (AOR = 3.94; 95% CI: 1.04-14.89, P = 0.044). About 29.6% of Salmonella isolates were multidrug-resistant (MDR). The total rate of coinfection with malaria and typhoid fever was comparable to that of previous studies. With the consideration of higher prevalence of drug resistance of Salmonella spp. and higher prevalence of malaria-typhoid fever coinfection, proper diagnostic procedure should be implemented for proper use of drugs.

Prevalence of Bacterial Urinary Tract Infection and Antimicrobial Susceptibility Patterns Among Diabetes Mellitus Patients Attending Zewditu Memorial Hospital, Addis Ababa, Ethiopia.

BackgroundUrinary tract infection (UTI) is caused by colonization and growth of microorganisms within the urinary system. Diabetic patients are more prone to bacterial UTI due to impaired host defense and high glucose concentration in urine. Surveillance of uropathogens and their antibiogram is a key to patient management.MethodsA hospital-based cross-sectional study was conducted from May to July, 2018. Urine samples were collected for culture and identification based on the standard protocol. An antimicrobial susceptibility test (AST) was done for all isolates using the Kirby–Bauer disk diffusion method. Data were entered into Epi-data version 3.2.1 and exported to the Statistical Package for the Social Science (SPSS) version 20.ResultsOut of 225 participants, significant bacteriuria was reported in 9.8% of the cultures. Five species of bacteria were isolated and E. coli (63.6%) was the leading uropathogen, followed by K. pneumoniae (13.6%). Duration of diabetes, previous history of UTIs and symptomatic UTI were found to be strongly associated with significant bacteriuria. Gram-negative bacterial isolates showed high sensitivity to nitrofurantoin and meropenem (100%). In contrast, a high level of resistance to ampicillin, doxycycline and cefuroxime (100%) and to amoxicillin-clavulanate (94.4%) was observed. Gram-positive bacteria showed high level of resistance to penicillin (100%). Multiple-drug resistance (MDR) was high for Gram-negative bacteria (100%).ConclusionPrevious history of UTIs and duration of diabetes were found to be important factors that increase the prevalence of UTI among diabetes patients. This study also showed a high prevalence of drug resistance to doxycycline, amoxicillin-clavulanate, cefuroxime and penicillin for both Gram-negative and Gram-positive bacteria. Since therapeutic selection for empirical treatment and management should be based on knowledge of the local bacterial profile and antimicrobial response, we suggest physicians take this high resistance profile in to consideration when prescribing antimicrobials against the pathogens in question.

High Prevalence of Drug Resistance and Class 1 Integrons in Escherichia coli Isolated From River Yamuna, India: A Serious Public Health Risk.

Globally, urban water bodies have emerged as an environmental reservoir of antimicrobial resistance (AMR) genes because resistant bacteria residing here might easily disseminate these traits to other waterborne pathogens. In the present study, we have investigated the AMR phenotypes, prevalent plasmid-mediated AMR genes, and integrons in commensal strains of Escherichia coli, the predominant fecal indicator bacteria isolated from a major urban river of northern India Yamuna. The genetic environment of blaCTX–M–15 was also investigated. Our results indicated that 57.5% of the E. coli strains were resistant to at least two antibiotic classes and 20% strains were multidrug resistant, i.e., resistant to three or more antibiotic classes. The multiple antibiotic resistance index of about one-third of the E. coli strains was quite high (>0.2), reflecting high contamination of river Yamuna with antibiotics. With regard to plasmid-mediated AMR genes, blaTEM–1 was present in 95% of the strains, followed by qnrS1 and armA (17% each), blaCTX–M–15 (15%), strA-strB (12%), and tetA (7%). Contrary to the earlier reports where blaCTX–M–15 was mostly associated with pathogenic phylogroup B2, our study revealed that the CTX-M-15 type extended-spectrum β-lactamases (ESBLs) were present in the commensal phylogroups A and B1, also. The genetic organization of blaCTX–M–15 was similar to that reported for E. coli, isolated from other parts of the world; and ISEcp1 was present upstream of blaCTX–M–15. The integrons of classes 2 and 3 were absent, but class 1 integron gene intI1 was present in 75% of the isolates, denoting its high prevalence in E. coli of river Yamuna. These evidences indicate that due to high prevalence of plasmid-mediated AMR genes and intI1, commensal E. coli can become vehicles for widespread dissemination of AMR in the environment. Thus, regular surveillance and management of urban rivers is necessary to curtail the spread of AMR and associated health risks.

Outer membrane protein A inhibits the degradation of caspase-1 to regulate NLRP3 inflammasome activation and exacerbate the Acinetobacter baumannii pulmonary inflammation

Acinetobacter baumannii (A. baumannii), one of the major pathogens that causes severe nosocomial infections, is characterised by a high prevalence of drug resistance. It has been reported that A. baumannii triggers the NOD-like receptor 3 (NLRP3) inflammasome, but the role of its virulence-related outer membrane protein A (ompA) remains unclear. Therefore, this study aimed to explore the effects of ompA on the NLRP3 inflammasome and its underlying molecular mechanisms. Results showed that ompA enhanced inflammatory damage, which was reduced as a result of knockout of the ompA gene. Additionally, ompA-stimulated expression of NLRP3 inflammasome was significantly blocked by silencing caspase-1, but activation of NLRP3 inflammasome was not altered after silencing ASC; this indicated that ompA was dependent on the caspase-1 pathway to activate the inflammatory response. Simultaneously, the wild-type (WT) strains triggered NLRP3 inflammasome after inhibition of caspase-1 degradation by proteasome inhibitor MG-132, aggravating tissue damage. These findings indicated that ompA may be dependent on the caspase-1 pathway to enhance inflammation and exacerbate tissue damage. Taken together, these results confirmed a novel capsase-1−modulated mechanism underpinning ompA activity, which further reveals the NLRP3 inflammasome pathway as a potential immunomodulatory target against A. baumannii infections.

Antibiotic Resistance and Phenotypic and Genotypic Detection of Colistin Resistance among Enterobacter Species Isolated from Patients of a Tertiary Care Hospital, Bangladesh

The prevalence of antimicrobial resistance among Enterobacter species is alarmingly high. Colistin as a last resort antibiotic reintroduced in the treatment pipeline to combat the drug resistant Enterobacter infection has led to emergence of colistin resistance. The study was designed to determine the prevalence of antibiotic resistance among isolated Enterobacter and to assess the occurrence of colistin resistance both phenotypically and genotypically in a tertiary care hospital, Bangladesh. This cross-sectional study was conducted during the period July2018 to June 2019. A total 350 different samples were processed. Enterobacter were identified phenotypically and were processed for antimicrobial susceptibility test (AST) by using modified disk diffusion method. Colistin resistance was determined by minimum inhibitory concentration (MIC) using agar dilution method. Colistin resistant strains were further processed for colistin resistance genes using polymerase chain rection (PCR). Among the total samples processed, 65.14% (228/350) yielded culture positive growth of which 12.28% (28/228) were Enterobacter species. Among isolated Enterobacter 22 (9.64%) were E. cloacae and 6 (2.63%) were E. aerogenes. In AST, 89.29%, 57.14% and 42.86% were resistant to ciprofloxacin, amikacin and imipenem respectively. Tigecycline and colistin were most effective antibiotics. Among colistin resistant Enterobacter isolates, 85.71%, 71.42%, 42.85% and 57.14% were positive for PmrC, PmrA, PhoP and PmrB respectively detected by PCR. Our study reports identification and distribution of drug resistant Enterobacter strains in a major tertiary care hospital. High prevalence of drug resistance and emergence of colistin resistance is indicative of deteriorating situation. Therefore, further extensive surveillance is mandatory.

Antimicrobial Susceptibility Pattern and Associated Factors of Pediatric Septicemia in Southern Ethiopia.

BackgroundSepticemia is one of the major causes of morbidity and mortality in pediatric patients throughout the world. Drug-resistant pathogens are one of the major challenges to control. The study aimed to identify the major etiological agents, antimicrobial susceptibility pattern and associated factors of septicemia among pediatric patients in southern Ethiopia.MethodsA cross-sectional study was conducted on pediatric patients. Blood samples were cultured and antimicrobial susceptibility testing was conducted by Kirby-Bauer disc diffusion techniques. Data were collected by pre-tested questionnaire to identify potential associated factors of septicemia. A bivariate logistic regression analysis was used and adjusted odds ratio with 95% CI at ≤0.05 level of significance was computed to determine the presence and strength of the association.ResultsOf 238 participants, 27 (11.3%) of them had a positive blood culture. Staphylococcus aureus (32.2%), coagulase negative Staphylococci (25%), and Klebsiella pneumoniae (14.3%) were the predominant isolates. The isolated bacteria showed high rates of resistance to amoxicillin, ceftriaxone, streptomycin and ampicillin. Multi-drug resistance (MDR) was observed in 82.1% of the isolates. Being infant [AOR=4.18, 95% CI, (1.3–13.0)], admission >10 days [AOR=5.54, 95% CI, (1.51–20.41)], burn [AOR=3.55, 95% CI, (1.02–12.38)] and wound cases [AOR=5.52, 95% CI, (1.50–20.34)] were associated with pediatric septicemia.ConclusionGram positive bacteria were the predominant isolates and majority of isolates were MDR pathogens. Very young age, prolonged hospital stays, burn and wound cases were associated with pediatric septicemia. Establishing antibiotic stewardship is mandatory to minimize the high prevalence of drug resistance.

HIV drug resistance in a cohort of HIV-infected MSM in the United States.

To analyze HIV drug resistance among MSM recruited for participation in the HPTN 078 study, which evaluated methods for achieving and maintaining viral suppression in HIV-infected MSM. Individuals were recruited at four study sites in the United States (Atlanta, Georgia; Baltimore, Maryland; Birmingham, Alabama; and Boston, Massachusetts; 2016-2017). HIV genotyping was performed using samples collected at study screening or enrollment. HIV drug resistance was evaluated using the Stanford v8.7 algorithm. A multiassay algorithm was used to identify individuals with recent HIV infection. Clustering of HIV sequences was evaluated using phylogenetic methods. High-level HIV drug resistance was detected in 44 (31%) of 142 individuals (Atlanta: 21%, Baltimore: 29%, Birmingham: 53%, Boston: 26%); 12% had multiclass resistance, 16% had resistance to tenofovir or emtricitabine, and 8% had resistance to integrase strand transfer inhibitors (INSTIs); 3% had intermediate-level resistance to second-generation INSTIs. In a multivariate model, self-report of ever having been on antiretroviral therapy (ART) was associated with resistance (P = 0.005). One of six recently infected individuals had drug resistance. Phylogenetic analysis identified five clusters of study sequences; two clusters had shared resistance mutations. High prevalence of drug resistance was observed among MSM. Some had multiclass resistance, resistance to drugs used for preexposure prophylaxis (PrEP), and INSTI resistance. These findings highlight the need for improved HIV care in this high-risk population, identification of alternative regimens for PrEP, and inclusion of integrase resistance testing when selecting ART regimens for MSM in the United States.

Healthcare-associated Infection in Intensive Care Units: Overall Analysis of Patient Criticality by Acute Physiology and Chronic Health Evaluation IV Scoring and Pathogenic Characteristics.

ABSTRACTObjectivesTo compare the predicted vs observed mortality rate, criticality, and length of stay of the patients with healthcare-associated infections (HAIs) in intensive care units (ICUs) of a tertiary health center through acute physiology and chronic health evaluation (APACHE) IV scoring. To analyze the drug sensitivity pattern of the isolated pathogen.DesignThis is a prospective observational study involving the patients admitted to various ICUs of a tertiary care teaching hospital. Among 1,229 patients who were admitted in the ICUs for a period of 2.5 months (74 days), 767 patients stayed beyond 48 hours. They were monitored and 87 of them who developed HAIs were included in the study. The organisms isolated from the infection site were identified, and the drug resistance pattern was reported as per standard guidelines. The patients were followed up till their discharge, and adequate details pertaining to the study were collected including demographic details and physiological and biochemical parameters to calculate APACHE IV score, length of stay, and prognosis.SettingIntensive care units of JSS Hospital, Mysuru, Karnataka, India.Subjects/patientsAll patients who developed HAI in ICUs.InterventionsNil.Measurements and main resultsThe HAI rate observed in this study was 15.7%. Ventilator-associated pneumonia (VAP) was the most common type of infection. Klebsiella and Acinetobacter were the frequently isolated organisms. There was a high prevalence of drug resistance among these pathogens. The ICU mortality in infected patients was 21.83%, roughly twice as that of uninfected patients. The observed length of stay was 11.66 (±8.53) days.ConclusionHealthcare-associated infection was associated with long duration of ICU stay. There was a high prevalence of drug resistance to various antibiotics. Acute physiology and chronic health evaluation IV score was not found to be good scoring system to predict the mortality and length of stay in the patients who had HAI.How to cite this articleGunasekaran S, Mahadevaiah S. Healthcare-associated Infection in Intensive Care Units: Overall Analysis of Patient Criticality by Acute Physiology and Chronic Health Evaluation IV Scoring and Pathogenic Characteristics. Indian J Crit Care Med 2020;24(4):252–257.

High prevalence of multi drug resistant tuberculosis in people living with HIV in Western India

BackgroundMost studies assessing drug resistant tuberculosis (DRTB) in human immunodeficiency virus (HIV) co-infected patients in India have used conventional culture- based systems to diagnose DRTB that have a longer turnaround time leading to risk of amplification of resistance to an empirical regimen. We determined the prevalence of DRTB amongst people living with HIV (PLHIV) using the line probe assay and determined risk factors associated with the presence of multi drug resistant tuberculosis (MDRTB).MethodsA Cross-sectional study was undertaken at Poona Hospital and Research Center (PHRC) and the Institute of Infectious Diseases, two tertiary level private care centers in Pune, India. Consenting PLHIV with confirmed Pulmonary TB (PTB) and/or extra-pulmonary TB (EPTB) diagnosed based on detection of Mycobacterium TB by line probe assay (Geno Type MTBDRplus version 2) on clinical specimens were included. Those with documented past history of DRTB were excluded. Resistance against anti-TB drugs was determined by the same assay. The prevalence of any form of drug resistant TB (DRTB), MDRTB, Rifampicin resistant TB (RRTB) and Isoniazid (INH) mono-resistant TB were determined as the proportion of these amongst all included PLHIV-TB. A multivariate analysis was conducted to determine risk factors that were statistically associated with MDRTB, DRTB, RRTB and INH mono-resistant TB.ResultsTwo hundred PLHIV were recruited. The prevalence (95% CI) of MDRTB, INH mono- resistance and RR resistance was 12.5% (7.9–17.1%), 9% (6.9–11.2%) and 2.5% (1.4–3.6%), respectively. The prevalence (95% CI) of MDRTB among new and relapsed patients was 8.8% (6.5–11.1%) and 23.1% (17.2–28.9%), respectively. Tuberculosis relapse was the only factor significantly associated with MDRTB, DRTB and INH mono-resistant TB.ConclusionWe document a high prevalence of drug resistance to anti-TB drugs including MDRTB among PLHIV in our setting using Geno Type MTBDRplus directly on clinical specimens. This validates the WHO recommendation of performing routine rapid molecular resistance testing prior to initiating anti-TB treatment among all PLHIV with presumptive TB. Using rapid molecular testing especially Geno Type MTBDRplus (that detects resistance to INH and Rifampicin simultaneously) reduces the turn-around time helping in optimizing treatment.

Combining Phylogenetic and Network Approaches to Identify HIV-1 Transmission Links in San Mateo County, California.

The HIV epidemic in San Mateo County is sustained by multiple overlapping risk groups and is an important hub for HIV transmission in northern California. Limited access to care has led historically to delayed clinical presentation, higher rates of opportunistic infections, and an increased prevalence of antiretroviral drug resistance. The virologic and clinical consequences of treatment within these multiple ethnic and behavioral groups are poorly understood, highlighting the need for efficient surveillance strategies that are able to elucidate transmission networks and drug resistance patterns. We obtained sequence data from a group of 316 HIV-positive individuals in the San Mateo AIDS Program over a 14-year period and integrated epidemiologic, phylogenetic, and network approaches to characterize transmission clusters, risk factors and drug resistance. Drug resistance mutations were identified using the Stanford HIV Drug Resistance Database. A maximum likelihood tree was inferred in RAxML and subjected to clustering analysis in Cluster Picker. Network analysis using pairwise genetic distances was performed in HIV-TRACE. Participants were primarily male (60%), white Hispanics and non-Hispanics (32%) and African American (20.6%). The most frequent behavior risk factor was male-male sex (33.5%), followed by heterosexual (23.4%) and injection drug use (9.5%). Nearly all sequences were subtype B (96%) with subtypes A, C, and CRF01_AE also observed. Sequences from 65% of participants had at least one drug resistance mutation. Clustered transmissions included a higher number of women when compared to non-clustered individuals and were more likely to include heterosexual or people who inject drugs (PWID). Detailed analysis of the largest network (N = 47) suggested that PWID played a central role in overall transmission of HIV-1 as well as bridging men who have sex with men (MSM) transmission with heterosexual/PWID among primarily African American men. Combined phylogenetic and network analysis of HIV sequence data identified several overlapping risk factors in the epidemic, including MSM, heterosexual and PWID transmission with a disproportionate impact on African Americans and a high prevalence of drug resistance.

Molecular Epidemiology and Antimicrobial Susceptibility of Clostridium difficile Isolates from a University Teaching Hospital in China.

While the developed world has seen a significant increase in the number of scientific articles on Clostridium difficile infection (CDI), the developing world still lags behind on this subject due to limited laboratory capacity, low awareness, and limited surveillance of this problem. As such, CDI is considered a neglected but potentially huge problem in developing countries. The major aim of this study was to systemically evaluate the utility of several molecular typing tools for CDI, including their relevance in epidemiological studies in developing countries such as China. A total of 116 non-repetitive toxigenic C. difficile isolates from Chinese patients, were studied. The isolates comprised 83 (71.6%) A+B+CDT- isolates, 27 (23.3%) A-B+CDT- isolates, and 6 (5.1%) A+B+CDT+ isolates. Typing methods evaluated included multilocus variable-number tandem-repeat analysis, PCR ribotyping, multilocus sequence typing, and sequencing of slpA and tcdC genes, which identified 113, 30, 22, 18, and 8 genotypes each and exhibited discriminatory powers of 0.999, 0.916, 0.907, 0.883, and 0.765, respectively. Compared to A+B+ strains, A-B+ strains exhibited higher prevalence of drug resistance to clindamycin, erythromycin, levofloxacin, rifampicin, rifaximin, and tetracycline. Furthermore, drug resistance rates of strains with different PCR ribotypes differed, supporting the importance of molecular typing in management and control of CDI. Based on our earlier suggestion to improve the diagnostic laboratory capacity of CDI in developing countries, setting up efficient surveillance programs complemented by relevant molecular typing methods is warranted.

Genotyping of mutations detected with GeneXpert

Objective/backgroundTuberculosis remains an important cause of mortality worldwide. Previous tuberculosis treatment is a strong determinant of multi-drug resistant tuberculosis. The study objective was to describe the mutations detected of Mycobacterium tuberculosis (MTB) complex clinical strains screened with GeneXpert isolated from previously treated patients in Côte d’Ivoire. MethodsSputum collected and decontaminated by the n-acetyl-l-cysteine method was used to perform Ziehl–Neelsen staining, GeneXpert MTB/rifampicin, and culture on Lowenstein–Jensen medium. Drug susceptibility testing (DST) for first-line drugs was performed in a Bactec 960 Automated System. After strain identification by antigen MPT64 detection, DNA extraction, and genotyping with MTBDRplus assay was performed and interpreted. The strains muted in rpoB without a specific protein identified and were sequenced. ResultsMutant sequences were detected in 60 sputum samples with GeneXpert MTB/rifampicin of which 55 were confirmed multi-drug resistant MTB strains after DST. The most frequent mutations responsible for rifampin resistance were detected with MTBDRplus assay for 49 (81.7%) clinical strains, while sequencing was required for 11 (18.3%). H526Q mutation, L533P, and D516V associated respectively with L533P, A532A, and S522L, and were observed for three relapse cases. For these cases, GeneXpert and sequencing results were concordant. Discrepancies between GeneXpert and mycobacteria growth indicator tube-DST for rifampin were observed for three strains, on which D516Y, H526C, and L533P were identified. ConclusionIn the setting of a high prevalence of drug resistance, characterization of the genetic basis of MTB strains resistant to rifampin could be screened first with MTBDRplus.

Tuberculosis-related mortality in people living with HIV in Europe and Latin America: an international cohort study

Management of tuberculosis in patients with HIV in eastern Europe is complicated by the high prevalence of multidrug-resistant tuberculosis, low rates of drug susceptibility testing, and poor access to antiretroviral therapy (ART). We report 1 year mortality estimates from a multiregional (eastern Europe, western Europe, and Latin America) prospective cohort study: the TB:HIV study. Consecutive HIV-positive patients aged 16 years or older with a diagnosis of tuberculosis between Jan 1, 2011, and Dec 31, 2013, were enrolled from 62 HIV and tuberculosis clinics in 19 countries in eastern Europe, western Europe, and Latin America. The primary endpoint was death within 12 months after starting tuberculosis treatment; all deaths were classified according to whether or not they were tuberculosis related. Follow-up was either until death, the final visit, or 12 months after baseline, whichever occurred first. Risk factors for all-cause and tuberculosis-related deaths were assessed using Kaplan-Meier estimates and Cox models. Of 1406 patients (834 in eastern Europe, 317 in western Europe, and 255 in Latin America), 264 (19%) died within 12 months. 188 (71%) of these deaths were tuberculosis related. The probability of all-cause death was 29% (95% CI 26-32) in eastern Europe, 4% (3-7) in western Europe, and 11% (8-16) in Latin America (p<0·0001) and the corresponding probabilities of tuberculosis-related death were 23% (20-26), 1% (0-3), and 4% (2-8), respectively (p<0·0001). Patients receiving care outside eastern Europe had a 77% decreased risk of death: adjusted hazard ratio (aHR) 0·23 (95% CI 0·16-0·31). In eastern Europe, compared with patients who started a regimen with at least three active antituberculosis drugs, those who started fewer than three active antituberculosis drugs were at a higher risk of tuberculosis-related death (aHR 3·17; 95% CI 1·83-5·49) as were those who did not have baseline drug-susceptibility tests (2·24; 1·31-3·83). Other prognostic factors for increased tuberculosis-related mortality were disseminated tuberculosis and a low CD4 cell count. 18% of patients were receiving ART at tuberculosis diagnosis in eastern Europe compared with 44% in western Europe and 39% in Latin America (p<0·0001); 12 months later the proportions were 67% in eastern Europe, 92% in western Europe, and 85% in Latin America (p<0·0001). Patients with HIV and tuberculosis in eastern Europe have a risk of death nearly four-times higher than that in patients from western Europe and Latin America. This increased mortality rate is associated with modifiable risk factors such as lack of drug susceptibility testing and suboptimal initial antituberculosis treatment in settings with a high prevalence of drug resistance. Urgent action is needed to improve tuberculosis care for patients living with HIV in eastern Europe. EU Seventh Framework Programme.

High prevalence of multidrug-resistance uropathogenic Escherichia coli strains, Isfahan, Iran.

Background and Objectives:Urinary tract infection (UTI) is one of the most frequent infectious diseases and can occur in all age groups. Escherichia coli is the main cause of this infection. Multiple resistances to antimicrobial agents are increasing quickly in E. coli isolates and may complicate therapeutic strategies for UTI. The aim of this study was to determine the antibiotic resistance pattern and the multidrug-resistance (MDR) phenotypes in uropathogenic E. coli (UPEC).Materials and Methods:A total of 135 UPEC isolates were collected from both outpatients (91 isolates) and inpatients (44 isolates) between September, 2012 and February, 2013. In order to determine the MDR among UPEC isolates, we have tested 15 antimicrobial agents and antibiotic susceptibility was done by Kirby-Bauer disk diffusion method.Results:The percentage of MDR isolates (resistant to at least three drug classes such as aminoglycosides, fluoroquinolones, penicillins, cephalosporins, or carbapenems) was 68% in the inpatients and 61% in the outpatients. Antibiotic resistance to ampicillin, ceftazidim, nalidixic acid, and trimethoprim/sulfamethoxazole were higher than 50%. Amikacin, nitrofurantoin, and gentamicin showed markedly greater activity (89.1%, 85.9%, and 82.4% sensitivity, respectively) than other antimicrobial agents. Resistance to meropenem did show either in outpatients or in inpatients.Interpretation and Conclusions:The high prevalence of drug resistance among UTI patients calls for continuous monitoring of the incidence of drug resistance for appropriate empiric selection of antibiotic therapy. Empirical treatment of UTIs should be relied on susceptibility patterns from local studies.