Resistance In Intensive Care Unit Research Articles

Multidrug Resistant Bacteria Isolated From Some Basrah Hospitals

General Background: Antibiotic resistance is a significant and growing public health concern, especially in hospital settings, where intensive care units (ICUs) often harbor multidrug-resistant organisms. Specific Background: Antimicrobial resistance in ICUs is a significant issue, necessitating a thorough assessment of bacterial susceptibility patterns to develop effective treatment protocols. Knowledge Gap: Despite the increasing concern, comprehensive studies focusing on bacterial resistance patterns in ICUs, particularly in diverse hospital settings, remain limited. Aims: The study aimed to assess the resistance patterns of bacterial isolates from blood, urine, and ICU surfaces to various antibiotics and identify the most resistant species. Results: Thirty blood, twenty urine, and fifty-six environmental samples were collected and cultured. Staphylococcus spp. exhibited 75% resistance to erythromycin, while Klebsiella spp., Pantoea spp., and E. coli showed 100% resistance to multiple antibiotics, including Ticarcillin, Piperacillin, and Cefixime. Confirmatory bacterial identification was performed using the Vitek 2 compact system, and resistance was measured across 25 antibiotics from various classes. Novelty: The study highlights the alarming 100% antibiotic resistance in various ICU-associated bacterial species, emphasizing the urgent need for revised antibiotic stewardship programs. Implications: The study underscores the importance of monitoring AMR patterns in hospitals and adjusting antibiotic therapies to combat rising resistance, particularly in ICUs, highlighting the need for robust surveillance. Highlights: 100% resistance: Klebsiella, Pantoea, E. coli resist multiple antibiotics in ICU. ICU risk: Multidrug-resistant bacteria prevalent in intensive care units. Urgent need: Update antibiotic protocols, enhance AMR surveillance in hospitals. Keywords: Antibiotic resistance, ICU, bacterial susceptibility, multidrug-resistant organisms, hospital infections

Impact of antimicrobial resistance in critically ill patients in the intensive care unit

According to the Pan American Health Organization, multidrug-resistant pathogens are responsible for an increase in morbidity and mortality among hospitalized patients, leading to higher healthcare costs due to the need for prescribing more expensive medications. The aim of the research was to identify, through literature review, the impact of antimicrobial resistance in Intensive Care Units. The bibliographic review study employed a qualitative methodology; its scope was explanatory, and it utilized the historical-logical method for theoretical knowledge acquisition. For empirical knowledge, documentary analysis was used, including publications found in databases such as Scielo, PubMed, Lilacs, Dialnet, Redalyc, Google Scholar, Elsevier, institutional repositories, among others. It was evidenced that the direct causes of death and bacterial resistance in the Intensive Care Unit are sepsis, followed by septic shock, the multi-organ dysfunction syndrome, and some of the antimicrobials currently used in ICUs, such as Piperacillin-Tazobactam, Cefepime, Amikacin, Cefotaxime, and the germs that showed resistance to these antimicrobials, firstly identified were Enterobacter Aerogenes, Escherichia coli, Staphylococcus Aureus. It is concluded that, in terms of the incidence of healthcare-associated infections, there is a significant impact on the health system, increasing the morbidity and mortality of the patient by up to 50 %, including longer hospital stays, greater use of antibiotics, worse prognosis, higher complication rates, and even death

Nosocomial Infection and Antimicrobial Resistance in Intensive Care Units: Comparison of Secondary and Tertiary Hospital

Antibiyotik direnci, sağlık hizmetiyle ilişkili enfeksiyonlarda (SHIE) önemli bir sorun olarak karşımıza çıkabilmektedir. Çalışmada aynı il içinde bulunan ikinci basamak hastane (2.BH) ile üçüncü basamak hastane (3.BH) yoğun bakım ünitelerindeki (YBÜ) SHİE hızlarının ve antimikrobiyal direnç oranlarının karşılaştırılması amaçlanmıştır. 2.BH ve 3.BH’deki YBÜ’lerde, 1 Ocak 2017 – 31 Aralık 2019 tarihleri arasında, Centers for Disease Control and Prevention (CDC) kriterlerine göre SHİE tanısı almış 18 yaş ve üzerindeki hastalar çalışmamıza dahil edilmiştir. SHİE insidans hızı, insidans dansitesi ve Klebsiella spp., Pseudomonas spp. ve Acinetobacter spp.’de karbapenem direnç oranları karşılaştırılmıştır. YBÜ’lerde 2.BH’de 158, 3.BH’de 519 SHİE gelişmiştir. SHİE insidans hızı 3.BH’deki YBÜ’lerde 2.BH’dekilerden daha yüksek bulunmuştur. 2.BH YBÜ’lerinde 2017-2019 yılları arasındaki karbapenem dirençli Klebsiella spp. oranları 3.BH’ye kıyasla istatistiksel açıdan anlamlı olarak daha yüksek saptanmıştır (p=0.001). Hastaneler arasında Pseudomonas spp. ve Acinetobacter spp.türlerinde karbapenem direnç oranları açısından istatistiksel açıdan anlamlı bir fark bulunamamıştır (sırasıyla p=0.723, p=0.267). Her iki hastanede de yıllar arasında karbapenem direnci oranlarında anlamlı bir değişiklik saptanmamıştır (p>0.05). 3.BH YBÜ’lerde SHİE hızı daha yüksek saptanmasına rağmen direnç oranları 2.BH’ye kıyasla daha düşük veya benzer bulunmuştur. Bu farkı inceleyen ileri çalışmalar antimikrobiyal direncin azalmasında yardımcı olabilir.

Impact of the COVID-19 Pandemic on Epidemiology of Antibiotic Resistance in an Intensive Care Unit (ICU): The Experience of a North-West Italian Center.

The SARS-CoV-2 pandemic caused an increase in intensive care unit (ICU) hospitalizations with a rise in morbidity and mortality; nevertheless, there is still little evidence on the impact of the pandemic on antibiotic resistance in ICUs. This is a retrospective, monocentric epidemiological study. The aim of the study was to describe and analyze the impact of the SARS-CoV-2 pandemic on ICU bacterial resistance patterns. All bacteria isolated from all patients admitted to the E.O. Galliera ICU from January 2018 to December 2022 were included. Antibiotic resistance (AR) profiles were evaluated. A total of 1021 microorganisms were identified, of which 221 (12.47%) had a resistance pattern (resistant organisms; ROs). In this time, there were 1679 patients with a total of 12,030 hospitalization days. The majority of microorganisms were Gram-negative (79.66% in 2018, 77.29% in 2019, 61.83% in 2020, 62.56% in 2021, and 60.75% in 2022), but an increase in Gram-positive microorganisms was observed (20.34 to 39.25% between 2018 and 2022). The prevalence of AR was 19.44% in 2018, 11.54% in 2019, 38.04% in 2020, 34.15% in 2021, and 39.29% in 2022 for Gram-positive microorganisms and 19.86% in 2018, 13.56% in 2019, 18.12% in 2020, 12.41% in 2021, and 12.31% in 2012 for Gram-negative microorganisms. The incidence of ROs showed a COVID-19-related increase in 2020-2021, followed by a lowering trend since 2021, and a new increase in 2022. Possible explanations are antibiotic overtreatment and a decrease in containment measures. An interesting finding was the cumulative lowering trend of carbapenem-resistant K. pneumoniae and P. aeruginosa, probably due to different patient features.

Discovering Association Rules in Antimicrobial Resistance in Intensive Care Unit.

Multidrug resistant infections in intensive care units represent a worldwide problem with adverse health effects and negative economic implications. As artificial intelligence techniques are increasingly applied in diagnosing, treating, and preventing antimicrobial resistance, in this study, we explore the use of association rule mining in the antibiotic resistance profile of critically ill patients suffering from multidrug resistant infections.

Carbapenems consumption and Klebsiella resistance in intensive care units in Egypt: A study to evaluate the effect of an antimicrobial stewardship program.

The high prevalence of carbapenem-resistant Klebsiella imposes optimizing antibiotic consumption. We aimed to evaluate the impact of antibiotic stewardship program on carbapenem consumption and the Klebsiella resistance. We retrospectively evaluated critically ill patients with isolated Klebsiella species from Elaraby hospital, Egypt during the period from April 2017 to January 2019. We collected data related to carbapenems consumption and Klebsiella clinical isolates with their antimicrobial susceptibility. Based on susceptibility, Klebsiella isolates were classified into sensitive, extended spectrum beta-lactamase (ESBL) producer, and carbapenem-resistant Klebsiella (CRK), respectively. Our primary outcome was the change in carbapenems consumption after implementing the program, while the secondary outcomes were the changes in the incidence of CRK. The study included 205 patients with isolated Klebsiella species during the study period. The antibiotic stewardship program started in March 2018. Out of the 205 patients, 61 patients (29.8%) represented the pre-intervention sample, and 144 patients (70.2%) represented the post-intervention sample. Applying the antibiotic stewardship program was associated with a significant decrease in the carbapenems consumption from 38.9 to 26.6 defined daily dose/1000 patient-days (p = 0.02). The incidence of CRK was decreased from 85.25% of total Klebsiella isolates to 48.6% (p < 0.001). Klebsiella species were more likely to be in a lower category of resistance after applying the program with an odds ratio of 6.3 (2.88-13.73) using ordinal logistic regression. Applying the antibiotic stewardship program could reduce the unnecessary carbapenems use in the ICU with a subsequent decrease in the emergence of the Klebsiella-resistant strains.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

Cathetar Related Antimicrobial Resistance Pattern in Intensive Care Unit Patients: A Single Centre Study

Background&#x0D; Urinary catheter is the most common cause of urinary tract infection (UTI) which has been associated with three fold increase risk in mortality. A high level of resistance was noted among the admitted patients for cephalosporin. The primary aim of the study is to known the strain of pathogens; its drugs sensitivity and resistance in intensive care unit (ICU) patients which help the physician in proper management and reduces the mortality and morbidity in urinary catheter related complication.&#x0D; Methods&#x0D; This study was conducted in Intensive care unit patients of Hayatabad medical complex Peshawar Pakistan over a period of 1 year from 1st January to 31st December 2019. Medical charts were reviewed and 100 patients were selected based on inclusion criteria and their urine culture and sensitivity reports were noted to know about the most common pathogens, its drugs sensitivity and resistance in these patients. Clinical and Laboratory Standards Institute (CLSI) used for uropathogen by culture and Disc diffusion method to determined antimicrobial susceptibility pattern. The data were shifted from excel sheet to SPPS 21 IBMS version.&#x0D; Results &#x0D; The mean age (standard deviation) of patients was 51.60+26.59 years (Median age 58.50 years). Of the total, 64 were female and the remaining were male patients. It was found that most common pathogens in urine sample was E. coli. Maximum pathogens were sensitive to intra venous meropenem (65%), and fosfomycin (55%).&#x0D; Conclusion&#x0D; It is concluded that resistance patterns of uropathogens changes which results in treatment failure. Further, based on clinical practice, meropenem, fosfomycin, and cefepime had high sensitivity profile against catheter related infection in ICU.

Patterns of antimicrobial consumption and bacterial resistance in intensive care units: a pilot study from Palestine

Patterns of antimicrobial consumption and bacterial resistance in intensive care units: a pilot study from Palestine

Association between antibiotic resistance in intensive care unit (ICU)-acquired infections and excess resource utilization: Evidence from Spain, Italy, and Portugal.

Intensive care unit (ICU)-acquired infections with antibiotic-resistant bacteria have been associated with substantial health and economic costs. Moreover, southern Europe has historically reported high levels of antimicrobial resistance. We estimated the attributable economic burden of ICU-acquired infections due to resistant bacteria based upon hospital excess length of stay (LOS) in a selected sample of southern European countries. We studied a cohort of adult patients admitted to the ICU who developed an ICU-acquired infection related to an invasive procedure in a sample of Spanish, Italian, and Portuguese hospitals between 2008 and 2016, using data from The European Surveillance System (TESSy) released by the European Centers for Disease Control (ECDC). We analyzed the association between infections with selected antibiotic-resistant bacteria of public health importance and excess LOS using regression, matching, and time-to-event methods. We controlled for several confounding factors as well as time-dependent biases. We also computed the associated economic burden of excess resource utilization for each selected country. In total, 13,441 patients with at least 1 ICU-acquired infection were included in the analysis: 4,106 patients (30.5%) were infected with antimicrobial-resistant bacteria, whereas 9,335 patients (69.5%) were infected with susceptible bacteria. The unadjusted association between resistance status and excess LOS was 7 days (95% CI, 6.13-7.87; P < .001). Fully adjusted models yielded significantly lower estimates: 2.76 days (95% CI, 1.98-3.54; P < .001) in the regression model, 2.60 days (95% CI, 1.66-3.55; P < .001) in the genetic matching model, and a hazard ratio of 1.15 (95% CI, 1.11-1.19; P < .001) in the adjusted Cox regression model. These estimates, alongside the prevalence of resistance, translated into direct hospitalization attributable costs per ICU-acquired infection of 5,224€ (95% CI, 3,691-6,757) for Spain, 4,461€ (95% CI, 1,948-6,974) for Portugal, and 4,320€ (95% CI, 1,662-6,977) for Italy. ICU-acquired infections associated with antibiotic-resistant bacteria are substantially associated with a 15% increase in excess LOS and resource utilization in 3 southern European countries. However, failure to appropriately control for significant confounders inflates estimates by ∼2.5-fold.

Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship.

BackgroundIncreasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians.Aim and objectiveTo demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption.Materials and methodsWe compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis.ResultsPostintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI.ConclusionThe present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization.How to cite this articleAgarwal J, Singh V, Das A, Nath SS, Kumar R, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021;25(6):635–641.

Clinical, phenotypic and genotypic profile of carbapenem resistant gram negative infections in intensive care units

Carbapenems are currently the only active beta-lactams effective against the ESBL producing pathogens; this has led to an increase in their use not only for documented infections but also for empirical treatment of acquired infections in ICU patients. Thus, there is a selective pressure for carbapenem resistance in intensive care units of tertiary care hospitals. Carbapenem resistant infections are associated with high morbidity &amp; mortality. 1. To screen for carbapenem resistance among gram negative infections in ICU patients by disc diffusion &amp; confirmation by Vitek 2 system; 2: To detect the carbapenemase production by phenotypic methods; 3: To confirm the presence of resistant gene by PCR; 4: To find out the attributable risk factors from the clinical history of such patients; 5: To follow up &amp; estimate mortality rate in such infections and its statistical correlation A total of 160 gram negative isolates [E.coli(71), Klebsiella(63), Acinetobacter(10), Pseudomonas(9) and Enterobacter(7)] from patients of various intensive care units were screened by disc diffusion out of which 53(33.12%) were carbapenem resistant. Resistant isolates were further tested by Vitek 2 system for determination of MICs, Modified Hodge test(MHT) and Combined Disc test(CDT) for carbapenemase production and subjected to multiplex PCR for detection of resiatant gene i.e., bla NDM-1, bla VIM, bla IMP and bla KPC. Follow up of all the cases till the end of hospital stay was done and mortality rate was calculated.Results: 53 isolates(33.12%) were carbapenem resistant, 17 isolates were MHT positive while 39 were CDT positive. 24 isolates [E.coli(12), Klebsiella(7), Acinetobacter(3), Pseudomonas(1) and Enterobacter(1)] showed the presence of NDM-1 gene on PCR. Gentamicin(35%), Amikacin (45%), Tigecycline(88%) &amp; Colistin(100%) were sensitive for carbapenem resistant GNBs. Mortality in carbapenem sensitive infections in ICUs was 21% whereas resistant infections showed 37% (p value &amp;#60;0.05).Conclusion: 45% of carbapenem resistance is due to presence of NDM-1 gene, E.coli was the commonest isolate. Other mechanisms of resistance such as excessive ESBL production, porin loss may be responsible for resistance in remaining isolates. Effective infection control measures should be taken to prevent the spread of these super bugs in a ICU.

Bacterial resistance in intensive care units: a review

Bacterial resistance in intensive care units: a review

Increased Risk for Carbapenem-ResistantEnterobacteriaceaeColonization in Intensive Care Units after Hospitalization in Emergency Department

Carbapenem-resistant Enterobacteriaceae (CRE) colonization is common in hospital patients admitted to intensive care units (ICU) from the emergency department. We evaluated the effect of previous hospitalization in the emergency department on CRE colonization at ICU admission. Our case–control study included 103 cases and 201 controls; cases were patients colonized by CRE at admission to ICU and controls were patients admitted to ICU and not colonized. Risk factors were emergency department stay, use of carbapenem, Simplified Acute Physiology Score, upper digestive endoscopy, and transfer from another hospital. We found that ED stay before ICU admission was associated with CRE colonization at admission to the ICU. Our findings indicate that addressing infection control problems in EDs will help to control carbapenem resistance in ICUs.

Current trends in epidemiology and antimicrobial resistance in intensive care units

Intensivecare units (ICUs) have a unique environment within the hospital setting. Thefragility of the patients facilitates the presence of hospital-acquiredinfections (HAIs). To minimize the impact of HAIs, a series of antibioticstewardship strategies including mixing, cycling and combination therapies havebeen developed. Nonetheless, the impact of antibiotic resistance in HAIs inICUs remains extremely high. Most HAIs are caused by multidrug-resistantmicroorganisms, originating from contaminated ICUs surfaces or devices or frompatients admitted for infectious processes. Moreover, antibiotic resistance mayremain occult and be silently introduced into the ICU by a commensal member ofthe microbiomes of patients or health care personnel and thereafter transmittedto a pathogenic microorganism already residing in the ICU. The pathogenicmicroorganisms most frequently residing in ICUs include Escherichia coli and members of the so-called ESKAPE group ( Enterococcus faecium,Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii,Pseudomonas aeruginosa and Enterobacter spp .). These microorganismsshow resistance to most of the antibacterial agents commonly used in ICUs andhave been associated with the presence of specific mechanisms of chromosomal ortransferable resistance. Furthermore, when more than one antibiotic-resistantdeterminant is encoded within the same genetic structure lead to the phenomenaof co-selection of resistance. In some cases, ESKAPE microorganisms showresistance to all the scheduled antibacterial agents, requiring the use of“last resort” antibacterial agents such as ceftaroline, colistin ortigecycline. Unfortunately, resistance to all these antimicrobial agents hasbeen reported. The current antibiotic resistance observed in ICUs is of greatconcern and is dramatically advancing to a worrisome end: the return to apre-antibiotic era in which a series of antibiotic-untreatable pan-resistantmicroorganisms colonize ICUs causing severe and deadly infections. Urgentactions to firmly control antibiotic use in all environments are essential toput a halt to or mitigate the development of antibiotic resistance, while thedevelopment of new treatment alternatives is a research priority.

The Use of Liquids Ionic Fluids as Pharmaceutically Active Substances Helpful in Combating Nosocomial Infections Induced by Klebsiella Pneumoniae New Delhi Strain, Acinetobacter Baumannii and Enterococcus Species.

This review deals with various microbiological activities of ionic liquids, which constitute the first anti-infective defense against multi-drug-resistant bacteria—with a particular emphasis placed on medicine and pharmacology. The quoted data on the biological activity of ionic liquids including their antimicrobial properties (depending on the type of a cation or an anion) and are discussed in view of possible applications in nosocomial infections. Dedicated attention is given to finding infections with the Klebsiella pneumoniae New Delhi strain, Acinetobacter baumannii, and Enterococcus species, which are responsible for the induction of antibiotic resistance in intensive care units. Diagnosis and treatment using current antibiotics is a significant problem in hospital care, and the relevant burden on the health systems of the European Union member states induces the search for new, effective methods of treatment. Ionic liquids, due to their antibacterial effect, can be considered topical and general medications and may provide the basis for treatment to eliminate the antibiotic resistance phenomenon in the future. At present, the number of infections with resistant pathogens in hospitals and outpatient clinics in the European Union is growing. In 2015–2017, a significant incidence of respiratory and bloodstream infections with bacteria resistant to antibiotics from the 3rd generation group of cephalosporins, glycopeptides, and carbapenems were observed. The paper presents examples of synthesized bifunctional salts with at least one pharmaceutically active ion in obtaining a controlled release, controlled delivery, and biological impact on the pathogenic bacteria, viruses and fungi. The ionic liquids obtained in the presented way may find applications in the treatment of wounds and infections.

Evaluation of vancomycin therapy in the adult ICUs of a teaching hospital in southern Iran.

BackgroundVancomycin resistance in intensive care units (ICUs) accounts for significant morbidity and excess costs. The objective of the present study was to determine the appropriateness of vancomycin use in the various ICUs of Nemazee Hospital, Shiraz, Iran.MethodsThis prospective study was performed on 95 critically ill patients (48 males and 47 females) who were treated with vancomycin for at least 3 subsequent doses in 6 ICUs during 12 months. Required demographic, clinical, and paraclinical data were collected by a pharmacist. Fifteen indexes were considered for evaluation of vancomycin use.ResultsVentilator-associated hospital-acquired pneumonia (22.6%), sepsis (22.1%) and CNS infection (12.6%) were found to be the most important indications for vancomycin prescription. Vancomycin was prescribed empirically in 81% of patients. None of the patients received loading dose, and most of the patients received fixed dose. The rate of prolonged empiric antibiotic therapy was 68.5% in patients who received vancomycin. The mean score of vancomycin use in the ICUs of Nemazee Hospital was 7.1±0.6 out of 15, implying that the rate of vancomycin use was in accordance with the guideline proposed by the Department of Clinical Pharmacy of Nemazee Hospital based on Infectious Diseases Society of America by 47.3%.ConclusionBased on our results, the weakness in using vancomycin was related to not administering loading dose, the practice of prescribing fixed-dose vancomycin and prolonged duration of empiric therapy. Efforts to improve the pattern of vancomycin prescription and utilization in these ICUs should be undertaken.

The effects of antibiotic cycling and mixing on antibiotic resistance in intensive care units: a cluster-randomised crossover trial

Whether antibiotic rotation strategies reduce prevalence of antibiotic-resistant, Gram-negative bacteria in intensive care units (ICUs) has not been accurately established. We aimed to assess whether cycling of antibiotics compared with a mixing strategy (changing antibiotic to an alternative class for each consecutive patient) would reduce the prevalence of antibiotic-resistant, Gram-negative bacteria in European intensive care units (ICUs). In a cluster-randomised crossover study, we randomly assigned ICUs to use one of three antibiotic groups (third-generation or fourth-generation cephalosporins, piperacillin-tazobactam, and carbapenems) as preferred empirical treatment during 6-week periods (cycling) or to change preference after every consecutively treated patient (mixing). Computer-based randomisation of intervention and rotated antibiotic sequence was done centrally. Cycling or mixing was applied for 9 months; then, following a washout period, the alternative strategy was implemented. We defined antibiotic-resistant, Gram-negative bacteria as Enterobacteriaceae with extended-spectrum β-lactamase production or piperacillin-tazobactam resistance, and Acinetobacter spp and Pseudomonas aeruginosa with piperacillin-tazobactam or carbapenem resistance. Data were collected for all admissions during the study. The primary endpoint was average, unit-wide, monthly point prevalence of antibiotic-resistant, Gram-negative bacteria in respiratory and perineal swabs with adjustment for potential confounders. This trial is registered with ClinicalTrials.gov, number NCT01293071. Eight ICUs (from Belgium, France, Germany, Portugal, and Slovenia) were randomly assigned and patients enrolled from June 27, 2011, to Feb 16, 2014. 4069 patients were admitted during the cycling periods in total and 4707 were admitted during the mixing periods. Of these, 745 patients during cycling and 853 patients during mixing were present during the monthly point-prevalence surveys, and were included in the main analysis. Mean prevalence of the composite primary endpoint was 23% (168/745) during cycling and 22% (184/853) during mixing (p=0·64), yielding an adjusted incidence rate ratio during mixing of 1·039 (95% CI 0·837-1·291; p=0·73). There was no difference in all-cause in-ICU mortality between intervention periods. Antibiotic cycling does not reduce the prevalence of carriage of antibiotic-resistant, Gram-negative bacteria in patients admitted to the ICU. European Union Seventh Framework Programme.

Surveillance of Antibiotic Use and Resistance in Intensive Care Units (SARI).

The project entitled Surveillance of Antibiotic Use and Resistance in Intensive Care Units (SARI) was initiated in Germany in 2000. In this article, we describe developments in antibiotic use and resistance rates in the participating intensive care units over the years 2001-2015. The intensive care units supplied monthly figures on patient days, antibiotic use (in defined daily doses, DDD), and resistance data for 13 pathogens. The density of antibiotic use per 1000 patient days was calculated on the basis of antibiotic use, DDD, and patient days, and the resistance density per 1000 patient days was calculated from the number of resistant pathogens. In the years 2001-2015, data on 2 920 068 patient days were collected in 77 intensive care units. The average overall antibiotic use rose by 19% over this period, with a marked increase in the density of carbapenem use (from 76 to 250 DDD per 1000 patient days, +230%) and piperacillin-tazobactam use (from 42 to 146 DDD per 1000 patient days, +247%). The proportion of Escherichia coli and Klebsiella pneumoniae isolates that were resistant to third-generation cephalosporins increased markedly initially, then remained stable over the remainder of the observation period. The proportion of methicillin-resistant Staphylococcus aureus was stable over the entire period. The rates of vancomycin resistance among Enterococcus faecium isolates and imipenem resistance among gram-negative pathogens increased from 2.3% to 13.3% and from 0.1% to 0.3%, respectively. The resistance density of gram-negative multiresistant pathogens in the participating intensive care units increased markedly. The rise in imipenem-resistant pathogens arouses particular concern. The increased use of broad-spectrum/reserve antibiotics may well have contributed to this development. Efforts to use antibiotics rationally, e.g., with the support of multidisciplinary "antibiotic stewardship" teams, are therefore vitally important. As participation in SARI is voluntary, these surveillance data cannot be considered representative of Germany as a whole.

Epidemiology of multidrug-resistant Gram-negative pathogens isolated from ventilator-associated pneumonia in ICU patients.

Antibiotic resistance among Gram-negative pathogens isolated from ventilator-associated pneumonia (VAP) poses a grave threat in intensive care unit (ICU) patients. The aim of this study was to assess the prevalence of pathogens in ICU patients and their drug resistance profile. The prevalence of extended-spectrum β-lactamases (ESBLs), AmpC β-lactamases and metallo-β-lactamases (MBLs) was also assessed. Tracheal aspirates were collected aseptically from 87 ICU patients between May 2012 and January 2014. Cultured isolates were identified by standard microbiological techniques. Antimicrobial susceptibility testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. ESBLs and AmpC β-lactamases were detected both phenotypically and genotypically; MBLs were detected phenotypically. A total of 77 isolate were cultured. Gram-negative bacteria comprised 68 (88.3%) of the total isolates, among which 49 (72.1%) were multidrug-resistant (MDR). Gram-positive organisms comprised four (5.2%) of the total isolates and all four (100%) were MDR. Aspergillus fumigatus (6.4%) was the only fungal pathogen identified. Pseudomonas aeruginosa was the predominant pathogen associated with VAP. The rising trend of antibiotic resistance in Gram-negative organisms is alarming. Regular monitoring of the pattern of resistance in ICUs is critical in effective management of VAP patients.