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Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

Research Article

MICROBIAL PROFILE OF NOSOCOMIAL INFECTIONS IN THE PAEDIATRIC

INTENSIVE CARE UNIT AT A TERTIARY CARE HOSPITAL

Chandrashekar GS1, Sanchita Shettigar2, Ronald Roche2, Dr Narendra Nayak2, Anitha KB2, Santhosh Soans1
1 2
Dept. of Paediatrics and Dept. of Microbiology, A.J. Institute of Medical Sciences, Mangalore.

ABSTRACT

Background: Nosocomial infections (NI) are major public health concern because of the substantial morbidity and
the mortality which are associated with them.
Objectives: To know the incidence of NI, site of infection, pathogens involved and their antibiogram.
Methods: One year prospective study involving children who were admitted to PICU for more than 48 hours were
included. Isolates were identified from the clinical samples including blood, urine, sputum, wound/pus swab,
intravenous catheter tips, endotracheal secretions/tip, urinary catheter, central venous line, inter costal drainage
catheter tip.
Result: Out of 288 patients, 34 patients had NI. The overall NI rate was 9.26 % and the incidence density was 16.8
per 1000 patient-days. Primary bloodstream infections (38.2%), pneumonia (29.4%), and urinary tract infections
(26.5%) were most frequent. Nosocomial-related mortality was 23.5% and most commonly due to pneumonia
(62.5%). Staphylococcus aureus (46%) were the most common bloodstream isolates. Pseudomonas aeruginosa
(40%) followed by Acinetobacter baumanii (30%) were the most common species reported from pneumonia and
Escherichia coli (44%) from urinary tract infections. Nearly, 78% of pneumonia, 82% of urinary tract infection and
94% of blood stream infection were associated with ventilator use, urinary catheter and central venous catheter
respectively. All bacterial isolates showed high frequency of resistance to multiple antibiotics.
Conclusion: The presence of NI was associated with a long period of hospitalization and use of invasive devices.
Adherence to infection control protocols and short term use of invasive devices and judicious use of antibiotics are
important in preventing such infections.

Keywords: Antibiotics, Children, Nosocomial infection.

INTRODUCTION these infections lead to extra hospital expenditure thus

Nosocomial infection (NI) in the paediatric intensive overburdening the already strained health economy. In

care unit (PICU) is associated with increased studies conducted by various authors, the incidence of

mortality, morbidity and length of stay. In addition nosocomial infections ranged from 5.3% to 27.3%.1-5

Int j clin surg adv 2014; 2(4):1-8 1


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

It is defined as infection that begins 48 hours after Those having fever prior to admission to the PICU, or

admission to hospital.6 The commonest types are any other clinical features of infection secondarily

ventilator-associated pneumonia (VAP), central line- acquired in the wards prior to transfer to the PICU

associated bloodstream infection, urinary catheter- were excluded.

related infection and surgical site infection. The


Out of 367 children admitted, 288 patients (< 18 years
common pathogens include Staphylococcus aureus,
of age) who stayed more than 48 hours were included
Pseudomonas aeruginosa, Candida, Escherichia coli
in the study. Detailed history and clinical examination
and Klebsiella species. Prevention of infection is
were done giving special emphasis to risk factors.
fundamental and can be achieved through good
Routine laboratory investigations included complete
antimicrobial use and infection control, including hand
blood count, X-ray chest and urine examination.
hygiene. Microbiological cultures are essential for

rapid and accurate diagnosis, which improves Specific site related investigations included the
outcomes and reduces drug resistance. This study following:
aimed to determine the incidence of NI, site of

infection, pathogens involved and their antibiogram. • Blood culture at the time of admission to

rule out an already existing infection and as

MATERIAL AND METHODS and when patient developed clinical features

This is a prospective study on the incidence of NI suggestive of an infection.

involving patients admitted to PICU from July 2011 to


• Central venous line or intravenous catheter
June 2012 at A.J. Institute of Medical Sciences,
(IV) tips were cultured in those with
Mangalore. Patients were suspected to have developed
suspected thrombo-phlebitis along with
nosocomial infections after 48 hours of admission to
simultaneous blood culture from a site
the PICU if they had (i) unexplained fever >38ºC or
different from the site of IV catheter
>100.4 ºF, leukopenia <4000 WBC/mm3 or

leukocytosis >12,000 WBC/mm3; (ii) new infiltrates • Urine and tips of indwelling catheters were

on chest X-ray, persistent tracheal aspirates or cultured simultaneously in patients with

secretions; (iii) turbid urine, suprapubic tenderness, suspected urinary tract infections.

dysuria, burning micturition; (iv) thrombophlebitis.


• Culture from wound/pus swab

Int j clin surg adv 2014; 2(4):1-8 2


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

• Pleural fluid and, inter costal drainage


Primary
catheter (ICD) tips were also cultured.
bloodstream
infections
5.88%
• Sputum samples or tips of endotracheal pneumonia
26.47% 38.23%
tubes (ET) or swabs taken from the tips of
29.41% urinary tract
endotracheal suction catheter along with the
infections
tip of ETs were cultured.
Wound
infection
After removal under full aseptic precautions, the tip of

each catheter was cut using a sterile blade and the tip

was sent to microbiology laboratory in a sterile


Figure 1. Types of nosocomial infections in PICU
container for bacterial culture. The isolates were

identified and antibiotic susceptibility was determined Primary bloodstream infections and pneumonia were

by Kirby Bauer’s disc diffusion method according to reported more frequently in infants aged 12 months or

Clinical and Laboratory Standards Institute (CLSI) less as compared with older children. Urinary tract

guidelines.7 infections were reported more frequently in children

>5 years old compared with younger children.

OBSERVATION AND RESULTS Staphylococcus aureus (46%) were the most common

A total of 367 patient admissions and 2019 patient- bloodstream isolates, and aerobic Gram-negative

days were evaluated. Among the 288 patients, 34 bacilli were reported in 38% of primary bloodstream

patients had NI (28 patients with single site and 6 infections. Pseudomonas aeruginosa (40%) followed

patients with dual site). The overall NI rate was 9.26 by Acinetobacter baumanii (30%) were the most

% and the incidence density was 16.8 per 1000 common species reported from pneumonia and

patient-days. Primary bloodstream infections (38.2%), Escherichia coli (44%) from urinary tract infections

pneumonia (29.4%), and urinary tract infections (Table 1& Figure 2). Nearly, 78% of pneumonia, 82%

(26.5%) were most frequent and were almost always of urinary tract infection and 94% of blood stream

associated with use of an invasive device (Figure 1). infection were associated with ventilator use, urinary

catheter and central venous catheter respectively. The

presence of NI was associated with a long period of

Int j clin surg adv 2014; 2(4):1-8 3


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

hospitalization and use of invasive devices.

Nosocomial-related mortality was 23.5%, the

pneumonia-associated mortality rate was 62.5% and DISCUSSION

the primary bloodstream infection-associated mortality Patients in ICU are always at higher risk of developing

rate was 37.5%. Mortality was higher in patients with nosocomial infections with antibiotic resistant strains.

NI, compared to patients without NI. Prevention of NIs is the key procedure in quality of

healthcare. Accurate data on NI rates are essential for

evaluation of current infection prevention activities

and for planning further interventions in hospital as

well as at national level. The study conducted by

various authors on the incidence of nosocomial

infections ranged from 5.3% to 27.3%.1-5 In our study,

the overall NI rate was 9.26 % and the incidence

density was 16.8 per 1000 patient-days. Infection rate

was highest in primary blood stream infection


Figure 2-Percentage of nosocomial infections caused
followed by pneumonia and urinary tract which was
by different pathogens
similar to other studies.8,9,10 However, Patwardhan RB

All bacterial isolates showed high frequency of et al had found highest NI in urinary tract followed by

resistance to multiple antibiotics. In case of gram wound infections and pneumonia.5 In their study,

negative bacilli, susceptibility to imipenem (89%), blood stream infection was less common condition

meropenem (86%), piperacillin-tazobactam (70%), causing nosocomial infection. Similarly, Hossein

cefoperazone-sulbactam (67%) and amikacin (56%) Masoumi et al had observed ventilator-associated

was better than ampicillin, gentamicin, co- pneumonia was the most common nosocomial

trimoxazole, cefotoxime. ceftriaxone, ceftazidime, infection, followed by urinary tract infections and

ciprofloxacin and levofloxacin (Table 2). In case of clinical sepsis.4

gram positive cocci, vancomycin , teicoplanin and In the present study, an increased duration of stay in

linezolid showed 100% sensitivity and amikacin PICU and the number of days of intervention were

(50%). associated with increased NI rate which was similar to

Int j clin surg adv 2014; 2(4):1-8 4


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

Table 1. Distribution of nosocomial infections in PICU by site of infection

Organisms Primary blood Pneumonia Urinary tract Wound Total

stream infection infection infection number

Pseudomonas aeruginosa 02 04 01 00 07

Acinetobacter baumanii 01 03 00 00 04

Escherichia coli 01 00 04 00 05

Klebsiella pneumoniae 01 02 01 00 04

Staphylococcus aureus 06 01 01 01 09

Streptococcus spp. 00 00 00 01 01

Enterococcus spp. 01 00 00 00 01

Candida spp. 01 00 02 00 03

Total 13 10 09 02 34

Percentage 38.23 29.41 26.47 5.88 100

study done by Porto JP et al.8 However, Richards MJ adequate use of initial empirical antibiotic therapy.

and colleagues9 had refuted this observation. Further Nosocomial-related mortality in our study was 23.5%,

they have reported primary bloodstream infections and the pneumonia-associated mortality rate was 62.5%

surgical site infections were more frequently seen in and the primary bloodstream infection-associated

infants aged 2 months or less as compared with older mortality rate was 37.5%. Abramczyk ML et al had

children. Urinary tract infections were reported more reported nosocomial-related mortality was 21.3%, the

frequently in children >5 years old compared with pneumonia-associated mortality rate was 11.4% and

younger children which was similar to present study. the primary bloodstream infection-associated mortality

They have also found that NI was almost always rate was 33.3%.3 They concluded that mortality was

associated with use of an invasive device. significantly higher in patients with NI, compared to

Nosocomial infection associated mortality is patients without NI. Bowen-Jones et al. analyzed

multifactorial, and depends on the patients’ mortality rates in children admitted to the ICU and

characteristics, infection site, etiologic agent and

Int j clin surg adv 2014; 2(4):1-8 5


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

Table 2: Antibiotic resistance in clinical pathogenic baterial isolates.

Per cent isolates showing antibiotic resistance

Antibiotics Pseudomonas Acinetobacter Enterococcus Escherichia Klebsiella Streptococcus Staphylococcus

aeruginosa baumanii spp. coli pneumoniae spp. aureus

Penicillin -- -- R -- -- R 89

Ampicillin 86 100 R 80 75 R 89

Amoxyclav 71 75 R 60 75 S 78

Erythromycin -- -- R -- -- S 67

Clindamycin -- -- S -- -- S 44

Co- -- 100 R 60 100 R 78

trimoxazole

Gentamicin 57 75 S 40 75 S 67

Amikacin 43 50 S 40 50 S 56

Cefotaxime 57 50 S 20 25 S 67

Ceftriaxone 43 50 S 20 25 S 56

Ceftazidime 29 50 -- 40 25 S 67

Ciprofloxacin 71 75 R 60 75 R 67

Levofloxacin 71 75 R 60 50 R 67

Imipenem 14 25 S 20 00 -- --

Meropenem 14 25 S 20 00 -- --

Cefoperazone- 43 25 S 20 25 -- --

sulbatam

Pipercillin- 29 25 S 40 25 -- --

tazobatam

Vancomycin -- -- S -- -- S 00

Teicoplanin -- -- -- -- -- -- 00

Linezolid -- -- -- -- -- -- 00

R- Resistant, S- Sensitive

Int j clin surg adv 2014; 2(4):1-8 6


Microbial profile of nosocomial infections in the paediatric intensive care unit Chandrashekar GS et a l

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CORRESPONDENCE

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