"EPIDEMIOLOGY, MANAGEMENT AND OUTCOME OF MULTI DRUG

RESISTANT INFECTIONS AMONG ICU PATIENTS IN A TERTIARY

CARE CENTRE - AN OBSERVATIONAL STUDY"
By

Dr. HARSHITHA REDDY POLAM

REGISTRATION NUMBER: M166001092

DISSERTATION SUBMITTED TO THE

Dr. N.T.R. UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA,
ANDHRA PRADESH
IN PARTIAL FULFILLMENTOF THE REQUIREMENTS FOR THE DEGREE OF

DOCTOR OF MEDICINE IN GENERAL MEDICINE

UNDER THE GUIDANCE OF

Dr. THIPPESWAMY
PROFESSOR

DEPARTMENT OF GENERAL MEDICINE

P.E.S.INSTITUTE OF MEDICAL SCIENCES AND RESEARCH
KUPPAM, ANDHRA PRADESH-517425
2016-19

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12-12-2018

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 ACKNOWLEDGEMENT
Iam very fortunate to extend my gratitude and sincere thanks to all those who have helped
me to complete my dissertation. I am grateful to my Parents Mr. Polam Rama Krishna
Reddy (business man), Mrs.Polam Sreevani (home maker) for their love and affection.I
thank my husbandMr.Mannem Venkata Rami Reddy (IT professional)for helping me in
completing thesis work patiently.

I Will be grateful forever to my guide, Dr.Thippeswamy , M.D, Professor, Department of

General Medicine, PESIMSR, KUPPAM, AP for his unsurpassable guidance and
encouragement in making this study possible.

I am very thankful to Professor and Head of Department of Medicine Dr.SRINIVAS RAO, M.D,
Professor and Head, Department ofMedicine, P.E.S.I.M.S.R, KUPPAM, for his Constant
guidance, support, motivation and encouragement during this entire study.

Professor Dr.Y.J.Visweswara Reddy M.D, the person who has mastered the art of clinical
medicine, for his excellent guidance, encouragement and constant inspiration, patience,
wisdom, timely support and guidance during my P.G. course. This dissertation bears an
indelible imprint of his valuable suggestions, highly professional advice and meticulous care
taken in guiding me to carry out this work. It is my good fortune to have worked under such
a wonderful person who is an embodiment of knowledge.

I am again very thankful to my respected teachers, Professor Dr.Nagarajan. N M.D,

Associate Professor Dr. Nagaraj. N M.D, Professor, Dr.Uma. M. A MD, Associate
Professor,Dr.Lakshmi visruja MD, Assistant professor for their valuable guidance and
motivation throughout my postgraduate career.

I would like to acknowledge Medical Director, Dr. Suresh Krishnamurthy, M.D., MRCP
(UK),FRCP,FACC (USA), for the financial, academic support and for allowing me to utilise the
clinical material and laboratory services of PESIMSR, KUPPAM.

My deep appreciation to my seniors in the department, and all my fellow PGS from 2016and
2017 batch, for promoting a stimulating and welcoming academic and social environment.

I gratefully acknowledge the nursing staff of department of General Medicine for helping
with the collection of blood for investigations and administration of the study medication.

I also thank Mrs. Sunitha Bhavana office assistant and Mr. Yousuf, attender for their help.

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I am thankful to the Principal, Dr.H.R.Krishna Rao and Medical Superintendent,
Dr.T.Venugopal Rao and the Ethical Committee, P.E.S.I.M.S.R, Kuppam for allowing me to
conduct this study.

I am very grateful to all the patients who have Cooperated and participated in this study,
without their understanding and support this work would not have been possible.

Dr. P.HARSHITHA REDDY

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 LIST OF ABBREVATIONS

ICU- intensive care unit

HIV-human immunodeficiency virus

CONS-Coagulase negative staphylococcus

S.AUREUS-staphylococcus Aureus

E.COLI -Escherichia coli

BSI-blood stream infections

MRSA-methicillin resistant staphaureus

NNIS- National Nosocomial infection surveillance

NHSN-national health safety network

VRE-vancomycin resistant enterococcus

CLABSI-catheter related blood stream infections

E.FAECALIS-enterococcus faecalis

MDR-multi drug resistance

ESBL-extended spectrum beta-lactamases

NDM-1-new delhi metalo beta-lactamases

PA-peudomonas aureguniosa

A.B-acinetobacter baumannii

CDI-clostiridium difficile

RSV-respiratory syncitium virus

HBV-hepatitis b virus

HCV-hepatitis c virus
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HCW-health care worker

TABLE OF CONTENTS

S.NO CONTENTS PAGE

NUMBER

1. INTRODUCTION 7

2. AIMS AND OBJECTIVES 8

3. REVIEW OF LITERATURE 9

4. MATERIALS AND METHODS 24

5. RESULTS 26

6. DISCUSSION 41

7. SUMMARY 58

8. CONCLUSION 61

9. BIBLIOGRAPHY 63

10. ANNEXURES 70

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 LIST OF TABLES
S.NO PARTICULARS P.NO
1 Age distribution
26
2 Gender distribution
26-27
3 Specimen for microbial isolation
27-28
4 Type of infection
29
5 Number of infections
29
6 Bacterial species in the isolates of the study
participants 30
7 Type of Bacteria according to Gram’s stain
32
8 Drug sensitivity profile of Pseudomonas
32
9 Drug sensitivity profile of E.coli
33
10 Drug sensitivity profile of Klebsiella
34
11 Drug sensitivity profile of MRSA
35
12 Drug sensitivity profile of Enterococcus
36
13 Drug sensitivity profile of Enterobacter
37
14 Drug sensitivity profile of NFGNB
38
15 Outcome of the management
39
16 Outcome in relation to type of infection
40
17 Length of stay at hospital
40
18 Length of stay in relation to type of infection
41

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 LIST OF FIGURES

S.NO PARTICULARS P.NO

1 Age distribution 26

2 Gender distribution
27

3 Bacterial species in the isolates

31

4 Drug sensitivity profile of Pseudomonas

32

5 Drug sensitivity profile of E.coli

33

6 Drug sensitivity profile of Klebsiella

34

7 Drug sensitivity profile of MRSA

35

8 Drug sensitivity profile of Enterococcus

37

9 Drug sensitivity profile of Enterobacter

38

10 Drug sensitivity profile of NFGNB

39

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 INTRODUCTION
The intensive care unit often is called the epicentre of infections,
due to its extremely vulnerable population .There is always higher
risk of acquiring multiple infection through invasive procedures
which include (intubation, mechanical ventilation, vascular access,
etc.)

There will be rupture and distortion of protective barriers and

invasion of microorganisms.

To this, administration of several drugs, which also predispose for

infections.

The ICU patients has higher occurrence rates of hospital acquired

infections (20-30% of all ICU-admissions), leading to an enormous
impact on morbidity, hospital costs, and often, survival .

To this problem is the added problem of hospital acquired multidrug

resistant infections.

The ICU is the factory for creating, disseminating, and amplifying

antimicrobial resistance.

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The emergence of MDR infections has been more due to misuse of
antibiotic use rather than the vulnerability and the virulence of the
organism.

About 33% of patients being admitted to ICU in PESIMSR are critically

ill, harbouring MDR organisms.

Hence this prospective observational study is taken up to study the

pattern of multidrug resistance,management and its clinical outcome
in ICU setting.

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 AIMS AND OBJECTIVES

To determine the Epidemology ,Management and Clinical outcome of

multidrug resistant infections in ICU setting of PESIMSR kuppam.

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 REVIEW OF LITERATURE
Antibiotics History :

The management of microbial infections in ancient world is well-

documented.(4)

The modern era of antibiotics had begun with the discovery of penicillin by Sir
Alexander Fleming in the year 1928. (4,13)

The antibiotics have transformed modern medicine and saved millions of

lives.

Antibiotics were first prescribed to treat infections in the year 1940.(5)

Penicillin was successful in controlling bacterial infections

However, afterwards , penicillin resistance became a substantial clinical

problem.

By 1950s, many of the breakthroughs of the before decade were

threatened.(7)

Later new beta-lactam antibiotics were discovered, developed, and deployed,

restoring confidence.(4,7)

However, the first case of (MRSA) was identified during that same decade, in
the UK in 1962 and in the USA in 1968. (4,5)

Resistance had developed to almost all the antibiotics that had developed
posing a great threat to future generations.(5)

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Vancomycin was brought into the market in the year 1972 for the treatment
of methicillin resistance in both Staphylococcus and coagulase-negative
staphylococci. (4,5)

It was thought that vancomycin resistance was difficult to occur at that time .
(4)

However, Vancomycin resistance was reported in CONS in 1979 and 1983.4

From the late 1960s through the early 1980s,pharmaceutical industry has
brought into market a lot of new antibiotics.but later periods we have not seen
a new antibiotics coming up .(7)

As a result, in 2015, many decades after the use of antibiotics, bacterial

infections have again become a threat.7

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 Prevalence of infections in the ICU

Though there was enormous advances in modern medicine and intensive care,
the incidence of sepsis in intensive care units continues to rise.

In a study of 1265 ICUs , 60% of ICU patients at the time of survey were
considered infected, with infection being a strong independent predictor for
mortality . (22)

The risks of infection in general and with a resistant pathogen in particular

increased with the length of patient stay in the ICU.

Many factors contribute to the high incidence of these infections in the ICU
and the associated poor patient outcomes:

When we compare to general population , patients admitted to icu have many

co morbid illness and poor immunity .hence the prevalence of multidrug
resistance is significantly higher in this group .(23)

The high use of indwelling catheters among ICU patients provides a portal of
entry of organisms into vital body organs and sites.

The use and maintenance of the catheters account for frequent contact with
healthcare personnel, which predispose patients to colonization and infection
with nosocomial pathogens.(24)

MDR organisms , such as methicillin-resistant Staphylococcus aureus (MRSA),

vancomycin-resistant enterococci (VRE), Acinetobacter baumannii,
Enterobacteriaceae that produce extended-spectrum beta-lactamases and
carbapenemases (eg, ESBLs and CREs, respectively), and carbapenem-resistant
Pseudomonas aeruginosa, are all being isolated with increasing frequency in
ICUs .(25,26)

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If patient acquire infection by any of these organisms , it becomes difficult to
treat and has with increased risk of morbidity, mortality, and higher health
care costs.(27,28)

Compared with patients in the general hospital population, patients in ICUs are
subjected to increased selective pressure and increased colonization
pressure.(29)

Many studies of ICU-acquired infections are from industrialized countries,

hence rates of infection may be higher in developing countries, as explained
by a multicenter prospective cohort surveillance study of 46 hospitals in
Central and South America, India ,Morocco, and Turkey .

An overall rate of 14.7 % (or 22.5 infections per 1000 ICU days) was
observed.(30)

Ventilator associated pneumonia (VAP); 24.1 cases per 1000 ventilator days
(range 10.0 to 52.7 cases)

Catheter-related bloodstream infection (CRBSI); 12.5 cases per 1000 catheter

days (range 7.8 to 18.5 cases)

Catheter-associated urinary tract infections (CAUTI); 8.9 cases per 1000

catheter days (1.7 to 12.8 cases

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 Common infectious syndromes in the ICU

The most common and clinically important infections in the ICU are those
associated with the supportive devices that patients in the ICU often require.
These include intravascular catheter-related bloodstream infection, ventilator-
associated pneumonia, and catheter-associated urinary tract infection.

Catheter associated urinary tract infection :

Urinary tract infection (UTI) is the most common nosocomial infection,

accounting for more than 40 percent of all nosocomial infections .(32)

In the United States, CAUTIs are responsible for 900,000 additional hospital
days per year and contribute to >7000 deaths .(34,35)

CAUTIs are the second most common cause of nosocomial bloodstream

infection , which have an attributable mortality of approximately 15 to 25
percent . (36-40) The Medicare and Medic aid Services does not support
hospitals for CAUTIs, which further increases the cost burden of these
infections on hospitals in the United States.

In addition to actual infection, asymptomatic bacteruria often leads to

significant laboratory testing and inappropriate antimicrobial utilization in the
absence of an established infection .(39,41)

Inappropriate treatment of asymptomatic bacteriuria is associated with

adverse clinical outcomes . (42)

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The urinary tract in catheterized patients also serves as a reservoir for
multidrug-resistant bacteria, which can cause either infection or asymptomatic
bacteriuria . (39)

Ventilator associated pneumonia:

Ventilator-associated pneumonia is infection of lung tissue that develops 48

hours or more after intubation in mechanically ventilated patients.

Hospital pneumonia is the second most common hospital-acquired infection

and occurs frequently in the setting of endotracheal intubation and mechanical
ventilation.(43)

Intravascular catheter-related bloodstream infection:

Arterial and central venous catheters are frequently used in critical care
patients because of the need for hemodynamic monitoring and intravenous
therapeutics.

Bloodstream infections involving these catheters are common in ICUs and are
associated with significant morbidity and mortality.(44)

Prevalence of drug-resistant organisms :

There has been a rapid rise in the rate of resistance among bacterial pathogens
recovered in intensive care units.(15,16)

A comparison of the reports from the National Healthcare Safety Network

System at the Centers for Disease Control and Prevention from 1999 and
2006 to 2007 demonstrates increasing prevalence of multidrug-resistant
pathogens in ICUs in the United States.

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VRE (from 24.7 to 33.3 percent of enterococci isolates)

MRSA (from 53.5 to 56.2 percent of S. aureus isolates)

P. aeruginosa resistant to imipenem or fluoroquinolones (from 16.4 to 25.3

and from 23.0 to 30.7 percent of P. aeruginosa isolates, respectively)

A. baumannii resistant to carbapenems (from 11 to 30 percent of A.

baumannii isolates)
Enterobacteriaceae resistant to third-generation cephalosporins, mainly
extendedspectrum beta-lactamase (ESBL) producers (from 10.4 to 25 percent
of Klebsiella Pneumonia and 3.9 to9 percent of Escherichia coli.

Enterobacteriaceae resistant to carbapenems (CREs) (from 0 to 8 percent of K.

pneumoniae and from 0 to 3 percent of E. coli)

The emergence of broad-spectrum resistance among gram-negatives is

particularly worrisome since therapeutic options are scarce, and sometimes no
effective antimicrobial agent is available at all.

Two additional common and significant pathogens in ICU infections are

Clostridioides (formerly Clostridium) difficile and Candida spp.

These are not "traditional" multidrugresistant organisms (MDRO), but risk

factors for infections due to these pathogens are similar to those associated
with MDRO infections, and thus the affected populations are similar.

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Risk factors for resistant infections

Certain characteristics double the risk of infections with multidrug-resistant

pathogens in ICUs by contributing to increased selective pressure (leading to
the emergence of multidrug-resistant organisms) and/or increasedcolonization
pressure (leading to ineffective containment of these organisms) .(19,38,39)

Specifically, risk factors for resistant infections reported from ICUs include the
following (12,40-45)

Older age

Lack of functional independence and decreased cognition

Presence of underlying comorbid conditions (eg, diabetes, renal failure,

malignancies, immunosuppression) and higher severity of acute illness indices

Long duration of hospitalization before to the ICU admission, including

interinstitutional transferring (particularly from nursing homes)

Frequent encounters with healthcare environments (eg, hemodialysis units,

ambulatory daycare clinics)

Frequent contact with healthcare personnel concurrently caring for multiple

patients, whose hands can serve as vehicles for transfer of pathogens between
patients.

Sharedequipment and contaminated environments can also serve as reservoirs

and vectors that contribute to acquisition of infection in the ICU.

Presence of indwelling equipment such as central vein catheters ,ryles tube

,foleys tube , and tracheal tubes, which bypass natural host defense
mechanisms and serve as portals of entry for pathogens

Recent surgery or other invasive procedures

Receipt of antimicrobial therapy prior to the ICU admission, which creates

selective pressure promoting the emergence of multidrug-resistant bacteria

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The association between prior receipt of antibiotics and infection with drug-
resistant organisms has been demonstrated in several studies and by various
methodologies.

In case-control studies, exposure to antibiotics has consistently been

associated with the emergence of resistance to that same or a different class
of antimicrobial agent

As an example, receipt of fluoroquinolones has been linked to the emergence

of piperacillinresistant P. aeruginosa .(47)

In a study of patients with nosocomial pneumonia, those infected with

piperacillin-resistant strains of P. aeruginosa were more likely to have received
fluoroquinolones before to their pneumonia (OR 4.6, 95% CI 1.7-12.7).

In a separate study, antibiotic exposure was the strongest single predictor for
infection with extensively drug-resistant gram-negative pathogens .(46)

The association between certain antibiotic use and emergence of resistance

has also been supported by studies that used longitudinal time-series analyses
to determine rates of resistance when various antibiotic agents were more
commonly used at a particular institution(48) and studies that demonstrate
reductions in multidrug-resistant pathogens with the implementation of
antimicrobial stewardship programs and various strategies to minimized
unnecessary antimicrobial use .(49)

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 MULTI DRUG RESISTANCE MECHANISMS

Multidrug resistance in bacteria is attained by the collection of genes, each

coding for resistance to a single drug, on R plasmids. This formation of
resistance genes on R plasmid is mediated by transposons ,integrons and ICSR
elements.

Integrons are powerful in producing multidrug resistance. they assemble

several resistance genes in a correct orientation and supply a strong promoter
for their expression.

This resistance gene once incorporated into an integron becomes tagged, and
that it could then easily be a part of another integron.

R plasmids are maintained extremely well and are often transferred efficiently
from cell to cell

2)Another mechanism of multidrug resistance is that the bacteria will have

multiple efflux pumps on the surface that could effectively pump out the
drugs.

The RND superfamily pumps, in gram-negative bacteria are especially

important as they are usually coded by chromosomal genes and can be
overexpressed easily .

These pumps could put out many antibiotics that are in current use now.

3) In some gram-negative species, these mechanisms may become augmented

by having mutations in porins. These porins are present on outer membrane
later that can prevent entry of antibiotics.

Persistence of pathogenic micro organisms occur in an antibiotictreated

patient because they may get into a physiologically resistant state.

There is no need for any genetic variations for above mentioned mechanism
needed.

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 FUTURE ISSUES

1. There is a persistant need to define the molecular details of the

resistance mechanism. This may lead to useful inhibitors of multidrug
efflux pumps or to inhibitors of the R plasmid transfer process.

2. There are also practical issues of preventing the further increase in

multidrug resistant bacteria. One lofigal idea is to minimize the need to
use antibiotics and judicious use of them can curtail this emerging
problem.
Indeed, there is a striking correlation between the usage of β-lactams and the
frequency of occurrence of penicillin-resistant pneumococci in the member
countries of European Union .

3. Simultaneous administration of more than one agent (as is done with

tuberculosis) may be considered.

For example, an inhibitor of multidrug efflux pumps lowers the MICs of various
drugs strongly in gram-negative bacteria and may prevent the emergence of
resistant organisms .

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26
 STUDIES ON MDR INFECTIONS IN ICU SETTINGS

1)A prospective observational study was done on adult patients admitted in

ICU of B. P Koirala Institute of Health Sciences from July to December 2017.
(70)

The incidence of multi-drug resistant gram-negative bacteria infections was 47

% (64/137) . Among them Acinetobacter species (41%, 52/128) was the
commonest followed by Klebsiella (28%, 36/128) and Pseudomonas (21%,
27/128).(71)

Patients with multi-drug resistant gram-negative bacteria had high

healthcare-associated infections (95%, 61/64 versus 20%, 2/10;
p=<0.001).(71,72)

Mortality was 38% (24/64), 20% (2/10) and 10% (4/ 41) in multi-drug resistant,
infections. the odds ratio (CI) for in-hospital-mortality in multidrug resistant
and non-multi-drug resistant group was (4.7[1.4–15.5], p=0.01) and 2.60 [0.38–
17.8], p=0.32) respectively. (73)

Multi-drug resistant patients also had longer intensive care unit and hospital
stay.

The incidence of multi-drug resistant gram-negative bacterial infections was

remarkably high in intensive care unit and showed a significant association
with healthcare-associated infections and in-hospitalmortality.(74)

2 )A study conducted at Brazilian hospital revealed Both Gram-positive and

negative isolates expressed resistance to most of the penicillins and
cephalosporins groups of antibiotics.

Combined therapy with vancomycin and meropenem or imipenem gave the

most effective treatment against Gram-positive and Gramnegative isolates
based on empirical therapy. (76)

Higher frequencies of multi drug resistant bacteria in ICUs warn us to

administer a few effective antibiotics in hospitals more wisely in order to
reduce selective pressure on sensitive strains. (74,71)

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This could save the life of ICU patients and prevent spread of resistant isolates
in these critical wards.

3)A retrospective observational study was conducted on 106 consecutive critically

patients with liver disease admitted in the Intensive Care Unit between March 2015
and February 2017.

Out of the 106 patients enrolled , 23 patients had infections by MDR bacteria. The
MDR-infected patients had severe liver disease (Child–Pugh score 11 ± 2.3 vs. 7 ±
3.9; P = 0.04), longer duration of antibiotic usage (6 ± 2.7 days vs. 2 ± 1.5 days; P =
0.04), greater use of total parenteral nutrition (TPN) (73.9% vs. 62.6%; P = 0.04),
and more concurrent antifungal administration (60.8% vs. 38.5%; P = 0.04). (94)

The mortality was higher in MDR group (hazard ratio = 1.86; P< 0.05

The study details a high prevalence of MDR bacterial infection in critically ill patients
with a higher mortality over non-MDR bacterial infection and also identified the
independent predictors of such infections.(75)

Rapidly emerging resistant bacteria threaten the extraordinary health benefits that
have been achieved with antibiotics.(73,70)

This is a global crisis that reflect the overuse of these drugs and the lack of
development of new antibiotic agents to address the challenge.

Antibiotic-resistant infections place a substantial health and economic burden on the

health care system and population.

Coordinated efforts to implement new policies, renew research efforts, and pursue
steps to manage the crisis are greatly needed.

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 MATERIALS AND METHODS

• Study Design: Hospital-based Observational Study

• Study Period: This study is conducte over a period of 18 months from

January 2017 to june 2018.

Study Area: PESIMSR, Kuppam, AP

• Study Population: in this study a total number of 160 study subjects

were taken, who were aged 15 yrs and above and who has met the
inclusion criteria. the study population included patients admitted to
Medical, Surgical , Emergency and trauma ICU settings.

Sample size calculation:

• Based on Qatar study

• Patients with at least one organism

which was MDR = 43/106 (40.6%)

• Prevalence (p)=0.406% = 0.41%

---------------------------------------------------------------

Based on this value,

• p = probability of an event = 0.41%

• q = non-probability of the event

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 Formula for Sample size calculation:

• n = Z2 p(1-p)

d2

• n = sample size

• Z = 1.96, at 95% Confidence Interval

• p = probability of an event = 0.41%

• 1-p = non-probability of the event = 0.59%

• d = Precision =8% = 0.08

Calculation for sample size:

• n = Z2 p(1-p) p = 0.41%

d2 q = 1 – 0.41 = 0.59%

d = 0.08

• n= = 3.84 x 0.41 x 0.59 = 0.9289

(0.08)2 0.0064

n = 145

Sample size:

• Expected proportion of subjects who may refuse to participate: 10%

10% of 145= 14.5= 15 Therefore,

145 + 15 = 160 subjects are to be selected.

• Hence, it was decided to take a sample of 160.

30
 Sampling technique:

Convenient sampling method

Procedure:

After taking Written Informed consent, the patient will be subjected

to investigations that include collection of specimens(blood, pus, ET
secretions, sputum, etc). the samples were sent for culture .the results
were collected. Analysis of the reports, along with Antibiotics patient
received and the final out come were done.

The results obtained from this study will be compared to similar studies
done and results were interpreted in the form of tables ,bar graphs and
pie charts for better understanding.

Methods: Tools & techniques:

• Proforma containing a Semi-structured questionnaire for data

collection by interviewing the subjects:

Part 1: Socio-demographic data

Part 2:Information related to the epidemiology,

management and outcome of Multi drug

resistance

Analysis of data:

• The data will be entered into MS Excel 2007 version and further
analysed using Epi Info 7.1.

• For descriptive analyses, the categorical variables will be analyzed by

using percentages and the continuous variables will be analyzed by
calculating mean ± Standard Deviation.

31
 • For inferential analyses, tests such ast’ test, Chi square test etc will be
applied and p<0.05 will be considered as statistically significant.
Regression analysis will be done for the associated risk factors.

RESULTS
Table 1: Age distribution (n=160)

Age (in years) Frequency Percentage

<25 8 5.0

26-40 33 20.6

41-60 69 43.1

>60 50 31.3

Total 160 100.0

In the study ,40-60 yrs age group has maximum number of study subjects which

accounts for 43.1% of total study.

Figure 1: Age distribution (n=160)

Age distribution (in years)

80
69
70

60
50
50

40
33 Frequency
30

20

10
8

0
<25 26-40 41-60 >60

32
Table 2: Gender distribution (n=160)

Gender Frequency Percentage

Male 97 60.6

Female 63 39.4

Total 160 100.0

The gender prevalence was male to female of 1.5:1 respectively.

Figure2: Gender distribution (n=160)

Gender distribution
120

100
97

80
63
60
Frequency

40

20

0
Male Female

Table 3: Specimen for microbial isolation (n=160)

Specimen Frequency Percentage

Endotrachealsecretion 53 33.1

Blood 49 30.6

33
Urine 21 13.1

Sputum 17 10.6

Pus 14 8.8

CSF 4 2.5

Stool 2 1.3

Total 160 100.0

Table 4: Type of infection (n=160)

Type of infection Frequency Percentage

Monomicrobial 136 85.0

Polymicrobial 24 15.0

Total 160 100.0

Out of 160, 136 patients had monomicrobal MDR infection which is 85% where as patients
with polymcrobial infections were 15%.

Table 5: Number of infections (n=160)

Number of infections Frequency Percentage

Single isolate 136 85.0

Two isolates 21 13.1

Three isolates 1 0.6

Four isolates 2 1.3

Total 160 100.0

34
Two patients had four different species isolated from different specimen samples,while three
different organisms isolated in one patient and two different organisms isolated in 21 patients.

Table 6: Bacterial species in the isolates of the study participants (n=189)

Bacterial species Frequency Percentage

Klebsiella 36 19.0

Pseudomonas aeruginosa 36 19.0

Escherichia coli 24 12.7

Coagulase Negative Staphylococcus 20 10.6

MRSA 18 9.5

NFGNB 15 7.9

Staphylococcus aureus 8 4.2

Acinetobacter 7 3.7

Streptococcus pneumonia 7 3.7

Other Gram positive organisms 5 2.6

Proteus 4 2.1

Enterobacteriacae 3 1.6

Enterococcus 2 1.1

Candida 1 0.5

Citrobacter 1 0.5

Listeria 1 0.5

Other Gram negative organisms 1 0.5

Total 189 100.0

35
Figure3: Bacterial species in the isolates (%) (n=189)

0.5 Klebsiella
1.1 0.5 0.5
1.6 0.5 Pseudomonas aeruginosa

2.6 2.1 Escherichia coli

Coagulase Negative
19 Staphylococcus
3.7
MRSA
3.7
NFGNB
4.2
Staphylococcus aureus

Acinetobacter
7.9
Streptococcus pneumoniae
19 Other Gram positive
organisms
Proteus
9.5
Enterobacteriacae

Enterococcus
10.6 12.7
Candida

Citrobacter

Listeria

Other Gram negative

organisms

Out of all the specimen samples KLEBSIELLA, PSEUDOMONAS and Ecoli

were isolated in maximum number of samples,(51.0%) followed by CONS and

36
others. The above pie chart illustrates the increased prevalence of gram

negative MDR infections in ICU setup.

Table 7: Type of Bacteria according to Gram’s stain (n=189)

Type of Bacteria Frequency Percentage

Gram’s Positive 43 22.8

Gram’s Negative 146 77.2

Total 189 100.0

The gram negative infections were more in occurance with 77.2% which was

four times greater tham gram positive infections.

Table 8: Drug sensitivity profile of Pseudomonas (n=36)

Drug
1 2 3 4 5 6 7 8 9 10 11 Total
sensitivity
125
Present 12 25 21 21 6 0 15 0 0 10 15
(31.6%)

271
Absent 24 11 15 15 30 36 21 36 36 26 21
(68.4%)

396
Total 36 36 36 36 36 36 36 36 36 36 36
(100%)

37
[1=Penicillins (33.3%); 2=B-Lactamases (69.4%); 3=Imipenem (58.3%); 4=Meropenem
(58.3%); 5=Ciprofloxacin (16.7%); 6=Levofloxacin (0%); 7=Amikacin (41.7%); 8=Gentamicin
(0%); 9=Ceftriaxone (0%); 10=Cefepime (27.8%); 11=Colistin (41.7%)]

Figure4: Drug sensitivity profile of Pseudomonas (n=36)

40
36 36 36
35
30
30
26
25
25 24
21 21 21 21
20 Sensitive
15 15 15 15 Resistant
15
12
11
10
10
6
5
0 0 0
0
1 2 3 4 5 6 7 8 9 10 11

[1=Penicillins; 2=B-Lactamases; 3=Imipenem;4=Meropenem; 5=Ciprofloxacin;

6=Levofloxacin; 7=Amikacin; 8=Gentamicin; 9=Ceftriaxone;10=Cefepime; 11=Colistin]

Table 9: Drug sensitivity profile of E.coli (n=24)

Drug Total
1 2 3 4 5 6 7 8 9 10 11 12 13
sensitivity

98
Present 9 9 8 8 10 0 12 0 8 9 0 15 10
(31.4%)

214
Absent 15 15 16 16 14 24 12 24 16 15 24 9 14
(68.6%)

312
Total 24 24 24 24 24 24 24 24 24 24 24 24 24
(100%)

[1=Piperacillin(37.5%); 2=Tazobactum(37.9%); 3=Imipenem(34.0%);

4=Meropenem(34.3%); 5=Amoxicillin clavulonate(43.3%); 6=Ampicillin(0%);

38
7=Ciprofloxacin(53.0%); 8=Ceftriaxone(0%); 9=Cefepime(36.0%);
10=Amikacin(40.9%); 11=Gentamicin(0%); 12=Teicoplanin(69.4%);
13=Cotrimoxazole(46.7%)]

Figure5: Drug sensitivity profile of E.coli (n=24)

30

25 24 24 24

20

16 16 16
15 15 15 15
15 14 14 Sensitive
1212
Resistant
10 10
10 9 9 9 9
8 8 8

0 0 0
0
1 2 3 4 5 6 7 8 9 10 11 12 13

[1=Piperacillin; 2=Tazobactum; 3=Imipenem; 4=Meropenem; 5=Amoxicillin clavulonate;

6=Ampicillin; 7=Ciprofloxacin; 8=Ceftriaxone; 9=Cefepime; 10=Amikacin; 11=Gentamicin;
12=Teicoplanin; 13=Cotrimoxazole]

Table 10: Drug sensitivity profile of Klebsiella (n=36)

Drug
1 2 3 4 5 6 7 8 9 10 Total
sensitivity
106
Present 15 17 8 0 12 0 15 18 0 21
(29.4%)

254
Absent 21 19 28 36 24 36 21 18 36 15
(70.6%)

360
Total 36 36 36 36 36 36 36 36 36 36
(100%)

39
[1=Piperacillin-Tazobactum(41.7%); 2=Ticarcillin-Tazobactum (47.7%);
3=Amoxicillin clavulonate(22.7%); 4=Ampicillin(0%); 5=Amikacin(34.7%); 6=Gentamicin
(0%); 7=Ciprofloxacin(44.2%); 8=Ofloxacin(53.5%);
9=Ceftriaxone(0%); 10=Cefepime(63.6%)]
Figure6: Drug sensitivity profile of Klebsiella (n=36)

40
36 36 36
35

30 28

25 24
21 21 21
20 19
1818 Sensitive
17
15 15 15 Resistant
15
12

10 8

5
0 0 0
0
1 2 3 4 5 6 7 8 9 10

[1=Piperacillin-Tazobactum; 2=Ticarcillin-Tazobactum’ 3=Amoxicillin

clavulonate;4=Ampicillin; 5=Amikacin; 6=Gentamicin; 7=Ciprofloxacin;
8=Ofloxacin;9=Ceftriaxone; 10=Cefepime]

Table 11: Drug sensitivity profile of MRSA (n=18)

Drug Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14
sensitivity

Present 5 0 11 0 4 4 11 0 0 6 4 10 13 4 72
(28.6%)

Absent 13 18 7 18 14 14 7 18 18 12 14 8 5 14 180
(71.4%)

Total 18 18 18 18 18 18 18 18 18 18 18 18 18 18 252
(100%)

[1=Amoxacallin clavulonate(27.8%); 2=Ampicillin(0%); 3=Amikacin(62.3%);

4=Gentamicin(0%); 5=Cefoxitin(23.1%); 6=Ciproflox(23.3%);

40
7=Ofloxacin(64.8%); 8=Erythromycin(0%); 9=Azithromycin (0%); 10=Cotrimoxazole(36.3%);
11=Clindamycin (24.4%); 12=Vancomycin(61.7%); 13=Linezolid(80.9%);
14=Rifampicin(25.1%)]

Figure7: Drug sensitivity profile of MRSA (n=18)

20
18 18 18 18
18

16
14 14 14 14
14 13 13
12
12 11 11
10
10 Sensitive
8
8 Resistant
7 7
6
6 5 5
4 4 4 4
4

2
0 0 0 0
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14

[1=Amoxacallin clavulonate; 2=Ampicillin; 3=Amikacin; 4=Gentamicin; 5=Cefoxitin;

6=Ciproflox; 7=Ofloxacin; 8=Erythromycin; 9=Azithromycin;
10=Cotrimoxazole; 11=Clindamycin; 12=Vancomycin;13=Linezolid;14=Rifampicin]

Table 12: Drug sensitivity profile of Enterococcus (n=2)

Drug Total
1 2 3 4 5 6 7 8 9 10 11 12 13
sensitivity

9
Present 0 0 1 0 0 1 2 0 0 2 1 0 2
(34.6%)

17
Absent 2 2 1 2 2 1 0 2 2 0 1 2 0
(65.4%)

26
Total 2 2 2 2 2 2 2 2 2 2 2 2 2
(100%)

41
[1=Amoxacallin clavulonate(0%); 2=Ampicillin(0%); 3=Amikacin(50.0%);
4=Gentamicin(0%); 5=Cefoxitin(0%); 6=Ciproflox(50%); 7=Ofloxacin(100.0%);
8=Erythromycin(0%); 9=Azithromycin (0%); 10=Cotrimoxazole(100.0%);
11=Vancomycin(50.0%); 12=Clindamycin (0%); 13=Linezolid(100.0%)]

Figure8: Drug sensitivity profile of Enterococcus (n=2)

2.5

2 2 2 2 2 2 2 2 2 2
2

1.5

Sensitive
11 11 11
1 Resistant

0.5

0 0 0 0 0 0 0 0 0 0
0
1 2 3 4 5 6 7 8 9 10 11 12 13

[1=Amoxacallin clavulonate; 2=Ampicillin; 3=Amikacin; 4=Gentamicin; 5=Cefoxitin;

6=Ciproflox; 7=Ofloxacin; 8=Erythromycin; 9=Azithromycin; 10=Cotrimoxazole;
11=Vancomycin; 12=Clindamycin; 13=Linezolid]

Table 13: Drug sensitivity profile of Enterobacter (n=3)

Drug Total
1 2 3 4 5 6 7 8 9 10 11 12 13 14
sensitivity

Present 1 0 1 0 0 1 2 0 1 0 1 0 2 0 9
(21.4%)

Absent 2 3 2 3 3 2 1 3 2 3 2 3 1 3 33
(78.6%)

Total 3 3 3 3 3 3 3 3 3 3 3 3 3 3 42
(100%)

42
[1=Tigecycline (33.3%); 2=Doxycicline(0%); 3=Amikacin(34.0%);
4=Gentamicin(0%); 5=Piperacillin(0%); 6=Ticarcillin(35.0%); 7=Tazobactum-
Clavulonate(70.7%); 8=Amoxacillin(0%); 9=Ampicillin(36.0%); 10=Cifoxitin(0%);
11=Cefepime(36.7%); 12=Ciproflox(0%);
13=Teicoplanin(74.7%); 14=Cotrimox(0%)]
Figure9: Drug sensitivity profile of Enterobacter (n=3)

2.5

2 2 2 2 2 2 2 2 2 2
2

1.5

Sensitive
11 11 11
1 Resistant

0.5

0 0 0 0 0 0 0 0 0 0
0
1 2 3 4 5 6 7 8 9 10 11 12 13

[1=Tigecycline ; 2=Doxycicline; 3=Amikacin; 4=Gentamicin; 5=Piperacillin; 6=Ticarcillin;

7=Tazobactum-Clavulonate; 8=Amoxacillin; 9=Ampicillin; 10=Cifoxitin; 11=Cefepime;
12=Ciproflox; 13=Teicoplanin; 14=Cotrimox]

Table 14: Drug sensitivity profile of NFGNB (n=15)

Drug
1 2 3 4 5 6 7 8 9 10 11 Total
sensitivity
41
Present 7 8 0 3 10 0 5 3 0 0 5
(24.8%)
124
Absent 8 7 15 12 5 15 10 12 15 15 10
(68.4%)

165
Total 15 15 15 15 15 15 15 15 15 15 15
(100%)

43
[1=Piperacillin-Tazobactum(46.7%); 2=Ticarcillin-Tazobactum (53.9%);
3=Ampicillin(0%); 4=Amoxicillin (20.6%); 5=Imipenem (69.3%); 6=Cefixime(0%);
7=Cefepime (35.3%); 8=Amikacin(21.4%); 9=Gentamicin(0%);
10=Ciprofloxacin (0%); 11=Cotrimox(36.7%)]

Figure10: Drug sensitivity profile of NFGNB (n=15)

16 15 15 15 15

14
12 12
12
10 10 10
10
8 8
8 7 7 Sensitive
Resistant
6 5 5 5

4 3 3

2
0 0 0 0
0
1 2 3 4 5 6 7 8 9 10 11

[1=Piperacillin-Tazobactum; 2=Ticarcillin-Tazobactum; 3=Ampicillin; 4=Amoxicillin;

5=Imipenem; 6=Cefixime; 7=Cefepime; 8=Amikacin; 9=Gentamicin; 10=Ciprofloxacin;
11=Cotrimox]

Table 15: Outcome of the management (n=160)

Outcome Frequency Percentage

Discharged 118 73.7

Death 42 26.3

44
 Total 160 100.0

In the study group patients received treatment according to culture sensitivity

reports.the outcome was analysed in the form of either patients got cured and

discharged or patient had expired during icu stay.

Out of 160, 118 patients recovered from MDR infection and shifted from

icu to ward and got discharged. Where as 42 patients died in the ICU during

hospital stay.

Table 16: Length of stay at hospital (n=160)

Length of stay (in days) Frequency Percentage

<5 24 15.0

5-10 107 66.9

11-15 19 11.9

> 15 10 6.2

Total 160 100.0

Table 17: Outcome in relation to type of infection (n=160)

Outcome
Type of infection Total X2-value
Discharged Death (p-value)

Monomicrobial 107 29 136 (100%) 11.3665

(<0.001*)

45
Polymicrobial 11 13 24 (100%)

Total 118 (73.8%) 42 (26.2%) 160 (100%)

(*p<0.05 is statistically significant)

The mortality rate was 54% with molymicrobial infections where as it was 21% for
monomicrobial infections.

Table 18: Length of stay in relation to type of infection (n=160)

Length of stay
Type of infection Total X2-value
< 10 days > 10 days (p-value)

Monomicrobial 115 21 136 (100%)

Polymicrobial 16 8 24 (100%) 4.4007

(0.03*)
Total 131 (81.9%) 29 (18.1%) 160 (100%)

(*p<0.05 is statistically significant)

Study group who had polymicrobial infection had longer length of stay and
higher mortality rates compared to others.

46
 DISCUSSION

The growing resistance to antibacterials is a serious problem in all parts of the world
and is now acknowledged as a major public health crisis.

The emergent multidrug-resistant (MDR) bacteria are more relevant in the Intensive
Care Units (ICUs) because of the high mortality consequent upon narrowed
therapeutic options in the face of increased severity of infection.

Moreover, high antibiotic selection pressure and overuse in the non-ICU areas also
manifest their deleterious effects in the ICU.

Many studies have shown the high prevalence of MDR infections in patients who
were critically ill.(53)

However, the risk factors for acquisition and the magnitude of their effects on the
vulnerability are poorly understood and inadequately described in most studies.(41)

This study was conducted on 160 cases of adult patients who were admitted to ICU
of PES institute of medical sciences and research during the period from January
2017 to June 2018.

47
AGE DISTRIBUTION:

The study population ranged from 15 years to 92 years. Patients aged Less than 25

years age were 8 in number. Two patients were above 90 years.

Significant percentage of population was in forty one to sixty years of age which

constitute nearly 69%. In Nepal study, this percentage was 43% below the age of 65

years .

STUDY TYPE AGE GROUP WITH HIGHER

FREQUENCY OF INFECTIONS(IN

YEARS)

NEPAL STUDY 25-45

BRAZILIAN STUDY 20- 40

PRESENT STUDY 41-60

The 5th and 6th decade preponderance in the current study is attributable to

rural background , smoking habits and comorbid conditions especially

Diabetes mellitus.

48
GENDER DISTRIBUTION :

In the current study ,out of 160 subjects,97 were male and 63 were females

with percentage of 60.6% and 39.4% respectively.

This is possibly due to increased comorbidities and risk factors which were

more in men compared to women population. In Nepal study this percentage

was 59% and 41% respectively(43) and in Brazilian study it was 44% and 56%

respectively.(76)

Specimen for microbial isolation

Out of all the specimens,endotracheal tube aspirates were highest with number
being 53 and that accounts for 33% followed by blood and urine that constitute 30%
and 13%respectively.

Since the patients were on endotracheal intubation and ventilation , ventilator

associated infections were expectedly more. Intravenous catheterization invariably
contributed to significant isolation of infective organisms.

In the MDR group, bacteria were most frequently isolated from the lower respiratory
tract infection (LRTI) followed by BSI , UTI and SSI .

49
Type of infection :

Out of 160 , 136 patients were found to have infection with single organism which accounts
for majority i.e 85% and remaining 24 (15%) had multiple organisms causing multi drug
resistance.

In our study ,monomicrobial infections which was exhibiting multidrug resistance was
significant.

In the Nepal and Brazilian study there was no differentiation for monomicrobial and poly
microbial infections.

Number of infections

In this study, out of 160 patients , 136 showed infection of one system for example
respiratory system being the highest ( 85%)

Multi systems and multiple infections of 3 different systems constituted 0.6%

These findings in ICU patients poses a challenge to the treating physicians since multiple
drugs may be required simultaneously , adding to the cost and contributing to longer stay.

50
Bacterial species in the isolates of the study participants

Among the organisms isolated, kLEBSIELLA and PSEUDOMONAS were predominant

organisms followed by E.coli and CONS.The prevalence of gram negative bacterial
infections and contributing to resistance in ICU settings is higher.

In a comparative study at Brazilian hospital ICU setting,the incidence rate of multi-drug

resistant gram-negative bacteria infections was 47 per 100 admitted patients (64/137) with
128 episodes.

Acinetobacter species (41%, 52/128) was the commonest organisms followed by Klebsiella
pneumoniae (28%, 36/128) and Pseudomonas spp (21%, 27/128) in contrast to the current
study.

In our study, the prevalence of KLEBSIELLA, PSEUDOMONAS and E.coli was more than half
(51%)and also explain the fact that gram negative multidrug resistance infections was
highest (71%). These figures compare well with another study done at Patna , India in which
58% MDR-GNB were isolated from the total ICU specimens

Another study from New Delhi , India on epidemiology of MDR-GNB isolated from
ventilator-associated pneumonia in ICU patients found , 88% of total isolates to be GNB,
among which 72% were MDR [23].

A systematic review of the burden of MDR HCAI among ICU patients in Southeast Asia
showed substantially higher incidence of MDR Acinetobacter Baumannii (58%) than
reported from other parts of globe [24].

The findings of the current study is in concordance with the scenario of high prevalence of
MDR-GNB infections in ICUs of Asia including Nepal.

Drug resistance is a global phenomenon.

The present study showed high frequency of bacterial isolates producing beta-lactamases

Current studies from Nepal also have reported high incidence of ESBL (43% [6], 40% [21],
25% [7]) and MBL (65% [21], 50% [6], 37% [7]) from ICU.

51
Prevalence of ESBL and carbapenemases producing GNB from ICU was 22.7% and 9.6%
respectively in a recent study from New Delhi , India.

Studies from the west also have shown an increasing trend of ESBL with ICU GNB isolates

52
Type of Bacteria according to Gram’s stain :

The frequency of gram negative bacterial infection was higher (77.2%) than gram positive
infections ( 22.8% ) which is a universal phenomenon

DRUG SENSITIVITY PROFILES

TABLE SHOWING THE ANTIBIOTIC SENSITIVITY PROFILE TO ISOLATED

ORGANISMS IN THE CURRENT STUDY:

ISOLATE GRAM STAIN ANTIBIOTIC SENSITIVITY CURRENT

STUDY

PSEUDOMONAS GRAM CLAVULONIC ACID

NEGATIVE IMIPENEM,MEROPENEM
COLISTIN
ECOLI GRAM TEICOPLANIN
NEGATIVE AMIKACIN
CIPROFLOXACIN
KLEBSIELLA GRAM CEFEPIME
NEGATIVE OFLOXACIN

MRSA GRAM POSITIVE LINEZOID

LEVOFLOXACIN,OFLOXACIN

ENTEROBACTER GRAM LINEZOLID

NEGATIVE OFLOXACIN
COTRIMOXAZOLE
ENTEROCOCCUS GRAM POSITIVE
TAZOBACTUM,CLAVULONIC ACID
TEICOPLANIN
NON FERMENTING GRAM
BACILLI NEGATIVE
PIPERACILLIN,TICARCILLIN,MEROPENEM
At least two antibiotics were used in each case and de-escalation was done appropriately.

53
Outcome of the management

In the current study antibiotics were used as per culture sensitivity reports for optimum
periods of time.

Good nursing care, high Antiseptic precautions ,timely intervention, multidisciplinary

approach ,poly pharmacy and antibiotic stewardship (institution developed) were practiced
deligently by the ICU care team,headed by the intensivist for the best possible outcome.

In our study, out of total 160 ,118 (73.7%) patients recovered and discharged from icu

P value being(<0.001*)

The cause of death was multifactoral which includes socio-demographical factors

,comorbid illness,age ,gender,monomicrobial or poly microbial and prevalence of multidrug
resistance in the community and in ICU.

In Nepal study, In-hospital-mortality was 38% (24/64), 20% (2/10) and 10% (4/ 41) in multi-
drug resistant, non-multi-drug resistant and uninfected group respectively.(66)

In another study , at Department of Anaesthesiology and Intensive Care, GB Pant Institute of

Postgraduate Medical Education and Research, New Delhi, India Out of the 106 patients enrolled in
the study, 23 patients had infections caused by MDR bacteria.The mortality was higher in MDR group
(hazard ratio = 1.86; P< 0.05).(78)

STUDY MORTALITY PERCENTAGE

NEPAL STUDY ( 2017) 38%

BRAZILIAN STUDY ( 2007) 46%

KASTURBA STUDY (2016) 51.6%

Current study (2018 kuppam) 26.3%

54
Length of stay at hospital (n=160)

In the current study, the minimum period of ICU stay was 3-4 days and the maximum
being more than 15 days.

Out of 160 patients , 107 had an overall stay of 5-10 days(66.9%).The average period of
stay being 7 days.

Length of stay in relation to type of infection

In view of length of stay relation to type of infection, monomicrobial population group had
lesser than 10 days stay, where as the polymicrobial group stayed longer (>10 days) With a
statistical significance of p(0.03).

STUDY GROUP AVERAGE LENGTH OF STAY

NEPAL STUDY 10 DAYS

BRAZILIAN STUDY 7-10 DAYS

PRESENT STUDY 5-10 DAYS

Outcome in relation to type of infection

Monomicrobial infection group had better outcome than polymicrobial group with a
statistical significance of p(<0.05).

STUDY MDR MORTALITY STUDY SIZE

NEPAL STUDY 38% 64

PRESENT STUDY 26.2% 160

55
SUMMARY

The present study was conducted in the ICU of PES Medical college hospital ,

Kuppam , a tertiary care referral hospital.

The age of the patients ranged from 15 years to 92 years..significant percentage of

the population was in the age group of forty one to sixty years which constituted

nearly 69%.

Out of 160 subjects,97 were male and 63 were females with gender percentage

being 60.6% and 39.4% respectively.

Comorbidities like risk factors ( Diabetes mellitus , hypertension ,cardiac diseases,

obstructive and restrictive lung pathology ,smoking and prior history of Antibiotic use)

were more in men when compared to women population.

Majority of the isolates were grown from ET secretions followed by blood and urine.

Majority of the infections were either community acquired or ventilator associated

Multidrug resistant infections the causative organisms being Pseudomonas and

Klebsiella.

Monomicrobal infections were in majority and most of them being gram negative
infections.

Among the resistant organisms Pseudomonas showed better sensitivity to Beta

lactamases and Carbepenems.

Ecoli showed better sensitivity to Amikacin and Ciprofloxacin .

Klebsiella for Ofloxacin and Cefepime .

MRSA was most sensitive to Linezolid .

ENTEROBACTER were sensitive to Teicoplanin , where as ENTEROCOCCUS to

LINEZOLID and CO-TRIMOXAZOLE.

NFGNB were sensitive to PENICILLINS and CARBAPENEMS.

56
There was better out come and lesser mortality by following Hospital Stewardship
policy.

Mortality rate for mono microbial infections was 15%

Mortality rate for poly microbial infections was 85%

Monomicrobial infection group had better outcome than polymicrobial group with a
statistical significance of p(<0.05).

The length of stay in mono microbial population group was lesser than 10 days
where as with poly microbial group it was >10 days which was statisticallly
significant p(0.03).

The length of stay in ICU was between five to ten days in the majority of cases.

Beyond ten days of stay mortality rates were higher.

57
 CONCLUSION

The control of antibiotic use seems to require a multidisciplinary approach involving

ID physicians, microbiologists, pharmacists and administrators.

To be effective, one need to bring in discipline in the prescriptions of antibiotics in all

settings – hospital, ambulatory including office practice and primary care.

The areas that require further investigation and improvement include the following:

• Prescribing recommendations for choice of empiric antibiotic for the seriously ill and
for those infected with MDR organisms

• Every hospital need to audit ICU care and prescribe antibiotics according to culture
and sensitivity reports.

However the recommendations will be applicable to the institution and the area of
practise only.Hospital stewardship is individual to each establishment.

Hospital stewardship is need of the hour.

The practise of personal prophylaxis and hand hygiene wil go a long way in curbing
drug resistance.

58
 LIMITATIONS

Further studies recruiting higher number of patients not only in ICU ,but also in other
critical areas of the hospital are required to draw scientific conclusions and
recommend appropriate antibiotics

59
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67
 ANNEXURE-1

PROFORMA

A STUDY OF EPIDEMIOLOGY, MANAGEMENT AND CLINICAL OUTCOME OF MULTIDRUG

RESISTANT INFECTIONS IN ICU

NAME: AGE: SEX: DOA: DOD:

IP NO: ADDRESS: OUTCOME:

TYPE OF ADMISSION: MEDICAL/SURGICAL/EMERGENCY/TRAUMA

PATIENT DETAILS:

Study type

Hosp number

Date of birth

Age

Gender: Male: Female:

CLINICAL DETAILS:

Date of admission

Indication for admission

Location before ICU admission Home: Hospital:

Infectious disease type diagnosed in ICU

Site of infection in ICU

Source of culture Blood CSF Urine PUS ET SPUTUM

Date of specimen collection

Causative agent of diagnosed infectious disease

Length of stay in ICU before infections was diagnosed

68
ANTIMOCROBIAL DETAILS

Prior use of antibiotics one month before admission No Yes

If Yes Names:

Route of administration Oral Parenteral

Duration of administration (days)

A ntibiotic administration during ICU admission No Yes

If Yes ; names penicillins: cephalosporins: b-lactamases:

Carbapenems: macrolides:

Aminoglycosides: fluoroquinolones:

Linezolid: colistin: tegicycline: teicoplanin:

Any other (specify):

Route of administration: oral parenteral

Duration of administration (days)

Other underlying diseases(specify)

69
Possible risk factors

Immunosuppression Yes No

Surgery Yes No

Chronic renal failure Yes No

Chronic lung disease Yes No

Malignancy Yes NO

Neutropenia Yes No

Dialysis Yes No

Diabetes mellitus Yes No

Long term steroid use Yes No

Endotracheal tube use Yes No

Central Venous Catheters Yes No

Urethral Catheters use Yes No

Tracheostomy Yes No

Inadequate hand hygiene Yes No

Nasogastric tube Yes No

OUT COME DETAILS:

Total duration of ICU stay(days)

Duration of ICU stay after acquisition of ICU infection(days):

<5 <10 <15 <20

Out come: Discharged Died

Date of death or discharge from ICU

70
 CONSENT FORM

Date / / /

Intensive Care Unit Infections in PESIMSR Teaching Hospital

Kuppam

Contents of the Consent form was explained to the patients in the language they best

understand.

My name is Dr. Polam Harshitha Reddy post graduate of the Department of general medicine

, PESIMSR Teaching Hospital, Kuppam.I am carrying out the above-mentioned research

topic (approved by the Research and Ethics Committee of LUTH) to investigate the

Epidemology ,Management and Clinical out come of Multi drug resistan infections in the

Intensive Care Unit of the Hospital, and also how these infections affect the admitted patients

in terms of hospital-stay and recovery.

During this exercise, I will require you to tell me why you came to the hospital and the drugs

you are taking. Blood samples (5-10mls), urine, wound swab, and/or sputum may be taken

from you, first day on admission and 48 hours later. The process of taking the specimen will

not cause you any extra pain or injury as the tests will constitute routine investigations

needed for your management. More so, you will not be required to pay for the tests.

The information you give shall be kept very confidential and shall be useful to the

Department of General Medicine and to improve the management of patients with similar

conditions. You are free to decline to participate in this study. You have the right to withdraw

at any given time if you choose to, and the quality of care you are receiving will not be

compromised in any way.

Sincerely,

71
Dr. POLAM HARSHITHA REDDY.

……………………………………….. ........../........./..........

Signature Date

I agree to take part in this Project.

.................................................... ......../......../............

Patient’s/Relative Signature Date

................................................... ........./.........../...........

Witness Signature Date

72
73
 KEY TO MASTER CHAT

Type of admission: Reason for ICU:

m-medicine R-respiratory

T- trauma C- cardiovascular

S-surgical N-neurological

K-kidney/renal

G- gastrointestinal

M-monitoring

O-others

T-trauma

OutCome:

E-expired

D-death

Co morbid conditions

D-diabetes K-chronic kidney disease

C-chronic obstructive pulmonary disease P- benign prostatic hypertrophy

H-hypertension I-immunological

TB- tuberculosis ILD- interstitial lung disease

HIV- human immunodeficiency virus O-obesity

HF-heart failure

L-cirrhosis of liver

74
Infection site: Type of Microorganism

R-Respiratory GP-gram positive

N-Neuroogical GN-gram negative

B-Blood stream/Hematological P-parasites

K-Kidney/Renal F-fungal

A-Abdomen V-virus

I-Intravascular catheter related infections O-others

O-Others

75
Species:

SA-staphylococcus Aureus C-Candida

SP-Streptococcus Pneumonia AG-Aspergillus

MRSA-Methicillin resistant staphylococcus T-Treponema Pallidum

EN-Enterococcus D-Dengue virus

CONS-Coagulase Negative Staphylococcus PF-Plasmodium Falciparum

OGP- other gram positive CT-citrobacter

EC-Escherichia Coli PM-proteus Mirablis

EB-enterobacter PV-plasmodium vivax

K-klebsiella AFB-acid fast bacilli

PA-pseudomonas

AC-acinetobacter

OGN-other gram negative

NFGNB- non fermenting gram negative bacilli

76
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
4
9
9
1 respir SPU
mall 5 9 amic atory, htn, TU
1 iga 0 f 2 u cvs dm 2 M yes GNB 1 Y D 8
5
0
0
RAJ 4 COP
ASE 7 5 AMIC D,D BLO
2 KAR 1 M 3 U SEPSIS M 2 OD YES GNB 1 Y D 16
5
0
0
8
FATI 5 4 BLO
3 MA 5 F 0 HDU SEPSIS HTN 1 OD YES GPC 1 Y E 3
5
0
1
0
PRA 4 5 AMIC BLO
4 BHU 7 M 9 U SEPSIS N/A 0 OD YES GNB 1 Y D 11
5
0
1
SUN 4 DENG SPU
DAR 3 8 AMIC UE,RE TU
5 I 3 F 0 U SP N/A 0 M YES GNB 1 D 6
5
0
1
6
UDA 6 6 AMIC SEPSIS CLD BLO
6 Y 0 M 9 U MODS ,HTN 2 OD YES GNB 1 Y D 5
5
0
MU 2
NI 8 PNEU SPU
VEN 3 1 AMIC MONI TU
7 KAT 7 M 6 U A N/A 0 M YES GNB 1 D 7
5 ET
NA 0 SEC
GAR 6 1 SDIC respir T2D RETI
8 AJU 5 M 0 U atory M 1 ON YES GPC 1 D 9

77
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
0
9
5
0
1
DEE 6
PIK 3 3 SDIC SEPSIS BLO
9 A 8 F 7 U MODS N/A 0 OD YES GNB 1 Y D 14
5
0
1
NAL 7 RENAL
1 APP 4 1 AMIC INFEC URI
0 A 6 M 3 U TION HTN 1 NE YES GNB 1 Y D 7
5
0
NAV 1 ET
KU 3 RESPI SEC
1 MA 6 3 AMIC RATO CVA, RETI
1 R 0 M 4 U RY HTN 2 ON YES GNB 1 Y D 6
4
0
1
KAS 6 RENAL
1 TUR 5 6 SDIC INFEC HTN, URI
2 I 1 F 5 U TION HF 2 NE YES GNB 2 Y E 3
4
0
1
7
1 JEE 2 3 AMIC BLO
3 VAN 7 M 1 U CVS,IE RHD 1 OD YES GPC 1 Y E 5
4
0
1
7 RESPI SPU
1 JHA 4 5 SDIC RATO TU
4 NSI 6 F 6 U RY N/A 0 M YES GNB 1 Y D 5
4
0
1
3
1 MU 5 3 CELLU T2D
5 RALI 7 M 9 SICU LITIS M 1 PUS YES GPC 1 Y E 6
1 PAP 8 4 SDIC PNEU SPU
6 AM 5 F 0 U MONI N/A 0 TU YES GNB 1 Y D 7

78
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
MA 1 A M
7
9
3
5
0
1
6 PYELO
1 BHA 3 6 AMIC NEPH T2D URI
7 GYA 9 F 4 U RITIS M 1 NE YES GNB 1 Y D 11
5
0
1
7 CIRRH
1 RAV 4 8 SDIC OSIS, BLO NFGN
8 I 1 M 9 U MODS N/A 0 OD YES B,GPC 1 Y D 8
5
0
1
ROJ 3 SEPSIS
1 ABE 2 9 AMIC ,MOD BLO GPC,G
9 E 0 F 6 U S N/A 0 OD YES NB 3 Y E 23
4
0
1
7
2 SIV 4 7 TRAU GNB,
0 A 3 M 7 SICU MA N/A 0 CSF YES GPC 2 Y D 17
4
0
1
9 PNEU SPU
2 BAL 4 1 AMIC MONI TU
1 AJI 5 M 2 U A HTN 1 M YES GNB 1 Y D 7
4
0
1
STE 9
2 PHE 5 1 AMIC
2 N 6 M 5 U CNS N/A 0 CSF yes GNB 1 Y D 8
4
0
1 CKD,
7 PNEU HTN, SPU
2 ANA 5 2 AMIC MONI T2D TU NFGN
3 ND 0 M 3 U A M 3 M YES B 1 Y D 14

79
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
5
0
2
8
2 SIV 3 7 SDIC BLO
4 AJI 3 M 6 U SEPSIS N/A 0 OD YES GNB 1 Y D 5
5
0
3
0 CELLU HTN,
2 CHU 4 9 LITIS,S T2D
5 KKA 7 F 2 SICU EPSIS M 2 PUS YES GPC 1 Y E 6
5
0
3
RAV 0 HTN,
2 IND 6 9 SDIC T2D URI
6 RA 1 M 6 U UTI M 2 NE YES GPC 1 Y D 7
5
0
3
MA 1 PNEU SPU
2 DH 2 9 SDIC MONI TU
7 U 3 M 6 U A N/A 0 M YES GNB 1 D 9
5
0
3
VIS 4 BRON SPU
2 HN 3 1 SDIC CHIEC TU
8 U 9 M 4 U TASIS N/A 0 M YES GNB 1 Y D 6
5
0
4 SEPSIS
9 ,PANC
2 AYA 4 7 AMIC REATI T2D BLO
9 PPA 1 M 6 U TIS M 1 OD YES GNB 1 Y E 13
5
0
4 ET
9 PNEU SEC
3 SYE 5 8 AMIC MONI CKD, RETI
0 D 3 M 5 U A HTN 2 ON YES GNB 1 Y E 7
MA 5
NJU 0 PYELO
3 NAT 2 6 SDIC NEPH URI
1 H 4 M 3 U RITIS N/A 0 NE YES GNB 1 Y D 3

80
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
9
6
5
0
6
5
3 UM 5 5 FOOT T2D
2 A 7 F 0 SICU ULCER M 1 PUS YES GPC 1 Y D 6
5
0
3
1
3 NAV 3 9 TRAU
3 EEN 0 M 6 SICU MA N/A 0 CSF YES GNB 1 Y E 21
5
1
1 ET
ANA 6 CVA,P SEC
3 MA 3 1 AMIC NEUM RETI
4 LAI 7 M 0 U ONIA N/A 0 ON YES GNB 1 Y D 6
5
0
9 ET
DHA 9 SEC
3 RM 3 6 AMIC TRAU RETI
5 A 2 M 7 U MA N/A 0 ON YES GNB 1 D 5
5
1
VEN 2
KAT 2 NEUR
3 APP 6 1 SDIC O,RES GP,G
6 A 5 M 6 U P N/A 0 CSF YES N 4 Y E 7
5
1
1
8 SEPSIS
3 DIV 2 5 AMIC ,MOD BLO GP,G
7 YA 6 F 7 U S N/A 0 OD YES N 4 Y E 15
5
1
THA 2
NG 6 PYELO
3 AVE 5 1 SDIC NEPH T2D URI
8 L 8 M 8 U RITIS M 1 NE YES GN 2 D 7
3 VAN 6 5 CELLU T2D
9 I 3 F 1 SICU LITIS M 1 PUS YES GP 1 Y D 6

81
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
2
7
1
5
5
1
4
0 T2D
4 TUL 4 7 CELLU M/H
0 ASI 6 F 1 SICU LITIS TN 2 PUS YES GP 1 Y D 5
5
1
6 ET
RAN 2 RESPI SEC
4 AM 5 8 SDIC RATO RETI
1 MA 1 F 0 U RY HTN 1 ON YES GN 1 D 7
5
1
8
6 RESPI SPU
4 MA 2 9 SDIC RATO TU
2 NI 4 M 5 U RY N/A 0 M YES GN 1 D 12
5
1
8 ET
MA 0 RESPI HF,H SEC
4 LAP 8 6 AMIC RATO TN,T RETI
3 A 9 M 3 U RY 2DM 3 ON YES GN 1 D 5
5
1
8
VEN 7 SEPSIS
4 KAI 7 7 AMIC ,MOD BLO GP,G
4 A 0 M 9 U S HTN 1 OD YES N 2 Y E 3
5
2
0
MA 2
4 TUT 6 2 SDIC T2D URI
5 HI 3 M 1 U UTI M 1 NE YES GN 2 Y D 6
5
2
0
SUG 6 GASTR T2D
4 UN 7 3 SDIC OENT M,H BLO
6 A 1 F 1 U ERITIS TN 2 OD YES GN 1 Y D 5

82
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
5
2
0 ET
JAY 9 SEC
4 ARA 4 9 AMIC RETI GN,G
7 M 5 M 6 U ARDS N/A 0 ON YES P 2 Y E 9
5
2
0
SRE 7 PNEU SPU
4 EDH 4 6 SDIC MONI TU
8 AR 1 M 3 U A N/A 0 M YES GN 1 Y D 5
5
1
8
LAK 6 SEPSIS
4 SH 3 9 AMIC ,MOD BLO
9 MI 7 F 1 U S N/A 0 OD YES GN 1 Y D 9
5
1
7
MEE 6 HTN,
5 NA 6 6 SDIC T2D URI
0 MA 3 F 4 U UTI M 2 NE YES GN 1 Y D 6
5
0
3 PNEU ET
GUR 7 MONI SEC
5 URA 5 2 AMIC A RETI
1 J 1 M 1 U ,ARDS HTN 1 ON YES GN 2 Y D 12
5
0
KRIS 6
HN 9
5 AM 7 2 SDIC T2D BLO
2 A 6 F 1 U SEPSIS M 1 OD YES GP 1 Y D 6
5
0
5 ET
3 SEPSIS T2D SEC
5 VAR 4 1 AMIC ,MOD M,H RETI
3 I 9 F 4 U S TN 2 ON YES GNB 1 Y D 7
5
0 PNEU HF,H SPU
5 LAT 8 3 MONI TN,T TU
4 HA 8 F 1 AICU A 2DM 3 M YES GPC 1 Y D 8

83
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
1
2
4
0
9
6 HTN,
5 RED 7 3 AMIC T2D BLO
5 APA 0 M 1 U SEPSIS M 2 OD YES GN 1 Y E 5
4
0
9
5
5 ANA 3 6 SDIC URI
6 ND 4 M 7 U UTI N/A 0 NE YES GN 1 Y D 5
4
0
1 ET
6 SEC
5 MA 5 6 AMIC RETI
7 NU 7 M 8 U ARDS N/A 0 ON YES GNB 1 Y D 7
4
0
2 ET
3 SEC
5 UDA 6 4 AMIC SEPSIS T2D RETI
8 Y 1 M 5 U ,ARDS M 1 ON YES GNB 1 Y D 9
4
0
2
6 SEPSIS T2D
5 RAJ 2 7 AMIC ,MOD M/H BLO GP,G
9 U 3 M 8 U S TN 2 OD YES N 2 Y E 4
4
0
2
1 SEPSIS T2D
6 GU 3 2 AMC ,MOD M/H BLO GP,G
0 NA 9 M 3 U S TN 2 OD yes N 2 Y D 12
4
0
2
ANA 7 GASTR HF,H
6 NTH 9 9 AMIC OENT TN,T STO
1 A 1 M 8 U ERITIS 2DM 3 OL YES GP 1 Y D 7
6 RAI 5 4 CELLU T2D
2 DU 7 M 0 SICU LITIS M 1 PUS YES GNB 1 Y D 8

84
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
2
9
8
7
4
0
2
SAR 7 SEPSIS HTN,
6 ASA 5 8 AMIC ,MOD T2D BLO
3 MA 1 F 9 U S M 2 OD YES GNB 2 Y E 5
4
0
VEN 2
KAT 3
6 APP 4 6 SDIC BLO
4 A 4 M 5 U SEPSIS HTN 1 OD YES GPB 1 Y D 7
4
0
2
3 PYELO
6 ROS 4 7 SDIC NEPH T2D URI
5 HINI 7 F 8 U RITIS M 1 NE YES GNB 1 Y D 4
4
0
2
9
6 JHA 3 5 AMIC BLO
6 NSI 7 F 6 U SEPSIS N/A 0 OD YES GPB 1 Y D 9
4
0
4 ET
7 PNEU SEC
6 RAV 2 8 SDIC MONI RETI
7 I 9 M 5 U A N/A 0 ON YES GNB 1 Y E 6
4
0
4 ET
5 PNEU SEC
6 VA 2 6 SDIC MONI RETI
8 MSI 0 M 7 U A N/A 0 ON YES GNB 2 Y E 5
4
0
4
7 PNEU SPU
6 VIJA 3 0 SDIC MONI TU
9 Y 9 M 9 U A N/A 0 M YES GPB 1 Y D 6

85
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
4
0
5
PAP 0
7 AIA 6 0 SDIC URI
0 H 5 M 3 U UTI HTN 1 NE YES GNB 1 Y D 5
4
0
5
9
7 LALI 6 2 AMC T2D BLO
1 TA 9 F 6 U SEPSIS M 1 OD YES GNB 1 Y D 12
4
0
GA 5 ET
NG 1 T2D SEC
7 AM 7 2 AMIC SEPSIS M/H RETI
2 A 5 F 3 U ,ARDS TN 2 ON YES GNB 1 Y D 7
4
0
5
2
7 GO 5 2 SDIC BLO
3 WRI 6 F 2 U SEPSIS N/A 0 OD YES GPB 1 Y D 6
4
0
5
MA 5
7 DHA 4 7 AMIC BLO
4 N 7 M 6 U SEPSIS N/A 0 OD YES GPB 1 Y E 11
4
0
5
RAB 8 T2D
7 IAB 8 9 AMIC M/H BLO
5 EE 1 F 0 U SEPSIS TN 2 OD YES GPB 1 Y D 5
4
0
5 ET
6 SEPSIS SEC
7 AKB 2 6 AMIC ,MOD RETI
6 AR 5 M 7 U S N/A 0 ON YES GNB 1 Y D 17
4 ET
0 SEPSIS HTN SEC
7 BAS 6 5 AMIC ,MOD /T2D RETI
7 HA 6 M 6 U S M 2 ON YES GNB 1 Y D 9

86
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
1
2
4
0
5 ET
MU 9 SEC
7 NEP 8 2 AMIC T2D RETI
8 A 6 M 1 U ARDS M 1 ON YES GNB 1 Y D 6
4
0
5
7
7 GIRI 7 8 SDIC T2D BLO
9 AH 4 M 6 U SEPSIS M 1 OD YES GPB 1 Y D 5
4
0
6
TAN 6
8 GAV 5 6 SDIC T2D BLO
0 EL 9 M 0 U SEPSIS M 1 OD YES GNB 1 Y D 6
4
0
6
TIR 7
8 UPA 3 2 SDIC URI
1 TI 6 M 1 U UTI N/A 0 NE YES GNB 1 Y D 4
4
0
6
3 SEPSIS
8 RAG 4 4 AMIC ,MOD BLO
2 AVA 3 M 1 U S N/A 0 OD YES GPB 1 Y E 9
4
0
LAK 7
SH 2
8 MA 7 3 CELUL T2D
3 MA 0 F 4 SICU ITIS M 1 PUS YES GPB 1 Y E 3
4
0
7
2 CELLU
8 6 1 LITIS, T2D URI GPB,G
4 GIRI 4 M 3 SICU UTI M 1 NE YES NB 2 Y E 8
8 CHA 6 4 SDIC PNEU ET
5 NCH 9 F 0 U MONI HTN 1 SEC YES GNB 1 Y D 12

87
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
A 6 A RETI
7 ON
9
8
4
0
RA 6 ET
MA 3 SEC
8 NAI 8 4 SDIC PNEU RETI
6 A 3 M 5 U ONIA HTN 1 ON YES GNB 1 Y D 5
4
0
6
4
8 RA 4 0 AMIC T2D BLO
7 MU 2 M 6 U SEPSIS M 1 OD YES GPB 1 Y D 9
4
0
6
7
8 KAL 4 0 SDIC URI
8 A 0 F 9 U UTI N/A 0 NE YES GNB 1 Y D 6
4
0
6
1
8 GOP 6 1 SDIC URI
9 AL 0 M 1 U UTI N/A 0 NE YES GNB 1 Y D 7
4
0
7
PAD 2
9 MA 7 2 SDIC T2D BLO
0 MA 1 F 3 U SEPSIS M 1 OD YES GNB 1 Y E 1
4
0
7 ET
6 SEC
9 TEJ 2 9 AMIC ARDS, RETI GPB,G
1 A 5 F 8 U SEPSIS N/A 0 ON YES NB 2 Y E 3
4
0
7
3
9 SHA 3 2 CELLU
2 NTI 6 F 1 SICU LITIS N/A 0 PUS YES GPB 1 Y D 17

88
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
4
0
MU 7 ET
NE 8 T2D SEC
9 MM 7 2 AMIC M/H RETI
3 A 8 F 3 U ARDS TN 2 ON YES GNB 1 Y D 7
4
0
8 ET
5 SEC
9 SUR 5 6 AMIC RETI
4 ESH 5 M 7 U ARDS HTN 1 ON YES GNB 1 Y D 1
4
0
8
RA 7
9 MA 4 0 SDIC T2D BLO
5 PPA 3 M 7 U SEPSIS M 1 OD YES GP 1 Y D 6
4
0
8
KIS 9
9 HOR 2 1 AMIC BLO
6 E 7 M 2 U SEPSIS N/A 0 OD YES GP 1 Y D 10
4
0
9 ET
BET 3 T2D SEC
9 APP 8 1 AMIC M/H RETI
7 A 0 M 6 U ARDS TN 2 ON YES GNB 1 Y E 6
4
0
9 ET
LAK 2 PNEU SEC
9 SH 7 3 SDIC MONI T2D RETI
8 MI 7 F 4 U A M 1 ON YES GNB 1 Y E 7
4
0
VEE 7 ET
RA 3 PNEU SEC
9 MM 5 4 SDIC MONI RETI
9 A 2 F 5 U A N/A 0 ON YES GNB 1 Y D 9
5
1 BHU 0 SEPSIS
0 VAN 5 1 AMIC ,MOD BLO
0 A 0 F 2 U S HTN 1 OD YES GPB 1 Y D 7

89
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
3
4
5
0
1 ET
1 MA 6 SEC
0 DHA 4 7 CELLU T2D RETI GP,G
1 VI 6 F 9 SICU LITIS M 1 ON YES NB 2 Y E 4
4
0
9 ET
1 9 PNEU SEC
0 LAT 2 9 SDIC MONI RETI
2 HA 1 F 9 U A HTN 1 ON YES GNB 1 Y D 6
4
0
9 ET
1 7 PNEU SEC
0 TEG 4 1 SDIC MONI RETI
3 AYA 7 M 2 U A HTN 1 ON YES GNB 1 Y D 9
4
0
TA 9 ET
1 MIL 1 PNEU SEC
0 ARA 7 2 SDIC MONI RETI
4 SA 5 M 3 U A TB 1 ON YES GNB 1 Y E 11
4
0
GO 9
1 WR 1
0 AM 5 4 AMIC T2D BLO
5 MA 4 F 5 U SEPSIS M 1 OD YES GP 1 Y E 3
5
0
8
1 CHE 2
0 NDR 5 3 SDIC URI
6 A 0 M 4 U UTI N/A 0 NE YES GNB 1 Y D 2
4
0
SIV 8
1 ALI 6
0 NG 6 7 CELLU T2D GP,G
7 AM 2 M 8 SICU LITIS M 1 PUS YES N 2 Y D 8
1 MO 3 4 AMIC PNEU SPU
0 HA 9 M 0 U MONI N/A 0 TU YES GNB 1 Y D 7

90
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
8 N 8 A M
4
5
6
4
0
8
1 RAJ 1
0 AM 4 6 AMIC BLO
9 MA 7 F 7 U SEPSIS HTN 1 OD YES GNB 1 Y D 9
4
0
8 HTN ET
1 RAJ 9 PNEU /T2D SEC
1 AIA 8 9 AMIC MONI M/C RETI
0 H 0 M 0 U A VA 3 ON YES GNB 1 Y D 7
4
0
KRIS 8
1 HN 1
1 APP 6 5 CELLU T2D
1 A 1 M 7 SICU LITIS M 1 PUS YES GPB 1 Y D 8
4
0
6
1 JAY 7 PNEU SPU
1 AM 5 9 SDIC MONI TU
2 MA 2 F 0 U A N/A 0 M YES GPB 1 Y D 12
4
0
1
1 MU 4
1 NIE 3 3 AMIC BLO
3 MA 8 F 4 U SEPSIS N/A 0 OD YES GPB 1 Y E 6
4
0
5 ET
1 9 SEC
1 RAV 5 3 AMIC ARDS, RETI GN,G
4 I 3 M 4 U SEPSIS HTN 1 ON YES P 2 Y D 10
4
0
4 ET
1 BOD 7 PNEU SEC
1 EPP 4 6 SDIC MONI RETI
5 A 7 M 1 U A HTN 1 ON YES GNB 2 Y D 9

91
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
5
0
3 ET
1 1 PNEU SEC
1 ARJ 2 2 SDIC MONI RETI
6 UN 6 M 7 U A N/A 0 ON YES GNB 1 Y E 3
5
0
RA 3
1 MA 4
1 NA 9 7 AMIC CVA, BLO
7 MA 0 F 8 U SEPSIS HTN 2 OD YES GNB 1 Y D 5
5
0
3
1 RAJ 6 T2D
1 AM 8 7 CELLU M/H
8 MA 4 F 8 SICU LITIS TN 2 PUS YES GPB 1 Y D 5
5
0
3
1 7
1 MU 6 1 SDIC T2D URI
9 RALI 6 M 6 U UTI M 1 NE YES GNB 1 Y D 8
5
0
5 ET
1 SEL 5 PNEU HTN SEC
2 VAR 7 0 MONI /T2D RETI GNB,
0 AJ 4 M 5 SDIU A M 2 ON YES GPB 2 Y E 12
5
0
5 ET
1 CHI 1 PNEU HF,H SEC
2 NN 7 2 AMIC MONI TN,T RETI
1 AYA 1 M 3 U A 2DM 3 ON YES GNB 1 Y D 5
5
0
5
1 2
2 NAI 5 3 SDIC URI
2 DU 4 M 4 U UTI N/A 0 NE YES GNB 1 Y D 7
5
1 0 SEPSIS
2 SAR 6 7 AMIC ,MOD BLO
3 OJA 0 F 1 U S HTN 1 OD YES GPB 1 Y D 3

92
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
1
2
5
0
7 ET
1 JAY 6 SEC
2 APP 5 1 AMIC RETI
4 A 9 M 9 U ARDS HTN 1 ON YES GNB 1 Y D 9
5
0
5 ET
1 SID 1 SEC
2 DAI 6 3 AMIC RETI
5 AH 7 M 4 U ARDS N/A 0 ON YES GNB 1 Y E 5
5
0
0 ET
1 JAY 1 PNEU SEC
2 AM 4 2 SDIC MONI RETI
6 MA 5 F 3 U A N/A 0 ON YES GNB 1 Y E 2
5
0
0
1 3
2 RAN 4 4 AMIC BLO
7 I 1 F 5 U SEPSIS N/A 0 OD YES GPB 1 Y D 4
5
0
SUB 0
1 RA 8 SEPSIS
2 MA 3 0 AMIC ,MOD BLO
8 NYA 6 M 9 U S N/A 0 OD YES GPB 1 Y D 9
5
0
0
1 4 SEPSIS
2 JYO 3 7 AMIC ,MOD BLO GNB,
9 THI 9 F 3 U S N/A 0 OD YES GPB 1 Y D 7
5
0
0 ET
1 NA 1 SEC
3 GAR 4 6 AMIC SEPSIS RETI
0 AJU 0 M 5 U ,ARDS HTN 1 ON YES GNB 1 Y D 6
1 SRI 5 5 SDIC PNEU ET
3 NIV 2 M 5 U MONI N/A 0 SEC YES GNB 1 Y D 12

93
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
1 AS 0 A RETI
6 ON
7
8
5
0
0 ET
1 PAP 8 PNEU SEC
3 AIA 5 6 SDIC MONI T2D RETI
2 H 4 M 5 U A M 1 ON YES GNB 1 Y D 4
5
0
PAD 0
1 MA 9 PYELO T2D
3 VAT 7 2 SDIC NEPH M/H URI
3 I 2 F 3 U RITIS TN 2 NE YES GNB 1 Y D 9
5
0
0 ET
1 KAN 9 PNEU SEC
3 AM 6 1 SDIC MONI RETI
4 MA 3 F 9 U A HTN 1 ON YES GNB 1 Y D 5
5
0
4
1 AN 0 SEPSIS
3 WA 4 0 AMIC ,MOD BLO
5 R 4 M 9 U S N/A 0 OD YES GPB 1 Y D 10
5
0
7
1 8 PNEU SPU
3 BAS 3 8 AMIC MONI TU
6 HA 8 M 0 U A N/A 0 M YES GNB 1 Y D 5
5
0
7
1 CHA 1 SEPSIS
3 NDR 5 9 AMIC ,MOD BLO
7 A 0 M 0 U S N/A 0 OD YES GNB 1 Y E 12
5
0
7 ET
1 3 PNEU SEC
3 AZA 2 4 SDIC MONI RETI
8 D 9 M 5 U A N/A 0 ON YES GNB 1 Y E 3

94
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
5
0
7
1 AZ 2
3 MA 4 2 CELLU T2D
9 BEE 9 F 1 SICU LITIS M 1 PUS YES GPB 1 Y D 6
5
0
0 ET
1 1 SEPSIS SEC
4 SEL 3 5 AMIC ,MOD RETI GPB,G
0 VI 9 F 6 U S N/A 0 ON YES NB 2 Y D 16
5
0
MA 0
1 NJU 9
4 NAT 4 9 AMIC T2D BLO
1 H 6 M 0 U SEPSIS M 1 OD YES GNB 1 Y D 6
5
0
0
1 KAIL 7 GASTR T2D
4 ASA 7 6 AMIC OENT M/H STO
2 M 6 M 2 U ERITIS TN 2 OL YES GPB 1 Y D 3
4
0
9
1 VAR 6
4 ALA 4 3 CELLU T2D
3 SMI 5 F 7 SICU LITIS M 1 PUS YES GPB 1 Y D 8
4
0
9 ET
1 DIN 4 PNEU SEC
4 AKA 2 7 SDIC MONI RETI
4 R 8 M 2 U A N/A 0 ON YES GNB 1 Y D 7
4
0
NAS 9 ET
1 IKA 0 PNEU SEC
4 MM 7 0 SDIC MONI RETI
5 A 5 F 0 U A HTN 1 ON YES GNB 1 Y E 10
KRIS 4 ET
1 HN 0 PNEU SEC
4 APP 6 0 SDIC MONI RETI
6 A 4 M 6 U A HTN 1 ON YES GNB 1 Y D 12

95
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
5
3
5
0
4
1 PEE 1
4 RAI 5 2 AMIC T2D BLO
7 AH 5 M 3 U SEPSIS M 1 OD YES GNB 1 Y D 9
5
0
6
1 VEN 7 SEPSIS
4 KAT 4 8 AMIC ,MOD BLO
8 ESH 1 M 9 U S N/A 0 OD YES GPB 1 Y E 5
5
0
1
1 RAJ 2
4 APP 3 3 CELLU T2D GNB,
9 A 4 M 4 SICU LITIS M 1 PUS YES GPB 2 Y D 3
5
0
LIN 3 ET
1 GA 7 PNEU SEC
5 MM 2 8 SDIC MONI RETI
0 A 4 F 9 U A N/A 0 ON YES GPB 1 Y D 8
5
0
3 ET
1 SUV 4 PNEU SEC
5 ARN 5 5 SDIC MONI RETI
1 A 6 F 6 U A N/A 0 ON YES GPB 1 Y D 6
5
0
4 ET
1 KON 5 T2D SEC
5 DAP 7 6 AMIC SEPSIS M/H RETI
2 PA 9 M 7 U ,ARDS TN 2 ON YES GNB 1 Y E 3
5
0
4
1 BAS 4
5 HEE 8 5 SDIC T2D URI
3 R 5 M 1 U UTI M 1 NE YES GNB 1 Y E 9
1 PRA 7 5 SDIC T2D URI
5 SAD 1 M 0 U UTI M/H 2 NE YES GNB 1 Y D 1

96
 m
type reaso com numbe infe posi micro ult OU LEN
a s ip of n for orbi r of ctio tive organ i_ M TC GTH
na g e n admi admis ditie comorb n isola ism no D O OF
me e x o ssion sion s idities site te type . R ME STAY
4 4 TN
8
7
6
5
0
4
1 3 SEPSIS
5 LALI 3 8 AMIC ,MOD BLO GP,G
5 THA 6 F 9 U S N/A 0 OD YES NB 2 Y D 17
5
0
5 ET
1 SUV 9 PNEU SEC
5 ARN 5 0 AMIC MONI T2D RETI
6 A 4 F 8 U A M 1 ON YES GNB 1 Y D 13
5
0
MA 5 ET
1 NIK 7 PNEU T2D SEC
5 AM 8 6 AMIC MONI M/H RETI
7 A 8 F 8 U A TN 2 ON YES GNB 1 Y D 22
5
0
5
1 NER 1 PNEU SPU
5 AJA 5 2 SDIC MONI TU
8 MA 4 F 7 U A HTN 1 M YES GPB 1 Y E 16
5
0
RA 3
1 MIR 9 SEPSIS HTN
5 EDD 5 2 AMIC ,MOD /T2D BLO
9 Y 9 M 1 U S M 2 OD YES GPB 1 Y D 9
5
0
CHA 1
1 NDR 6 CELLU
6 AM 4 3 AMIC LITIS, T2D BLO
0 A 3 F 9 U MODS M 1 OD YES GNB 1 Y E 6

97