Acinetobacter baumannii and its antibiotics susceptibility in selected hospital's intensive care units in Sana'a city-Yemen 2015 AD 1436 H
Ab Abdul ulra rahm hman Al Ali Moh ohamm mmed ed Za Zabad MSc. Medical Microbiology Dr Dr. . An Anwa war K. Al . Al-Madhag hagi Associate Professor of Medical Microbiology Dr Dr. . Khaled ed A. A. Al Al-Moy oyed ed Associate Professor of Medical Microbiology
Introduction
Introduction • Nosocomial infections is a cause of increased morbidity and mortality, throughout the hospitals and particularly in the ICUs which harbor critically ill patients • Acinetobacter baumannii is one of the most important nosocomial pathogens in ICUs
Introduction • A. baumannii is a Gram-negative non- fermentative coccobacilli causing respiratory, blood stream, and surgical site infections. • No published data are available about Acinetobacter in Yemen, Thus this study is the first study that executed to determine it’s prevalence and antibiotics susceptibility patterns
Introduction • Taxonomy of A. baumannii
Introduction • Habitat and Transmission • It is widely distributed in nature and are found in soil and fresh water. • It is a part of the bacterial flora of the skin ,oral cavity, URT and the GIT.
Introduction • Sources of Spread in Hospitals • The carriage rate of Acinetobacter on the skin of hospitalized patients is higher than the community • It was found persist in the environment for up to 13 days after patient discharge • It can survive on dry surfaces such as mattresses and equipments
Introduction
Introduction • Predisposing factors • Include advanced age, surgery, previous treatment with broad-spectrum antibiotics, use of invasive devices, burns, immunosuppression, Prolonged ICU stays, severe underlying diseases.
Introduction • Pathogenesis of A. baumannii • The precise mechanisms are unclear, • not known to produce either diffusible toxins or cytolysins • Few virulence factors have been identified; pilus biogenesis, iron uptake, quorum sensing and a Outer membrane proteins
Introduction • Clinical manifestation • Pneumonia • Bacteraemia • Urinary Tract Infections • Skin and Soft-Tissue Infections • Meningitis
Introduction • Multi-drug-resistant A. baumannii • There is a global emergence of A. baumannii strains resistant to all β - lactams, that illustrates the potential of this organism to up-regulate of innate resistance mechanisms and acquisition of foreign resistant genes
Introduction • Resistance to β – lactams mechanisms : • Expression of β – lactamases • Outer-membrane permeability • Modification of penicillin-binding proteins • Increased activity of efflux pumps • Resistance to Non- β -lactam Antibiotics • Include aminoglycoside phosphotransferases, acetyltransferases and adenyltransferases.
Introduction • Control of A. baumannii infection • Proper hand washing with antiseptic or alcohol-based soaps and appropriate gloves use • Use of antibacterial prophylaxis for critically ill patients • Monitoring trends in antimicrobial resistance
Introduction • Proper use of invasive procedures • Isolation of infected patient. • Environmental disinfection. • Hyperaggressive cleaning during outbreak • Appropriate antimicrobial use. • Rapid discharge of patients from hospital
Aims of the study
Aims of the study • This study was conducted to: Estimate the prevalence of 1. Acinetobacter baumannii in ICU's clinical and environmental samples. 2. Determine the antibiotics susceptibility patterns of isolates. 3. Study the risk factors contributed for its nosocomial infections.
Methodology
Methodology • The study design • It was a descriptive cross sectional study involved ICUs in 3 hospitals, 2 public and 1 private (USTH, Al-Thawra Hospital and Al-Kuwait Hospital) in Sana'a city, Yemen during the period from October 2012 to September 2013 .
Methodology • Data collection • Data was taken from each subject and collected in a predesigned questionnaire. • Specimen types and sampling • Clinical specimens : Respiratory specimens (tracheal aspirates) and blood were taken from study population
Methodology • Specimens collected under aseptic technique, respiratory aspirates taken after physiotherapy and before making bronchial washing. The blood specimens collected in commercial aerobic bottle. • Environmental samples : • Sterile moist swabs were collected from pillows, ventilators, tracheal tubes and central line catheters.
Methodology • The sample size • The sample size was calculated by Epi info • It was 280 ICUs patients and 80 ICUs environmental samples • Isolation Method: • Specimens directly inoculated on Leeds Acinetobacter Medium and MacConkey agar aerobically at 37 0 C overnight
Methodology • On LAM it was produced pink colored, small, smooth and convex colonies. • On MacConkey it was produced white colonies (non-lactose fermenter).
Methodology • Characteristics of selected isolates:- • Gram negative coccobacilli • Oxidase negative • Catalase positive • No fermentation on Kligler's Iron Agar • Negative reactions on SIM • Positive on Citrate Agar and • Negative on Urea Agar
Methodology • Confirmation of the A. baumannii • Growth on 44 0 C • Analytical Profile Index API20 NE • Antimicrobial Susceptibility Test: • Disc Diffusion Test performed according to standard procedure.
Results
Results • Sex distribution of studied patients Female Male 43% 57%
Results • The age groups distribution of studied patients <19 yrs >70 yrs 19-39 8% 14% yrs 28% 40-69 yrs 50%
Results p This result was agreed with a Prevalence of A. baumannii among ICUs patients This result was similar with studies study by Falagas et al , 2008 that performed in Spain (8%) (Corbella et reviewed 41 studies and found 14 12.9% al , 2000), India (9.6%) (Joshi et al , prevalence of Acinetobacter 12 2006) and the Philippines (5%) (Chua pneumonia in studies originating 10 and Alejandria, 2008). 7.1% from Asia between 4-44% 8 6 Series1 4 1.4% 2 0 Crude Blood Respiratory Prevalence specimen specimens
Results • The association between age and A. baumannii Age +ve culture χ 2 OR CI p groups/years No. % This was agreed with a study <19 n= 24 0 0 0 (0-5.9) 2.02 0.15 in Taiwan (Kuo et al , 2012) that found A. baumannii 19-39 n= 78 6 7.7 1.12 (0.4-3.3) 0.05 0.82 significantly higher with the age of 65 years and older 40-69 n= 140 10 7.1 1.00 (0.4-2.7) 0.0 1.00 >69 n= 38 4 10.5 1.7 (0.4-5.7) 0.76 0.38
Results • The association between the length of stay for ICU patients and of A. baumannii This result disagreed with +ve culture studies in South Korea ( Duration χ 2 OR CI p Jung et al , 2010) and (Days) No. % Turkey (Alp et al , 2009) <7 days n= 198 6 3.03 0.15 (0.05-0.4) 17.2 0.0000 that found no significant risk related to the 7-14 days n= 60 6 10.0 1.63 (0.5-4.8) 0.94 0.33 duration of stay in ICU 8 44.4 16.7 (4.9-57) 40.3 0.0000 15-30days n= 18 >30 days n= 4 0 0 0.0 (0-21) 0.31 0.57
Results The association between types of management procedures applied on patients and of A. baumannii This finding was +ve culture OR similar to the result χ 2 Procedures CI p No. % of a study in South Korea that reported 20 9 1.28 (1.2-1.3) 5.6 0.01 Mechanical a significant risk with ventilation n= 222 a statistical Central line n= 116 12 10.3 2.3 (0.8-6.3) 3.1 0.08 significant for tracheal tube Tracheal tube n= 118 18 15.2 14.4 (3.1-91) 20. 0.001 18 8.3 2.8 (0.6-12) 2.0 0.266 Nasogastric tube n= 216
Results The association between number of invasive procedures applied on patients and A. baumannii This result was agreed +ve with a study in Brazil that Number of invasive culture χ 2 OR CI p found a significant procedures No. % correlation for the use of more than two invasive 6 4.3 0.42 3.2 0.07 One invasive procedure (0.14- procedures (Prata-Rocha n= 138 1.2) et al , 2012). 4 6.0 0.0 0.69 Two invasive procedure (0.22- 0.1 n= 66 2.7) 5 10 13.1 2.94 (1.1-8.1) 5.7 0.017 Three invasive procedure n= 76
Results • The antibiotics susceptibility rates of 20 isolated A. baumannii from ICUs patients Antibiotics S% I% R% Pipracillin-Tazobactam 5 0 95 These results Imepenem 10 0 90 agreed with studies Amikacin 10 0 90 in the Philippines Ticracillin 0 10 90 (Chua and Doxycyclin 20 0 80 Alejandria, 2008), Cefepime 20 0 80 and Iran Colistin 100 0 0 (Yadegarinia et al , Polymyxin B 2013). 100 0 0
Results • Prevalence of A. baumannii in the ICUs environmental samples at studied hospitals This result was agreed with a study in the USA Types of No. of No. of All of the isolated A. +ve rate (Thom et al , 2011) that samples samples isolates baumannii from found a prevalence of A. patients and ICUs 20 1 5 Ventilators baumannii in the environments were environment of 9.8% and Pillows 20 3 15 indistinguishable using 85% of that isolates were Tracheal tube 20 2 10 both biotyping and genetically similar to the antibiogram typing. Central line 20 1 5 clinical isolates. Total 80 7 8.8
Conclusions and Recommendations
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