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      High antimicrobial resistant rates among Gram-negative pathogens in intensive care units : A retrospective study at a tertiary care hospital in Southwest Saudi Arabia

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      , PhD, MHPE
      Saudi Medical Journal
      Saudi Medical Journal

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          Abstract

          Objectives:

          To determine the distribution and resistance profiles of Gram-negative bacteria (GNB) in intensive care units (ICUs) at King Abdullah Hospital in Bisha, Saudi Arabia.

          Methods:

          A record based retrospective study was conducted from December 2016 to January 2018. In total, 3736 non-duplicate clinical specimens from the general intensive care unit (ICU), neonatal ICU (NICU), and coronary CU (CCU) were analyzed for pathogens.

          Results:

          Of 3736 specimens, 9.6% (358) were positive for pathogens, and GNB constituted the majority (290/358; 81%). Acinetobacter is predominant in the general ICU, whereas Klebsiella pneumoniae is common in the NICU and CCU. Overall, GNB revealed a high resistance rate for cefuroxime (75.8%) trimethoprim/sulfamethoxazole (73.4%), cefotaxime (72.9%), aztreonam (64.6%), piperacillin (62.1%), and ciprofloxacin (61.5%). Acinetobacter revealed a high resistance (93.4% to 97.5%) to all antimicrobials except colistin (4%). Klebsiella pneumoniae showed a high resistance to trimethoprim/sulfamethoxazole (71.8%), cefotaxime (71.4%) and aztreonam (65.2%). Pseudomonas aeruginosa showed good activity for aminoglycosides but increasing resistance for cephalosporins and meropenem. GNB exhibited a high rate of multi-drug-resistant (MDR) phenotypes (67.9%) with a higher level among Acinetobacter spp. (97.5%). There were no significant differences in the resistance rates of GNB from different ICUs except for imipenem ( p=0.002) and ciprofloxacin ( p=0.003).

          Conclusions:

          Increased antimicrobial resistance with high proportions of MDR patterns were found among GNB from ICUs. Comprehensive surveillance programs are needed to track the origins and emergence pathways of resistant pathogens.

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          Most cited references33

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          Antimicrobial susceptibility of Gram-negative organisms isolated from patients hospitalized in intensive care units in United States and European hospitals (2009-2011).

          Treatment of infections in the intensive care unit (ICU) represents a great challenge, especially those caused by Gram-negative organisms. Rapid introduction of appropriate antimicrobial therapy is crucial to reduce mortality; resistance rates in the ICU can be elevated due to antimicrobial selection pressure. We evaluated the antimicrobial susceptibility patterns of Gram-negative bacteria isolated from patients hospitalized in ICUs (ICU patients). The isolates were consecutively collected as part of the SENTRY Antimicrobial Surveillance Program from January 2009 to December 2011 and tested for susceptibility to multiple antimicrobial agents at a central laboratory by reference broth microdilution methods. Antimicrobial susceptibility results for 5989 bacterial isolates from ICU patients (3445 from the United States [USA] and 2544 from Europe [EU]) were analyzed and compared to those of 17,244 organisms from non-ICU patients (9271 from USA and 7973 from EU). Escherichia coli, Klebsiella spp., and Pseudomonas aeruginosa were the most frequently isolated organisms from ICU patients, followed by Enterobacter spp., Serratia spp., Haemophilus influenzae, Acinetobacter spp., and Proteus mirabilis. Susceptibility rates were generally lower among ICU isolates compared to non-ICU organisms. E. coli isolates from ICU patients exhibited elevated extended-spectrum β-lactamase (ESBL)-phenotype rates (13.7% in USA and 16.6% in EU); furthermore, only amikacin (90.5-94.8% susceptibility), colistin (99.8-100.0% inhibited at ≤2 μg/mL), imipenem (95.5-96.0%), meropenem (95.4-95.8%), and tigecycline (96.3-98.0%) exhibited good activity against Klebsiella spp. ESBL-phenotype rates have increased among both E. coli and Klebsiella spp. from ICU patients in the USA and in Europe, with the most noticeable increase among Klebsiella spp. from Europe (from 27.5% in 2009 to 41.8% in 2011; P = 0.015 and odds ratio = 0.89 [95% confidence interval, 1.13-3.18]). Meropenem susceptibility among Klebsiella spp. improved slightly in the USA but decreased markedly in Europe from 100.0% in 2009 to 89.7% in 2011. Only colistin (99.4% susceptible) and amikacin (97.3% in USA and 84.9% in EU) exhibited good activity against P. aeruginosa strains from ICU patients. The greatest differences in susceptibility rates between P. aeruginosa strains from ICU and non-ICU patients were observed for the anti-pseudomonal β-lactams, such as ceftazidime, meropenem, and piperacillin/tazobactam. The results of this study (101 medical centers) highlight major antimicrobial coverage problems and trends in antimicrobial resistance for USA and EU ICU patient isolates. Copyright © 2014 Elsevier Inc. All rights reserved.
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            Colistin MIC variability by method for contemporary clinical isolates of multidrug-resistant Gram-negative bacilli.

            In vitro evaluation of colistin susceptibility is fraught with complications, due in part to the inherent cationic properties of colistin. In addition, no reference method has been defined against which to compare the results of colistin susceptibility testing. This study systematically evaluated the available methods for colistin MIC testing in two phases. In phase I, colistin MICs were determined in 107 fresh clinical isolates of multidrug-resistant (MDR) Gram-negative bacilli (GNB) by broth microdilution with polysorbate 80 (BMD-T), broth macrodilution (TDS), and the Etest. In phase II, 50 of these isolates, 10 of which were colistin resistant, were tested in parallel using BMD-T, TDS, agar dilution, broth microdilution without polysorbate 80 (BMD), and the TREK Gram-negative extra MIC format (GNXF) Sensititre. The Etest was also performed on these 50 isolates using Mueller-Hinton agar (MHA) from three different manufacturers. Colistin MIC results obtained from the five methods were compared to the MIC results obtained using BMD-T, the method that enables the highest nominal concentration of colistin in the test medium. Essential agreement ranged from 34% (BMD) to 83% (TDS), whereas categorical agreement was >90% for all methods except for BMD, which was 88%. Very major errors (VMEs) (i.e., false susceptibility) for the Etest were found in 47 to 53% of the resistant isolates, depending on the manufacturer of the MHA that was used. In contrast, VMEs were found for 10% (n = 1) of the resistant isolates by BMD and 0% of the isolates by the TDS, agar dilution, and Sensititre methods. Based on these data, we urge clinical laboratories to be aware of the variable results that can occur when using different methods for colistin MIC testing and, in particular, to use caution with the Etest.
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              Molecular epidemiology of carbapenem-resistant Acinetobacter baumannii isolates in the Gulf Cooperation Council States: dominance of OXA-23-type producers.

              The molecular epidemiology and mechanisms of resistance of carbapenem-resistant Acinetobacter baumannii (CRAB) were determined in hospitals in the states of the Cooperation Council for the Arab States of the Gulf (Gulf Cooperation Council [GCC]), namely, Saudi Arabia, United Arab Emirates, Oman, Qatar, Bahrain, and Kuwait. Isolates were subjected to PCR-based detection of antibiotic resistance genes and repetitive sequence-based PCR (rep-PCR) assessments of clonality. Selected isolates were subjected to multilocus sequence typing (MLST). We investigated 117 isolates resistant to carbapenem antibiotics (either imipenem or meropenem). All isolates were positive for OXA-51. The most common carbapenemases were the OXA-23-type, found in 107 isolates, followed by OXA-40-type (OXA-24-type), found in 5 isolates; 3 isolates carried the ISAba1 element upstream of blaOXA-51-type. No OXA-58-type, NDM-type, VIM-type, or IMP-type producers were detected. Multiple clones were detected with 16 clusters of clonally related CRAB. Some clusters involved hospitals in different states. MLST analysis of 15 representative isolates from different clusters identified seven different sequence types (ST195, ST208, ST229, ST436, ST450, ST452, and ST499), as well as three novel STs. The vast majority (84%) of the isolates in this study were associated with health care exposure. Awareness of multidrug-resistant organisms in GCC states has important implications for optimizing infection control practices; establishing antimicrobial stewardship programs within hospital, community, and agricultural settings; and emphasizing the need for establishing regional active surveillance systems. This will help to control the spread of CRAB in the Middle East and in hospitals accommodating transferred patients from this region.
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                Author and article information

                Journal
                Saudi Med J
                Saudi Med J
                Saudi Medical Journal
                Saudi Medical Journal (Saudi Arabia )
                0379-5284
                October 2018
                : 39
                : 10
                : 1035-1043
                Affiliations
                [1] From the Department of Medical Microbiology, College of Medicine, University of Bisha, Bisha, Kingdom of Saudi Arabia
                Author notes
                Address correspondence and reprint request to: Dr. Mutasim E. Ibrahim, Department of Medical Microbiology and Parasitology, College of Medicine, University of Bisha, Bisha, Kingdom of Saudi Arabia. E-mail: mutasimhadi87@ 123456hotmail.com / meibrahim@ 123456ub.edu.sa ORCID ID: orcid.org/0000-0002-1734-8439
                Article
                SaudiMedJ-39-1035
                10.15537/smj.2018.10.22944
                6201019
                30284588
                b4078daf-77ef-4ce4-90b5-39c638dd5155
                Copyright: © Saudi Medical Journal

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 May 2018
                : 22 August 2018
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