Pattern of HospitalAcquired Pneumonia in Intensive Care Unit

Pattern of Hospital-Acquired Pneumonia in Intensive Care Unit of Suez Canal University Hospital By Nermine El-Maraghy Associate Professor of Medical Microbiology & Immunology FOMSCU, Egypt. Consultant of Medical Immunology FOMSCU, Egypt. Consultant of Infection control FOMSCU, Egypt.

Introduction

Introduction • Hospital acquired pneumonia (HAP) occurs more than 48 hours after hospital admission, ventilator associated pneumonia (VAP) occurs after 48 -72 hours of endotracheal intubation • HAP is the second most common nosocomial infection and accounts for approximately 25% of all infections in the Intensive Care Unit worldwide

Aim • To identify the etiology, initial evaluation, prevention, and treatment of adult patients with ICU HAP, and VAP in Suez Canal University (SCU) hospital and their management strategies.

Methodolog y

Methods • This study was conducted in the department of ICU, Suez Canal University Hospital; Ismailia, Egypt in the period from May to October 2013. • All the patients were subjected to clinical and radiological assessment, Endotracheal aspirate samples for culture, and sensitivity to determine the causative organisms, Clinical Pulmonary Infection Score (CPIS) was done in order to determine the severity of HAP

Table( 1) Modified Clinical Pulmonary Infection Score (CPIS) chart CPIS points Diagnostic feature 0 1 2 Tracheal secretions Rare Abundant and purulent Chest radiograph infiltrate None Diffuse Localized Temperature (°C) ≥ 36. 5 and ≤ 38. 4 ≥ 38. 5 and ≤ 38. 9 ≥ 39 or ≤ 36 White blood cells (× 109/L) ≥ 4. 0 or ≤ 11. 0 <4. 0 or >11. 0 plus band forms ≥ 0. 5 Pa. O 2/Fi. O 2 mm. Hg >240 or ARDS Microbiology Negative ≤ 240 and no ARDS Positive plus positive Gram stain

Results

Table (2): Demographic data of the studied patients. Freq. n=100 % ≤ 65 years 77 77% > 65 years 23 23% Male 73 73% Female 27 27% Specification Age sex

Table (3): The relation between the isolated organisms and the mechanical ventilation Mechanical ventilation (n=100) Isolated organisms MRSA Klebsiella pneumoniae Pseudomonas aeruginosa Proteus spp. E. coli Strept. viridans Methicillin sensitive Staph. aureus(MSSA) No growth Total P value = 0. 88 Total No. 36 Ventilated (VAP) % of Freq. column 32 35. 9 Non ventilated (HAP) % of Freq. column 4 36. 35 29 25 28. 1 4 36. 35 6 5 5. 7 1 9. 1 6 5 3 6 5 2 6. 8 5. 6 2. 2 0 0 1 0. 0 9. 1 2 2 2. 2 0 0. 0 13 100 12 89 13. 5 100 1 11 9. 1 100

Table (4): Relation between the isolated organisms and the onset of pneumonia among the studied patients Isolated organisms MRSA Klebsiella pneumoniae Pseudomonas aeruginosa Proteus spp. E. coli Strept. viridians Methicillin sensitive Staph. aureus(MSSA) No growth Total P value = 0. 32 Onset of pneumonia (n=100) Early Late Total No. Freq. % of column 36 5 29. 4 31 37. 3 29 4 23. 4 25 30. 2 6 0 0. 0 6 7. 2 6 2 11. 8 4 4. 7 5 1 5. 9 4 4. 7 3 2 11. 8 1 1. 3 2 0 0. 0 2 2. 6 13 3 17. 7 10 12. 0 100 17 100. 0 83 100. 0

Table (5): The relation between the detected organisms and the severity of pneumonia P value = 0. 007 Severity of pneumonia (n=100) Moderate Mild Isolated organisms Total No. % of Freq. colum n Severe Freq. % of column Freq. % of column MRSA 36 2 11. 1 18 38. 3 16 45. 7 Klebsiella pneumoniae 29 6 33. 3 17 36. 2 6 17. 1 6 1 5. 6 1 2. 1 4 11. 4 6 5 3 4 3 0 22. 2 16. 7 0. 0 1 0 3 2. 1 0. 0 6. 4 1 2 0 2. 9 5. 8 0. 0 2 0 0. 0 2 4. 2 0 0. 0 13 2 11. 1 5 10. 8 6 17. 1 100 18 100. 0 47 100. 0 35 100. 0 Pseudomonas aeruginosa Proteus spp. E. coli Strept. viridians Methicillin sensitive Staph. aureus(MSSA) No growth Total

Table (6): The relation between the detected organisms and the age P value = 0. 29 Age Isolated organisms MRSA Klebsiella pneumoniae Pseudomonas aeruginosa Proteus spp. E. coli Strept. viridans Methicillin sensitive Staph. aureus(MSSA) No growth Total No 36 ≤ 65 years % of Freq. column 30 39 > 65 years % of Freq. column 6 26. 3 29 20 25. 9 9 39. 3 6 5 6. 5 1 4. 3 6 5 3 5 4 1 6. 5 5. 1 1. 3 1 1 2 4. 3 8. 6 2 2 2. 6 0 0. 0 13 100 10 77 13. 1 100. 0 3 23 12. 9 23. 0

Table (7): The relation between concomitant illness and the severity of pneumonia (N=100) P value = 0. 04 Severity of pneumonia Mild Concomitant Total illness No. Moderate Severe Freq. % of column DM 41 2 11. 1 23 48. 9 18 51. 4 COPD 7 3 16. 7 3 6. 4 1 2. 9 OTHERS 21 3 16. 7 10 21. 3 7 20. 0 NONE 31 10 55. 5 11 23. 4 9 25. 7 Total 100 18 100. 0 47 100. 0 35 100. 0

Table (8): The relation between the isolated organisms and the sensitivity to the tested antibiotics P value = 0. 32 Imipenem Levofloxacin Ceftriaxone Cefoperazone Cefotaxime MRSA 44. 4% 27. 8% 11. 1% 8. 3% 19. 4% 8. 3% 0% Klebsiella spp. 3. 4% 75. 9% 44. 8% 13. 8% 3. 4% 0% 0% P. aeruginosa 66. 7% 50% 66. 7% 0% 0% Proteus spp. 50% 16. 7% 33. 3% 83. 3% 16. 7% 33. 3% 0% E. coli 0% 80% 40% 20% 0% 0% Strept. Viridians Methicillin sensitive Staph. aureus (MSSA) 0% 66. 7% 33. 3% 0% 0% 0% Amoxicillin Isolated organisms Vancomycin Tested antibiotic

Table (9): The relation between used antibiotics before ICU admission, and the isolated organisms (N=29). Used antibiotic Number % Isolated organism Ceftriaxone 3 21. 4% MRSA Cefotaxime 3 21. 4% MRSA Levofloxacin 3 21. 4% Klebsiella spp. Ciprofloxacin 2 14. 4% MRSA Azithromycin 3 21. 4% MRSA Total 14 Unknown antibiotics 15 Total 15 100% 46. 7% MRSA 40% Klebsiella spp 13. 3% P. aeruginosa 100%

Table (10): Relation between causative organisms and fate of the patients P value =0. 004 Fate (n=100) Isolated organisms Discharged No. MRSA 36 6 % of column 16. 2 Klebsiella pneumoniae 29 12 P. aeruginosa Proteus spp. E. coli Strept. viridans 6 6 5 3 Methicillin sensitive Staph. aureus (MSSA) 30 % of column 47. 7 32. 4 17 26. 9 1 5 4 2 2. 7 13. 5 10. 9 5. 4 5 1 1 1 7. 9 1. 6 2 2 5. 4 0 0 13 100 5 37 13. 5 100 8 63 12. 7 100 Freq. No growth Total Died Freq.

Conclusion

Conclusion Gram-negative organisms were isolated in 46% of cases, gram-positive organisms in 41% and the isolated organisms showed high resistance to most of the tested antibiotics.

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