Indian Journal of Critical Care Medicine
Volume 27 | Issue 1 | Year 2023

Multidrug Resistance: The Growing Menace in PICU

Shrishu R Kamathhttps://orcid.org/0000-0002-8030-1094

Department of Pediatric Intensive Care Unit, SIMS Hospital, Chennai, Tamil Nadu, India

Corresponding Author: Shrishu R Kamath, Department of Pediatric Intensive Care Unit, SIMS Hospital, Chennai, Tamil Nadu, India, Phone: +91 44-42010123, e-mail: shrishu@yahoo.com

How to cite this article: Kamath SR. Multidrug Resistance: The Growing Menace in PICU. Indian J Crit Care Med 2023;27(1):6–7.

Source of support: Nil

Conflict of interest: None

Received on: 26 December 2022; Accepted on: 27 December 2022; Published on: 31 December 2022

Keywords: Antimicrobial agents, Antibiotic stewardship, Multidrug resistance.

Antibiotic resistance in bacteria is obtained through various mechanisms, either genetic or acquired. Antibiotic resistance is a problem that plagues every ICU irrespective of the types of cases in it. These “superbugs” with antimicrobial resistance have emerged as one of the leading public health threats of the 21st century. The Review on Antimicrobial Resistance, commissioned by the UK Government, argued that AMR could cause an overall mortality of 10 million people per year by 2050. The spread of MDR organisms is an urgent issue requiring a global, coordinated action plan to address.15

Most antibiotic resistance is hospital-acquired, but few types of resistance are even passed on to community-acquired organisms—this is quite alarming. The ICU is the epicenter of this crisis of antimicrobial resistance in hospitalized patients, and the number of these bacteria is increasing with each passing day.

Newborn babies, infants, and children are substantially affected by antimicrobial resistance. Globally, infectious diseases remain a major cause of morbidity and mortality in children, and an estimated 2,14,000 newborn babies died from drug-resistant bacterial infections in 2015. The evidences supporting pediatric MDR infections compared to adults are very few.6,7

In the current issue of the journal, Patel et al. describe the incidence of MDR organisms in pediatric patients admitted to neurointensive care.8 They report 17.3/1000 patient days as the overall incidence of MDR infections in pediatric patients admitted to neurointensive care. MDR Klebsiella pneumoniae was the commonest pathogen (38.7%) isolated in this study followed by MDR Pseudomonas aeruginosa (22.5%) and MDR Escherichia coli (12.9%). The factors they associate include the length of stay in the neurosurgical ICU, ventilation >5 days duration with cardiac and respiratory comorbidities, and invasive emergency surgery with poor nutrition status. They also cite that the relatively underdeveloped immune system may be a factor for the same.

This incidence is concerning as children acquiring MDR infection will have prolonged stays and this itself will set a vicious cycle. The use of invasive medical devices and surgical interventions increases the risk of HAI. Advocating an antibiotic regulation policy will help in decreasing the incidence of MDR bugs. Implementing an Antibiotic Stewardship Program (ASP) to a large extent helps in regulating the use of high-end antibiotics in the ICU. The implementation of this program is not very easy especially when multiple caregivers are looking after a sick child. The process of de-escalation plays a key role in helping the use of these antibiotics for fewer days and thus preventing the development of MDR organisms. Narrowing the spectrum after the culture report especially is one of the ways that helps in de-escalation. Biomarkers may largely aid in better implementation of ASP.9

In low- and middle-income countries, implementation of ASP is an uphill task. The common practice for the management of infections in low-resource settings involves symptom-based and endemicity-guided diagnosis, and the subsequent prescription of broad-spectrum antimicrobials for unconfirmed infections. Lack of access to essential diagnostics, shortage of skilled laboratory personnel, and high cost and long turn-around times exacerbate diagnostic insufficiency in these countries. Thus, ineffective diagnostic stewardship leads to antimicrobial misuse.1013

Hand hygiene, screening and identifying patients who are at risk, implementation of ICU bundles, and surface cleaning are the main prongs of prevention of ICU infections. Implementation of these is a major uphill task and doctors are mostly the main culprits who fail to implement these. A united front against this current pandemic is necessary and we need to curtail our antibiotic usage as early as possible.

To conclude, the present study sheds light on the incidence of drug resistance in a very select type of pediatric neurosurgical ICU. The incidence is alarming and all measures should be taken to contain and eliminate these infections to prevent morbidity and mortality in children.


Shrishu R Kamath https://orcid.org/0000-0002-8030-1094


1. O’Neill J. Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations. London: Review on Antimicrobial Resistance, 2014.

2. de Kraker MEA, Stewardson AJ, Harbarth S. Will 10 million people die a year due to antimicrobial resistance by 2050? PLoS Med 2016;13:e1002184. PMC5127510.

3. National Office for Animal Health. NOAH response to final O’Neill AMR review report July 2016. Middlesex: National Office for Animal Health, 2016.

4. WHO. Antimicrobial Resistance. 2021. https://www.who.int/newsroom/fact-sheets/detail/antimicrobial-resistance (accessed February 23, 2021).

5. US Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. Atlanta, GA: US Department of Health and Human Services, 2019.

6. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736–1788. DOI: https://doi.org/10.1016/S0140-6736(18)32203-7.

7. Laxminarayan R, Bhutta ZA. Antimicrobial resistance—A threat to neonate survival. Lancet Global Health 2016;4:e676–e677. DOI: 10.1016/S2214-109X(16)30221-2.

8. Patel S, Prabhakar H, Kapoor I. Rate of Multidrug-resistance to Antimicrobial Drugs in Patients in Pediatric Neurointensive Care. Indian J Crit Care Med 2023;27(1):67–72.

9. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin infect dis 2007;44(2):159–177. DOI: 10.1086/510393.

10. Patel, R, Fang, FC. Diagnostic stewardship: Opportunity for a laboratory infectious diseases partnership. Clin Infect Dis 2018;67:799–801. DOI: 10.1093/cid/ciy077.

11. Okeke, IN. Divining Without Seeds: The Case for Strengthening Laboratory Medicine in Africa. Ithaca and London: Cornell University Press, 2011.

12. Loosli K, Davis A, Muwonge A, Lembo T. Addressing antimicrobial resistance by improving access and quality of care—A review of the literature from East Africa. PLoS Negl Trop Dis 2021;15:e0009529. DOI: https://doi.org/10.1371/journal.pntd.0009529.

13. Chokshi A, Sifri Z, Cennimo D, Horng H. Global contributors to antibiotic resistance. J Glob Infect Dis 2019;11:36–42. PMC6380099.

© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.