Background and aims: Ventilator-associated pneumonia (VAP) is an important cause of healthcare-associated infections, resulting in prolonged hospitalization with increased morbidity and mortality. Knowledge of predominant local pathogens and their antimicrobial susceptibility patterns helps in selection of appropriate initial antibiotic therapy in these critical cases. The objective of this study is to characterize the microbiology and antimicrobial susceptibility patterns of VAP isolates in a tertiary cancer center.
Subjects and methods: This is a 4-year qualitative observational study carried out at a tertiary care cancer hospital in Mumbai. All nondirect bronchoalveolar lavage specimens from patients with a clinical suspicion of VAP sent from the critical care unit to the department of microbiology were processed as per standard laboratory procedures. All isolates were identified to species level and an antimicrobial susceptibility testing was performed by the Kirby–Bauer disk diffusion method and/or the VITEK 2 automated identification and susceptibility system, according to Clinical and Laboratory Standards Institute guidelines.
Results: The study comprised 1,074 patients: 710 (66.10%) men and 364 (33.90%) women. A total of 827 bacterial isolates were obtained with 780 (94.32%) gram-negative organisms and 47 (5.68%) gram-positive organisms; of which Acinetobacter baumannii (38.7%), Pseudomonas aeruginosa (17.5%), and Klebsiella pneumoniae (16.6%) were the commonest. Of gram-negative bacilli, multidrug-resistant organisms constituted 87.50% and were susceptible to colistin.
Conclusions: VAP is associated with pathogens, such as A. baumannii, P. aeruginosa, and K. pneumoniae in our setting. High rates of resistance to aminoglycosides, β-lactam-β-lactamase inhibitor combinations, and carbapenems were noted.
Lassen HCA. The epidemic of poliomyelitis in Copenhagen, 1952. Proc R Soc Med 1954;47(1):67–71.
Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer, et al. American Thoracic Society: Infectious Diseases Society of America. Guidelines for the management of adults with hospital acquired, ventilator associated and healthcare associated pneumonia. Am J Respir Crit Care Med 2005;171(4):388–416. DOI: 10.1164/rccm.200405-644ST.
Chastre J, Fagon JY. Ventilator associated pneumonia. Am J Respir Crit Care Med 2002;165(7):867–903. DOI: 10.1164/ajrccm.165.7.2105078.
Arabi Y, Al-Shirawi N, Memish Z, Anzueto A. Ventilator-associated pneumonia in adults in developing countries: a systematic review. Int J Infect Dis 2008;12(5):505–512. DOI: 10.1016/j.ijid.2008.02.010.
Kalanuria AA, Zai W, Mirski M. Ventilator associated pneumonia in the ICU. J Crit Care 2014;18(2):208. DOI: 10.1186/cc13775.
Groeger JS, White P. Outcome for cancer patients requiring Mechanical Ventilation. J Clin Oncol 1999;17(3):991–997. DOI: 10.1200/JCO.19184.108.40.2061.
Schapira D, Studnicki J, Bradham D, Wolff P, Jarrette A. Intensive care, survival, and expense of treating critically ill cancer patients. JAMA 1993;269:783–786. DOI: 10.1001/jama.1993.03500060083036.
Davis KA. Ventilator associated pneumonia: a review. J Intensive Care Med 2006;21:211–226. DOI: 10.1177/0885066606288837.
Rakshit P, Nagar VS, Deshpande AK. Incidence, clinical outcome and risk stratification of ventilator-associated pneumonia: A prospective cohort study. Indian J Crit Care Med 2005;9(4):211–216. DOI: 10.4103/0972-5229.19761.
Gupta A, Agrawal A, Mehrotra S, Singh A, Malik S, Khanna A. Incidence, risk stratification, antibiogram of pathogens isolated and clinical outcome of Ventilator associated pneumonia. Indian J Crit Care Med 2011;15(2):96–101. DOI: 10.4103/0972-5229.83015.
Bonell A, Azarrafiy R, Huong VTL, Viet TL, Phu VD, Dat VQ, et al. A systematic review and meta-analysis of ventilator-associated pneumonia in adults in Asia: an analysis of national income level on incidence and etiology. Clin Infect Dis 2019;68(3):511–518. DOI: 10.1093/cid/ciy543.
Papazian L, Bregeon F, Thirion X, Gregoire R, Saux P, Denis JP, et al. Effect of ventilator associated pneumonia on mortality and morbidity. Am J Respir Crit Care Med 1996;154(1):91–97. DOI: 10.1164/ajrccm.154.1.8680705.
Balkhy HH, El-Saed A, Maghraby R, Al-Dorzi HM, Khan R, Rishu AH, et al. Multi drug-resistant versus sensitive Acinetobacter baumannii ventilator associated pneumonia at a tertiary care centre: characteristics, microbiology and outcomes. Am J Respir Crit Care Med 2012;18:50–53. DOI: 10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A6076.
Joseph N, Sistla S, Dutta T, Badhe A, Parija S. Ventilator associated pneumonia in a tertiary care hospital in India: incidence and risk factors. J Infect Dev Ctries 2009;3(10):771–777. DOI: 10.3855/jidc.396.
Dey A, Bairy I. Incidence of multidrug-resistant organisms causing ventilator associated pneumonia in a tertiary care hospital: a nine months’ prospective study. Ann Thorac Med 2007;2(2):52–57. DOI: 10.4103/1817-1737.32230.
Wałaszek M, Różańska A, Wałaszek MZ, Wójkowska-Mach J, The Polish Society of Hospital Infections Team. Epidemiology of ventilator-associated pneumonia, microbiological diagnostics and the length of antimicrobial treatment in the Polish Intensive Care Units in the years 2013–2015. BMC Infect Dis 2018;18:308. DOI: 10.1186/s12879-018-3212-8.
Gadani H, Vyas A, Kar AK. A study of ventilator-associated pneumonia: Incidence, outcome, risk factors and measures to be taken for prevention. Indian J Anaesth 2010;54(6):535–540. DOI: 10.4103/0019-5049.72643.
Rosenthal VD, Maki DG, Salomao R, Moreno CÁ, Mehta Y, Higuera F, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med 2006;145(8):582–591. DOI: 10.7326/0003-4819-145-8-200610170-00007.
Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short course empiric antibiotic therapy for patients with pulmonary infilterates in the intensive care units: a proposed solution for indiscriminate antibiotic prescription. AM J Respir Crit Care Med 2009;162(2 Pt 1):505–511. DOI: 10.1164/ajrccm.162.2.9909095.
Estella A, Monge MI, Perez Fontaina L, Sainz de Baranda A, Gala MJ, Moreno E. Bronchoalveolar lavage for diagnosing pneumonia in mechanically ventilated patients. Med Intensiva 2008;32(9):419–423. DOI: 10.1016/s0210-5691(08)75718-8.
Safdar N, Crnich CJ, Maki DG. The pathogenesis of ventilator-associated pneumonia: Its relevance to developing effective strategies for prevention. Respir Care 2005;50(6):725–739.
Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50:714–721.
Winn W Jr, Allen S, Janda W, Koneman E, Procop G, Schreckenberger P, et al. Koneman's colour atlas and textbook of diagnostic microbiology. 6th ed. Lippincot; 2006.
Wu CL, Yang DI, Wang NY, Kuo HT, Chen PZ. Quantitative culture of endotracheal aspirates in the diagnosis of ventilator-associated pneumonia in patients with treatment failure. Chest 2002;122(2):662–668. DOI: 10.1378/chest.122.2.662.
Sharpe JP, Magnotti LJ, Weinberg JA, Brocker JA, Schroeppel TJ, Zarzaur BL, et al. Gender disparity in ventilator-associated pneumonia following trauma: identifying risk factors for mortality. J Trauma Acute Care Surg 2014;77(1):161–165. DOI: 10.1097/TA.0000000000000251.
Torres A, Carlet J. Ventilator-associated pneumonia. European Task Force on ventilator-associated pneumonia. Eur Respir J 2001;17(5):1034–1045. DOI: 10.1183/09031936.01.17510340.
O’Grady NP, Murray PR, Ames N. Preventing ventilator-associated pneumonia: does the evidence support the practice? JAMA 2012;307(23):2534–2539. DOI: 10.1001/jama.2012.6445.
Park SA, Cho SS, Kwak GJ. Factors influencing ventilator-associated pneumonia in cancer patients. Asian Pac J Cancer Prev 2014;15(14):5787–5791. DOI: 10.7314/apjcp.2014.15.14.5787.
Chandrakanth C, Anushree, Vinod A. Incidence of ventilator associated pneumonia. Int J Med Clin Res 2010;1(2):11–13. DOI: 10.9735/0976-55220.127.116.11-13.
Chawla R. Epidemiology, etiology and diagnosis of hospital acquired pneumonia and ventilator associated pneumonia in Asian countries. Am J Infect Control 2008;36(4 Suppl.):93–100. DOI: 10.1016/j.ajic.2007.05.011.
Quartin AA, Kett DH, Scerpella EG, Huang DB. A comparison of microbiology and demographics among patients with healthcare-associated, hospital acquired, and ventilator-associated pneumonia: a retrospective analysis of 1184 patients from a large, international study. BMC Infect Dis 2013;13:561–564. DOI: 10.1186/1471-2334-13-561.
Rahal JJ, Urban C, Segal-Maurer S. Nosocomial antibiotic resistance in multiple Gram negative species: experience at one hospital with squeezing the resistance balloon at multiple sites. Clin Infect Dis 2002;34(4):499–503. DOI: 10.1086/338639.
Gottesman BS, Carmeli Y, Shitrit P, Chowers M. Impact of quinolone restriction on resistance patterns of Escherichia coli isolated from urine by culture in a community setting. Clin Infect Dis 2009;49(6):869–875. DOI: 10.1086/605530.
Craven DE, Steger KA. Epidemiology of nosocomial pneumonia. New perspectives on an old disease. Chest 1995;108(2 Suppl.):1S–16S. DOI: 10.1378/chest.108.2_supplement.1s.
Rello J, Sonora R, Jubert P, Artigas A, Rue M, Valles J. Pneumonia in intubated patients: role of respiratory airway care. Am J Respir Crit Care Med 1996;154(1):111–115. DOI: 10.1164/ajrccm.154.1.8680665.
Donlan RM. Role of biofilms in antimicrobial resistance. Asaio J 2000;46(6):S47–S52. DOI: 10.1097/00002480-200011000-00037.
Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001;358(9276):135–138. DOI: 10.1016/s0140-6736(01)05321-1.
Rajasekhar T, Anuradha K, Suhasini T, Lakshmi V. The role of quantitative cultures of non bronchoscopic samples in ventilator associated pneumonia. IJMM 2006;24(2):107–113. DOI: 10.4103/0255-0857.25226.
Goel V, Hogade SA, Karadesai SG. Ventilator associated pneumonia in a medical intensive care unit: microbiological aetiology, susceptibility patterns of isolated organisms and outcome. Indian J Anasth 2012;56(6):558–562. DOI: 10.4103/0019-5049.104575.
Divatia JV, Pulinilkunnathil JG, Myatra SN. Nosocomial infections and ventilator-associated pneumonia in cancer patients. Oncol Crit Care 2019;1419–1439. DOI: 10.1007/978-3-319-74588-6_125.
Baran G, Erbay A, Bodur H, Onguru P, Akinci E, Balaban N, et al. Risk factors for nosocomial imipenem-resistant Acinetobacter baumannii infections. Int J Infect Dis 2008;12(1):16–21. DOI: 10.1016/j.ijid.2007.03.005.
Neonakis IK, Spandidos DA, Petinaki E. Confronting multidrug-resistant Acinetobacter baumannii: a review. Int J Antimicrob Agents 2011;37(2):102–109. DOI: 10.1016/j.ijantimicag.2010.10.014.
Rice LB. Challenges in identifying new antimicrobial agents effective for treating infections with Acinetobacter baumannii and Pseudomonas aeruginosa. Clin Infect Dis 2006;43(2):S100–S105. DOI: 10.1086/504487.
Siau H, Yuen KY, Wong SSY, Ho PL, Luk WK. The epidemiology of Acinetobacter infections in Hong Kong. J Med Microbiol 1996;44:340–347. DOI: 10.1099/00222615-44-5-340.
Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A, et al. Antimicrobial resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009–2010. Infect Control Hosp Epidemiol 2013;34(1):1–14. DOI: 10.1086/668770.
Balkhy HH, El-Saed A, Maghraby R, Al-Dorzi HM, Khan R, Rishu AH, et al. Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia. Ann Thorac Med 2014;9(2):104–111. DOI: 10.4103/1817-1737.128858.
ÇİÇek AÇ, Düzgün AÖ, Saral A, Kayman T, Çİzmecİ Z, Balcı PÖ, et al. Detection of class 1 integron in Acinetobacter baumannii isolates collected from nine hospitals in Turkey. Asian Pac J Trop Biomed 2013;3(9):743–747. DOI: 10.1016/S2221-1691(13)60149-5.
Moreira MR, Guimaraes MP, Rodrigues AA, Gontijo Filho PP. Antimicrobial use and bacterial resistance in VAP. Rev Soc Bras Med Trop 2013;46(1):39–44. DOI: 10.1590/0037-868216722013.
Haeili M, Ghodousi A, Nomanpour B, Omrani M, Faizabadi MM. Drug resistance patterns of bacteria isolated from patients with nosocomial pneumonia at Tehran hospitals during 2009–2011. J Infect Dev Ctries 2013;7(4):312–317. DOI: 10.3855/jidc.2604.
Mehta Y, Jaggi N, Rosenthal VD, Rodrigues C, Todi SK, Saini N, et al. Effectiveness of a multidimensional approach for prevention of ventilator-associated pneumonia in 21 adult intensive-care units from 10 cities in India: findings of the International Nosocomial Infection Control Consortium (INICC). Epidemiol Infect 2013;141(12):2483–2491. DOI: 10.1017/S0950268813000381.
Mulin B, Talon D, Viel JF, Vincent C, Leprat R, Thouverez M, et al. Risk factors for nosocomial colonization with multiresistant Acinetobacter baumannii. Eur J Clin Microbiol Infect Dis 1995;14(7):569–576. DOI: 10.1007/BF01690727.