dgkh000292
10.3205/dgkh000292
urn:nbn:de:0183-dgkh0002928
Research Article
Nosocomial infections and antibiotic resistance pattern in open-heart surgery patients at Imam Ali Hospital in Kermanshah, Iran
Nosokomiale Infektionen und Antibiotikaresistenz nach offen herzchirurgischen Eingriffen im Imam Ali Hospital Kermanshah, Iran
Heydarpour
Heydarpour
Fatemeh
F
Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
author
Rahmani
Rahmani
Youssef
Y
Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
author
Heydarpour
Heydarpour
Behzad
B
Shaheed Beheshti Ave, Cardiovascular Research Centre, Imam Ali Hospital, Kermanshah, Iran, Phone: 08338395970Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
behzadheydarpoor@yahoo.com
author
Asadmobini
Asadmobini
Atefeh
A
Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
author
German Medical Science GMS Publishing House
Düsseldorf
610
open heart surgery
nosocomial infection
SSI
antibiotic resistance
Iran
offene Herzchirurgie
nosokomiale Infektion
SSI
Antibiotikaresistenz
Iran
20170524
engl
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung).
2196-5226
12
GMS Hygiene and Infection Control
GMS Hyg Infect Control
07
Hintergrund: Das Risiko nosokomialer Infektionen ist nach offen herzchirurgischen Eingriffen vergleichsweise hoch. Im Fall einer Infektion durch Antibiotika resistente Bakterien verlängert sich die Aufenthaltsdauer und erhöht sich die Mortalität. Zielsetzung: Von März 2011 bis März 2014 wurden die Häufigkeit nosokomialer Infektionen nach offen herzchirurgischen Eingriffen und die Antibiotikaresistenz der ätiologisch zugrunde liegenden Erreger im Imam Ali Hospital in Kermanshah, Westiran, untersucht. Material und Methoden: Die Querschnittsstudie wurde bei 135 Patienten mit einer nosokomialen Infektion nach offenen herzchirurgischen Eingriffen durchgeführt. Von jedem Patienten wurden die demographischen Daten und Risikofaktoren erfasst. Zur Bestimmung der Antibiotikaempfindlichkeit wurde die minimale Hemmkonzentration (MHK) im Verdünnungstest gemäß Protokoll des Clinical and Laboratory Standards Institute (CLSI) ermittelt. Die Auswertung erfolgte in SPSS-16.Ergebnisse: Von 6.000 Patienten (59,3% weiblich, 40,7% männlich) entwickelten 135 (2,25%) nach offenen herzchirurgischen Eingriffen eine nosokomiale Infektion. Der Anteil von Surgery Site Infections (SSI), Pneumonien, Harnweg- und Blutstrominfektionen betrug 52,6%, 37%, 9,6% bzw. 0,8%. E. coli, Klebsiella spp. and S. aureus waren die häufigsten Erreger. E. coli war am häufigsten gegen Imipenem (23,3%) resistent, Klebsiella spp. am häufigsten gegen Gentamicin (38,5%) und S. aureus am häufigsten gegen Cotrimoxazol (54,2%). Schlussfolgerung: Auf Grund der hohen Prävalenz von SSI sollten weitere Studien zur Abklärung der infrage kommenden Risikofaktoren durchgeführt werden. Da die Antibiotikaresistenz regional differiert, ist parallel zum kalkulierten Therapiebeginn ein Antibiogramm erforderlich, um die Therapie gezielt fortsetzen zu können.
Background: Patients undergoing open heart surgery have a relatively high risk of acquiring nosocomial infections. The development of antibiotic-resistant infections is associated with prolonged hospital stays and mortalities.Objectives: The present study was conducted to investigate nosocomial infections and the antibiotic resistance pattern in bacteria causing these infections in open heart surgery patients at Imam Ali Hospital in Kermanshah in the west of Iran over a 4-year period from March 2011 to March 2014.Materials and methods: The present cross-sectional study was conducted on 135 cases of nosocomial infection among open heart surgery patients. The demographic characteristics and the risk factors of each case of infection were recorded. The antibiotic susceptibility test was carried out using the Minimum Inhibitory Concentration (MIC) method based on the Clinical and Laboratory Standards Institute (CLSI) protocol. The data collected were then analyzed in SPSS-16.Results: Out of the 6,000 patients who underwent open heart surgery during this 4-year period at the selected hospital, nosocomial infections developed in 135 patients (2.25%), 59.3% of whom were female and 40.7% male. Surgery site infection (SSI), pneumonia (PNEU), urinary tract infection (UTI) and blood stream infection (BSI) affected 52.6%, 37%, 9.6% and 0.8% of the cases, respectively. E.coli, Klebsiella spp. and S. aureus were the most common bacteria causing the nosocomial infections. E. coli was most frequently resistant to imipenem (23.3%) Klebsiella spp. to gentamicin (38.5%) S. aureus to co-trimoxazole (54.2%). Conclusion: SSI had a high prevalence in this study. Further studies should therefore be conducted to examine the risk factors associated with SSI in open heart surgery. Various studies have shown that antibiotic resistance patterns are different in different regions. Finding a definitive treatment therefore requires an antibiogram.
IntroductionNosocomial infections are considered a serious threat to patients’ health, especially in intensive care units . About 8.7% of hospitalized patients worldwide develop nosocomial infections. These infections cause surgery failure, organ rejection, treatment failure, increased costs, death due to prolonged hospital stays after infection, and psychological stress in the patients , , . Nosocomial infections are estimated to be responsible for about 80,000 deaths in the US every year . Nosocomial infections can cause serious post-operative complications in patients and significantly increase the likelihood of death; they can also increase the need for antibiotic treatment as well as the economic burden of diseases .Cardiac patients, especially those undergoing heart surgery, appear to be at a greater risk for nosocomial infections due to their multiple surgical wounds, the use of invasive devices after surgery, the common use of antibiotics before surgery, and the longer hospital stays .Reports indicate a 5% to 21% prevalence of nosocomial infections after heart surgery, which can pose a serious health threat to these patients , . Moreover, the current trend of antibiotic administration before surgery may lead to the emergence of antibiotic-resistant pathogens in these patients. A major barrier to the treatment of nosocomial infections is the increase in antibiotic-resistant organisms. Preventing nosocomial infections is therefore gaining urgency , . Knowledge about the common pathogens in every <![CDATA[ho</PlainText></TextGroup>sp<TextGroup><PlainText>ital</PlainText></TextGroup> and hospital ward can contribute to the effective control of infections. Measuring the antibiotic resistance of bacteria is an essential task. To the best of the authors’ knowledge, the present study is the first of its kind on heart patients in western Iran that aims to investigate nosocomial infections and antibiotic resistance patterns among the pathogens causing these infections at Imam Ali Heart Hospital in Kermanshah, western Iran. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Materials and methods">
<MainHeadline>Materials and methods</MainHeadline><Pgraph>The present cross-sectional study was conducted on all patients who developed nosocomial infections at Imam Ali Hospital in Kermanshah over a four-year period from March 2011 to March 2014 using the census method. Nosocomial infections were defined according to the national guidelines for nosocomial infection care <TextLink reference="12"></TextLink>. Data pertaining to the patients affected by nosocomial infections, including demographic and clinical details, medical history, risk factors, type of infection and their clinical samples were collected and analyzed with SPSS-16. The risk factors defined were diabetes, hypertension, lung diseases, urinary catheter, suction, vein catheter, artery catheter, tracheostomy, and intubation. </Pgraph><Pgraph>The samples taken from the patients included discharge from infected deep tissue at the site of the surgical wounds, sputum, tracheal discharges, infected tissue debris, infected mediastinal tissue drainage, urine, and blood. The samples were taken by a laboratory technician and an infection control nurse and were immediately transferred to the laboratory. To avoid killing the microorganisms living in the samples, the samples were transferred in a nutritient soybean casein digest medium (Tryptone Soya Broth). The microorganisms causing the infections were detected based on standard guidelines for microbiological examination <TextLink reference="13"></TextLink>, <TextLink reference="14"></TextLink>.</Pgraph><Pgraph>The antimicrobial susceptibility test was performed using the standard broth dilution (Micro Dilution Broth) technique. The minimum inhibitory concentration (MIC) was defined as the minimum dose of an antibiotic that prevented the visible growth of bacteria following overnight culture, and was determined based on the CLSI protocol of 2010. A standard suspension, equivalent to McFarland standard of 0.5, was prepared using Mueller Hinton Broth (MHB; Merck, Germany) by employing a swab to remove a number of bacterial colonies from those grown on blood agar and eosin methylene blue (EMB) agar media and dissolving them in sterilized saline. The standard was then placed in a bain-marie for 1–2 hours and cultured on Mueller Hinton agar. The antibiotic discs purchased from the Padtan Teb Company (Tehran, Iran) were then placed on the standard.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>Of the 38,057 patients hospitalized during the four years from March 2011 to March 2014, 427 (1.1%) developed nosocomial infections, 257 (60.2%) of whom were female and 170 (39.8%) were male. A total of 6,000 of the hospitalized patients had open heart surgeries and 135 (2.25%) of them subsequently developed nosocomial infections; 80 of the patients who developed nosocomial infections (59.3%) were female and 55 (40.7%) were male. The mean overall age of the patients who developed nosocomial infections was 65.2 ± 11.83 years, and the mean age of those with heart surgeries who developed nosocomial infections was 69.6 ± 11.97 years (61.7 ± 11.93 years for female and 64.9 ± 99 years for male patients). Surgery Site Infection (SSI) occurred in 71 patients (52.6%), pneumonia in 50 patients (37%), urinary tract infection (UTI) in 13 (9.6%) patients, and blood stream infection (BSI) in one (0.8%) patient. <TextGroup><PlainText>Table 1 </PlainText></TextGroup><ImgLink imgNo="1" imgType="table"/> presents the demographic characteristics and risk factors for infection in the heart surgery patients. <TextGroup><PlainText>Table 2 </PlainText></TextGroup><ImgLink imgNo="2" imgType="table"/> presents the factors causing infection by the site and type of the nosocomial infection; Table 3 <ImgLink imgNo="3" imgType="table"/> shows these factors by hospital ward. </Pgraph><Pgraph>Table 4 <ImgLink imgNo="4" imgType="table"/> and Table 5 <ImgLink imgNo="5" imgType="table"/> show the antibiotic resistance pattern in the Gram-positive and the Gram-negative bacteria, respectively. The most common bacteria observed over four-year period included <Mark2>E. coli</Mark2>, which affected 30 patients (24%), <Mark2>Klebsiella</Mark2> spp., affecting 26 patients (21%), and <Mark2>S. aureus</Mark2>, affecting 24 patients (19%). The antibiotics to which <Mark2>E.coli</Mark2> was most resistant included imipenem in 7 cases (23.3%) and gentamicin and nalidixic acid in <TextGroup><PlainText>6 cases</PlainText></TextGroup> (20%). The antibiotics to which <Mark2>Klebsiella</Mark2> spp. was most resistant included gentamicin in 10 cases (38.5%) and imipenem in 7 cases (27%). <Mark2>S. aureus</Mark2> was most resistant to co-trimoxazole with 13 cases (54.2%) and penicillin with 9 (37.5%). </Pgraph></TextBlock>
<TextBlock linked="yes" name="Discussion">
<MainHeadline>Discussion</MainHeadline><Pgraph>Despite the great advances in surgical techniques, such as prophylactic antibiotics, disinfection and sterilization, SSIs still cause problems for a large number of patients <TextLink reference="15"></TextLink>. The rate of nosocomial infections was 2.25% in the present study, of which 1.18% were SSIs. Various studies have reported nosocomial infections after cardiac surgery to exceed 20% <TextLink reference="8"></TextLink>, <TextLink reference="16"></TextLink>, <TextLink reference="17"></TextLink>, <TextLink reference="18"></TextLink>, <TextLink reference="19"></TextLink>, <TextLink reference="20"></TextLink>. The incidence of nosocomial infections was reported as 16% in the study by Lomtadze et al. and 8.3% in the study by Davoodi et al. <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. Microbiological evidence suggests that 5% of open heart surgery patients develop nosocomial infections <TextLink reference="9"></TextLink>. Under-reporting appears to be in excess of 50% at Imam Ali Hospital of Kermanshah, and the health authorities need to take measures at the ministerial and regional levels in order to reduce this under-reporting. </Pgraph><Pgraph>SSI was reported as 1.18% in the present study, but as 3% in the study by Lepelletier et al. and 13.5% by Lee et al. <TextLink reference="23"></TextLink>, <TextLink reference="24"></TextLink>. Other studies have reported the rate of SSI to range from 3% to 10.4% <TextLink reference="15"></TextLink>, <TextLink reference="25"></TextLink>, <TextLink reference="26"></TextLink>, <TextLink reference="27"></TextLink>. Davoodi et al. reported this rate as 27.8% <TextLink reference="22"></TextLink>. The high percentage of SSI among cardiac surgery patients in the present study may be due to neglecting aseptic surgical techniques and postoperative hygiene.</Pgraph><Pgraph>In this study, diabetes was the main risk factor for SSI, as 42.3% of the infected patients were diabetics. Lee et al. reported this rate as 37.1% <TextLink reference="24"></TextLink>. According to studies conducted by Yamashita and Vardakas, diabetic patients are predisposed to a variety of infections, including nosocomial infections <TextLink reference="28"></TextLink>, <TextLink reference="29"></TextLink>. According to Lee et al., however, diabetes is not a significant risk factor for SSI <TextLink reference="24"></TextLink>. SSI in the present study was chiefly caused by <TextGroup><Mark2>E. coli</Mark2></TextGroup> (26.8%), followed by <Mark2>S. aureus</Mark2> and <TextGroup><Mark2>Klebsiella</Mark2><PlainText> spp.</PlainText></TextGroup> (14%). In studies by Davoodi et al., <Mark2>S. aureus</Mark2> was the main cause of SSI <TextLink reference="22"></TextLink>, <TextLink reference="30"></TextLink>, <TextLink reference="31"></TextLink>.</Pgraph><Pgraph>The present study reported the rate of pneumonia as 37%, Davoodi et al. reported it as 25.3% and Lomtadze et al. reported it as 7% <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. In line with the present findings, some of these studies reported intubation respiratory infections as a major risk factor for pneumonia <TextLink reference="21"></TextLink>, <TextLink reference="31"></TextLink>. </Pgraph><Pgraph>The main causes of respiratory infections were <TextGroup><Mark2>Klebsiella</Mark2><PlainText> spp.</PlainText></TextGroup> and <Mark2>S. aureus</Mark2> in the present study; in the study by Davoodi et al., however, <TextGroup><Mark2>P. aeruginosa</Mark2></TextGroup> and <TextGroup><Mark2>S. aureus</Mark2></TextGroup> were the main bacteria isolated from the cases of pneumonia <TextLink reference="22"></TextLink>. The main bacteria causing nosocomial pneumonia included <Mark2>P. aeruginosa</Mark2>, <Mark2>A. baumannii</Mark2> and Enterobacteriaceae <TextLink reference="32"></TextLink>.</Pgraph><Pgraph>The present study reported the rate of UTI as 9.6% and found its main risk factor to be urinary catheterization, which is in line with the results of other studies <TextLink reference="22"></TextLink>, <TextLink reference="33"></TextLink>, <TextLink reference="34"></TextLink>. The most common microorganism causing UTI in the present study was <Mark2>E. coli</Mark2>, Enterobacteriaceae in the study by Mirinazhad et al. and <Mark2>E. coli</Mark2> in many other studies conducted in Iran <TextLink reference="34"></TextLink>, <TextLink reference="35"></TextLink>, <TextLink reference="36"></TextLink>, <TextLink reference="37"></TextLink>, <TextLink reference="38"></TextLink>, <TextLink reference="39"></TextLink>. </Pgraph><Pgraph>The present study reported the rate of BSI 0.8%, Lomtadze et al. reported it as 7.8% and Davoodi et al. as 8.6% <TextLink reference="21"></TextLink>, <TextLink reference="22"></TextLink>. Barker reported the rate of BSI as 2.6% in children after cardiac surgery <TextLink reference="40"></TextLink>. The most common microorganisms causing BSI included <Mark2>E. coli</Mark2> in the present study, and <Mark2>E. coli</Mark2>, <Mark2>Enterococcus</Mark2> spp. and <TextGroup><Mark2>P. aeruginosa</Mark2></TextGroup> in the study by Al-Hazmi et al. <TextLink reference="41"></TextLink>.</Pgraph><Pgraph><Mark2>E. coli</Mark2>, <Mark2>Klebsiella</Mark2> spp. and <Mark2>P. aeruginosa</Mark2> were the most common Gram-negative bacteria and <Mark2>S. aureus</Mark2> the most common Gram-positive bacterium isolated in the present study. In Davoodi’s study, <Mark2>E. coli</Mark2> and <Mark2>P. aeruginosa</Mark2> were the most common Gram-negative bacteria and <Mark2>S. aureus</Mark2> the most common Gram-positive bacterium isolated <TextLink reference="22"></TextLink>. In a study by Lavakhamseh et al., the most common bacterium isolated from patients with nosocomial infection was <Mark2>E. coli</Mark2> <TextLink reference="42"></TextLink>.</Pgraph><Pgraph>In the present study, <Mark2>E. coli</Mark2> showed the highest resistance to imipenem (23.3%), followed by gentamicin (20%) and nalidixic acid (20%). In the study by Davoodi et al., <Mark2>E. coli</Mark2> showed the highest resistance to ceftazidime (27.5%) and imipenem (13.8%) <TextLink reference="22"></TextLink>. In Lavakhamseh’s study, <TextGroup><Mark2>E. coli</Mark2></TextGroup> showed the highest resistance to co-trimoxazole (57.47%) <TextLink reference="42"></TextLink>.</Pgraph><Pgraph>In the present study, <Mark2>Klebsiella</Mark2> spp. showed the highest resistance to gentamicin (38.5%) and imipenem (27%); in Davoodi’s study, it showed the highest resistance to ceftazidime (71.42%), followed by ceftriaxone (57.1%) and ciprofloxacin (57.1%) <TextLink reference="22"></TextLink>. In the present study, <TextGroup><Mark2>S. aureus</Mark2></TextGroup> showed a high resistance to co-trimoxazole (54.2%) and penicillin (37.5%), and 50% of the cases of <Mark2>S. aureus</Mark2> were multidrug resistant. In <TextGroup><PlainText>Davoodi’s</PlainText></TextGroup> study, <Mark2>S. aureus</Mark2> was resistant to penicillin in 38.7% of the cases and to co-trimoxazole in 38.7% <TextLink reference="22"></TextLink>.</Pgraph><Pgraph><Mark2>S. aure</Mark2><Mark2>us</Mark2> and <Mark2>S. epidermidis</Mark2> showed high levels of antibiotic resistance in the present study, with <Mark2>S. aureus</Mark2> showing a resistance of 12.5% to vancomycin; in <TextGroup><PlainText>Davoodi’s</PlainText></TextGroup> study, this rate was reported as 3.2%.</Pgraph><Pgraph>Infections caused by antibiotic-resistant pathogens are often associated with a higher mortality rate compared to the same infections caused by antibiotic-sensitive pathogens <TextLink reference="43"></TextLink>, <TextLink reference="44"></TextLink>. Careful infection control strategies should therefore be adopted and antibiotic-resistance patterns in nosocomial infections should be periodically reviewed, especially in cardiac surgery centers, in order to achieve more effective antibiotic treatment for patients. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Conclusion">
<MainHeadline>Conclusion</MainHeadline><Pgraph>The present study showed that the rate of nosocomial infection following open heart surgery is low and less than that suggested by microbiological evidence. The rate of SSI, however, was shown to be high (1.18%). SSI increases ICU stays by 2–3.7 times <TextLink reference="27"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink> and the mortality rate 3.4- to 36.7-fold <TextLink reference="25"></TextLink>, <TextLink reference="45"></TextLink>, <TextLink reference="46"></TextLink>, <TextLink reference="47"></TextLink>. Knowledge on how SSI is developed and its risk factors can be highly beneficial for the effective allocation of resources and the reduction of treatment costs. Further studies are therefore recommended on the risk factors associated with SSI and the reasons for the low rates of NIs in this hospital. Various studies suggest that antibiotic resistance patterns are different in different regions. An antibiogram is therefore essential for finding a definitive treatment.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Notes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph><SubHeadline>Acknowledgements</SubHeadline><Pgraph>This study was supported by Kermanshah University of Medical Science. The authors are grateful to <TextGroup><PlainText>Mr. Mohammad</PlainText></TextGroup> Reza Forozesh and Miss Zahra Hosseini for their kind assistance in data gathering.</Pgraph></TextBlock>
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<Caption><Pgraph><Mark1>Table 1: Demographic features and risk factors of infection</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 2: Causative agent of nosocomial infections</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 3: Causative agent of nosocomial infections by ward</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 4: Antibiotic resistance pattern of Gram-positive bacteria isolated from infection</Mark1></Pgraph></Caption>
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<Caption><Pgraph><Mark1>Table 5: Antibiotic resistance pattern of Gram-negative bacteria isolated from infection</Mark1></Pgraph></Caption>
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