EPIDEMIOLOGY AND MICROBIOLOGICAL PROFILE COMPARISON BETWEEN COMMUNITY AND HOSPITAL ACQUIRED INFECTIONS: A MULTICENTER RETROSPECTIVE STUDY IN LEBANON

Abstract

This was a retrospective cohort, multicenter study from five private hospitals located in Beirut and Mount Lebanon over one year. The objective of this study was to identify and characterize the species resistance of different pathogens between community acquired and hospital acquired infections pointing at patients’ related independent comorbidities and socio-demographic factors.

Full text

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§Hospital acquired infections have been
recognized for over a century as a critical
problem affecting the quality of health and a
principal source of adverse healthcare
outcomes [1]
§Multi-drug resistant strains are increasingly
isolated in these settings, including ESBL,
carbapenemase-producing Klebsiella
pneumoniae,Acinetobacter and Pseudomonas
aeruginosa [2].
§Furthermore, Staphylococcus aureus allows
susceptible individuals to become infected
through contact with persistently or
transiently colonized people [3]. Thus, these
bacteria are the most common hospital
acquired pathogens with increased morbidity
[4]
§Methicillin-resistant Staphylococcus aureus
(MRSA) appeared in 1961,one year after
methicillin was introduced into clinical use [5].
§This was a retrospective cohort, multicenter study from five private hospitals located in Beirut and
Mount Lebanon over one year.Among these, three were university hospitals whereas two were non
university hospital.The study duration was 6 months. Overall, 258 adult patients were included.
§Data were collected through a standardized sheet of patient identification. The record included
patient-specific parameters such as demographic data, underlying diseases and risk factors.
§Hospital acquired infections was defined as alocalized or systemic condition that resulted from an
adverse reaction due to the presence of infectious agents which occurred 48 hours or more after
hospital admission and was not incubating at the time of admission. Community acquired infections
were defined as an infection detected within 48 hours of hospital admitted patients [6].
§Isolates of Escherichia coli and Klebsiella pneumoniae were tested for extended-spectrum beta-
lactamase production. Staphylococcus aureus were tested for methicillin resistance.Pseudomonas
aeruginosa was tested for its multiple resistances.Streptococcus pneumoniae were tested against
penicillin susceptibility.
§The comorbidity of patients in the study included mainly immunosuppression, administration of
chemotherapy in the 12 months prior to hospital admission, radiation therapy, administration of
steroids for at least 3 months prior to hospital admission, chronic liver disease, chronic heart failure,
chronic respiratory disease, chronic renal failure, hematological disease, cancer, and diabetes mellitus
requiring insulin therapy or oral hypoglycemic agents before the infection.
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Community"
acquired
N=142"(55%)
Hospital"
acquired
N=116"(45%)
Total
N=258
P-
value
Temperature">38.3
°C 74(52.1%) 72(62.1%)
146(56.69
%)
0.091
Tachycardia">90"
beats/minute
91(64.1%) 97(83.6%)
188(72.9%)
<0.001
Tachypnea">"20"
breath/minute
47(33.1%) 52(44.8%)
99(38.4%)
0.047
Leucocytes">12000/mm3"
/<4000/mm
393(65.5%) 92(79.3%)
185(71.7%)
0.01
CRP
53(60.2%) 37"(86%)
90(34.9%)
0.003
Sepsis
105(73.9%)
115(99.1%)
220(85.3%)
<0.001
Severe"sepsis
56(39.4%) 92(79.3%)
148(57.4%)
<0.001
Defined"infection
69(48.6%) 84(72.4%)
153(59.3%)
<0.001
2=<I;*Q7*";BF;>C=\;*HJ**KLIC@:B;?@?C=>C*<=FC;B@=*@>*
GH?P@C=I*=>T*FHKKL>@CD*=F]L@B;T*@>J;FC@H>?
Multi
-resistant"bacteria
Community"
acquired
N=142
Hospital"
acquired
N=116
P-value
ESBL"
gram"negative"
pathogens
19"(13.4%) 35"(30.2%) 0.001
Klebsiella
pneumoniae
ESBL
1"(0.7%) 2"(1.7%) 0.424
MRSA
4"(2.8%) 15"(12.9%) 0.002
P. 9 A e r u g i n o s a 9
Resistant"to"
Imipenem
5"(3.5%) 15"(12.9%) 0.005
P. 9 A e r u g i n o s a 9
Resistant"to"
Aminoglycosides
3"(2.1%) 8"(6.9%) 0.058
P. 9 A e r u g i n o s a 9
Resistant"to"
Fluoroquinolones
3"(2.1%) 17"(14.7%) <0.001
P. 9 A e r u g i n o s a 9
Resistant"to"
Betalactams
other"than"
imipenem
4"(2.8%) 10"(8.6%) 0.041
Multi
-Resistant"P. 9
Aeruginosa9
4"(2.8%) 16"(13.8%) 0.001
Streptococcus"Resistant"to"
Penicillin
01"(0.9%) 0.105
$#1-411#&,
1- Cornejo-Juárez P, Vilar-Compte D, Pérez-Jiménez C, Namendys-Silva SA, Sandoval-Hernández S, Volkow-Fernández P. The impact of hospital-acquired infections with multidrug-resistant bacteria in an
oncology intensive care unit.International Journal of Infectious Diseases.2015 Feb 28;31:31-4.
2- Doyle JS, Buising KL, Thursky KA, Worth LJ, Richards MJ.Epidemiology of Infections Acquired in Intensive Care Units.Semin Respir Crit Care Med.2011;32(2):115–38
3-Ben-David D, Mermel LA, Parenteau S. Methicillin-resistant Staphylococcus aureus transmission:the possible importance of unrecognized health care worker carriage.Am JInfect Control.2008
Mar;36(2):93-7.
4- Nabera CK.Staphylococcus aureus Bacteremia:Epidemiology, Pathophysiology, and Management Strategies Clin Infect Dis. (2009)48(Supplement 4): S231-S237.
5-Miall LS, McGinley NT, Brownlee KG, Conway S P Methicillin resistant Staphylococcus aureus (MRSA) infection in cystic fibrosis.Arch Dis Child 2001;84:160–162
6-Ducel G, Fabry J, Nicolle L. Prevention of Hospital-acquired infections: a practical guide (2nd ed). 2002,WHO/CDS/CSR/EPH/2002.12
7-Zaman R, Dibb WL.Methicillin resistant Staphylococcus aureus isolated in Saudi Arabia:Epidemiology and antimicrobial resistance patterns. J Hosp Infect 1994;26(4):297-300
8-Klastersky, J. (1989). Infections in compromised hosts:considerations on prevention.Eur.J.Cancer Clin.Oncol.25 Suppl 2: S53-61
9-D.H. Au, C.L. Bryson, J.W. Chien, et al.The effects of smoking cessation on the risk of chronic obstructive pulmonary disease exacerbations J. Gen.Intern.Med., 24 (4) (2009), pp.457–463
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Patients’"risk"factors"
P
-
value
Community"
acquired"
N=142"(55%)
Hospital"
acquired"
N=116"(45%)
Age
0.001
<44"years
30"(21.9%) 8(7%)"
>44"years
107"(78.1%) 107(93%)
Gender
0.046
Male
65"(45.8%) 67"(58.3%)
Female
77"(54.2%) 48"(41.7%)
Hematologic"
malignancies
0.037
7"(4.9%) 14"(12.1%)
Chemotherapy"
0.02 2(1.4%) 9"(7.8%)
Chronic"liver"disease
0.473
3(2.1%) 8(4.3%)
Chronic"heart"
failure
0.365
44"(31%) 30"(25.9%)
Metastatic"
cancer
0.774
15"(10.6%) 11"(9.5%)
COPD
0.009
43"(30.3%) 19"(16.4%)
Alcoholism
0.183
3"(2.1%) 6"(5.2%)
Diabetes"
mellitus
0.392
50"(35.2%) 35"(30.2%)
Chronic"renal"
failure
0.757
26"(18.3%) 23"(19.8%)
Osteo
-muscular"Problem
0.482
16"(11.3%) 10"(8.6%)
Bone"marrow"
transplantation
0.482
1"(0.7%) 2"(1.7%)
Immuno
-compromised"
state
0.004
15"(10.6%) 28"(24.1%)
Prior"administration"of"
prednisone
0.049
11"(7.7%) 18"(15.5%)
Severe"
malnutrition
0.735
4"(2.8%) 5"(4.3%)
Solid"organ"
transplantation
0.746
10"(7%) 7"(6%)
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P=C@;>C?*@>*GH?P@C=I*=>T*FHKKL>@CD*=F]L@B;T*
@>J;FC@H>?
Community"
acquired
N=142"(55%)
Hospital"
acquired
N=116"(45%)
Total
N=258
P
-
value
Pseudomonas9
aeruginosa
9(6.3%) 22(19%) 31(12%) 0.002
Klebsiella
pneumoniae
4(2.8%) 12(10.3%) 16(6.2%) 0.013
Acinetobacter
baumannii
1(0.7%) 7"(6%) 8(3.1%) 0.017
]
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§These results are consistent with the concept that the majority of infections
caused by resistant pathogens were described as hospital acquired [7]. The
principal factors that contributed to the risk of acquiring hospital infection
include immuno-suppression and older age [8].
§COPD had arelationship with community acquired infections due its
exacerbations that require hospitalization [9].
§Microbiologists have to play an important role in the prevention of hospital
acquired infections because they are the first to detect the patients’
bacteriological flora and their pattern of resistance.
§Physicians should also be aware of patients’ comorbidities to properly guide
the initial therapy, particularly age, immuno-suppression and COPD.
§Since resistance is attributed to local epidemiology and uncontrolled use of
antimicrobial agents, further research involving alarge number of patients
from different hospitals are needed in order to confirm our findings and
highlight the need of antimicrobial stewardship.
§258 patients were included in this study.Of all patients,142
(55%) had hospital acquired infection and 116 (45%) had
community acquired.
§Table 1summarizes the correlation between the type of
infection acquired and patients’ clinical outcome.
§Table 2and 3show the Gram negative isolates and multi-
resistant bacteria correlated to the type of infection.
§All positive correlations in bivariate analysis were significant in
patients having hospital acquired infections except COPD.
§Multi-resistance was also significantly higher in these patients
too.
§Regarding multivariable analysis, older patients had almost 6
times the risk of developing hospital acquired infection and
those under immunosuppressors had 3times risk.
5.68
3.137
0.403
2.344
1.485
0.212
13.765
6.63
0.765
0
2
4
6
8
10
12
14
16
Older age Immunocompromised state COPD
Figure 1- Logistic regression of predictors of hospital
versus community acquired infections
ORa
Lower bond 95%CI
Upper bond 95% CI
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