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Research Article

Antibiotic sensitivity pattern of gram negative bacilli

isolated from the lower respiratory tract of ventilated
patients in the intensive care unit
Nidhi Goel, Uma Chaudhary, Ritu Aggarwal, Kiran Bala
Abstract

Background: Lower respiratory tract infections (LRTIs) are the most frequent infections among patients in Intensive
care units (ICUs). Aims: To know the bacterial profile and determine the antibiotic susceptibility pattern of the lower
respiratory tract isolates from patients admitted to the ICU. Settings and Design: Tertiary care hospital, retrospective
study. Materials and Methods: Transtracheal or bronchial aspirates from 207 patients admitted to the ICU were
cultured, identified, and antibiotic sensitivity was performed by standard methods. Statistical Analysis Used: SPSS
software was used for calculation of % R of 95% confidence interval (CI). Results: Of 207 specimens, 144 (69.5%)
were culture positive and 63 (30.4%) showed no growth. From 144 culture positives, 161 isolates were recovered, of
which 154 (95.6%) were Gram negative bacilli (GNB). In 17 (11.0%) patients, two isolates per specimen were recovered.
The most common GNB in order of frequency were Pseudomonas aeruginosa (35%), Acinetobacter baumannii (23.6%),
and Klebsiella pneumoniae (13.6%). A very high rate of resistance (80-100%) was observed among predominant GNB
to ciprofloxacin, ceftazidime, co-trimoxazole, and amoxycillin/clavulanic acid combination. Least resistance was noted
to meropenem and doxycycline. Conclusion: Nonfermenters are the most common etiological agents of LRTIs in
ICU.There is an alarmingly high rate of resistance to cephalosporin and ␤-lactam-␤-lactamase inhibitor group of drugs.
Meropenem was found to be the most sensitive drug against all GNB. Acinetobacter and Klebsiella spp. showed good
sensitivity to doxycycline.

Key words: Antibiotic susceptibility, gram negative bacilli, intensive care unit, ventilated patients

DOI: 10.4103/0972-5229.58540

Introduction is further complicated by the emergence of multiple

beta lactamase producers and multidrug resistant
Lower respiratory tract infections (LRTI) are the most
pathogens. In a recent report, Infectious Disease Society
common bacterial infections among patients in intensive
of America, specifically addressed three categories of
care units (ICUs) occurring in 10-25% of all ICU patients
gram negative bacilli (GNB), namely extended spectrum
and resulting in high overall mortality, which may range
beta lactamase (ESBL) producing Escherichia coli, and
from 22-71%.[1,2] Most common bacterial agents of LRTI
in the ICU are Pseudomonas, Acinetobacter, Klebsiella, Klebsiella spp., Multidrug resistant (MDR) Pseudomonas,
Citrobacter, Escherichia coli.[3-5] In almost all cases, there and carbapenem resistant Acinetobacter spp., as high
is a need to initiate empirical antimicrobial treatment priority bacterial pathogens.[6] All these major reports
before obtaining the microbial results, but the situation indicate the need for obtaining data on prevalent strains
in the ICU along with the susceptibility pattern, to
From: help in revising antibiotic policy and guiding clinicians
Department of Microbiology, Pt. B. D. Sharma University of Health Sciences,
Rohtak, India for the better management of patients. Prevalent flora
and antimicrobial resistance pattern may vary from
Correspondence:
Dr. Nidhi Goel, Department of Microbiology, Pt. BDS University of Health region to region depending upon the antibiotic pressure
Sciences, Rohtak, Haryana, India. E-mail: [email protected] in that locality. Therefore, the present study was

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Indian J Crit Care Med July-September 2009 Vol 13 Issue 3

designed to know the bacterial profile and determine In 17 (11.0%) specimens, there were two isolates per
the antimicrobial resistance pattern among the aerobic specimen and 127 (82.4%) specimens showed growth of
GNB isolated from LRT of patients admitted to the ICU a single organism. Table 1 represents the distribution
of our institute. of micro organisms recovered from the LRT specimens
of ICU patients. The most common GNB in order
Materials and Methods of frequency were P. aeruginosa (35%), Acinetobacter
baumannii (23.6%) and Klebsiella pneumoniae (13.6%). Very
The present retrospective study was conducted in
high rate of resistance (60-100%) was observed among
the Microbiology department of a teaching tertiary
care hospital during Jan-Dec 2007. Transtracheal or A. baumannii and K. pneumoniae isolates to ceftazidime,
bronchoscopic aspirates collected aseptically from amoxyclav, ciprofloxacin, amikacin, and cotrimoxazole.
207 patients of all age and sex groups requiring Meropenem and doxycycline were the most effective
mechanical ventilation for at least three days were in vitro drugs against A. baumannii, K. pneumoniae, and
included in study. All samples were plated right after Enterobacter [Table 2]. P. aeruginosa isolates showed
the collection and were further processed as per standard high rate of resistance to aztreonam (94.7%), netilmicin
protocol.[7] Single or mixed growth (two or more than (70.2%), ceftazidime (68.4%), ceftizoxime (68.4%),
two isolates per specimen) isolated from all the eligible and ofloxacin (68.4%) [Table 2]. Out of 57 isolates of
consecutive samples were identified by observing the P. aeruginosa, 23 (40%) were resistant to all the antibiotics
colony characteristic on the blood, Mac-Conkey agar plate used against P. aeruginosa in the panel. Meropenem
and biochemical reactions using standard microbiological was the most effective (77.2%) drug in vitro followed by
methods.[7] Isolates from repeat culture of previously piperacillin/tazobactum combination (50.5%) [Table 2].
recruited patients and isolates identified as commensals Bacterial resistance rates (%R 95% CI) to doxycycline for
or contaminants were excluded. Susceptibility testing various isolates except P. aeruginosa are given in Table 3.
was done by Disc diffusion method.[8] The following
antibiotics (Hi-Media Disc in mcg) were tested: Discussion
Amikacin(Ak) (30), ciprofloxacin(Cf) (5), ofloxacin (Of) Pneumonia is a frequent complication in patients
(5), aztreonam (Ao) (30), netilmicin (Nt) (30), doxycycline admitted to the ICU. It is frequently polymicrobial
(Do) (30), cotrimoxazole (co) (25), ceftazidime (Cz) (30), with predominently multi drug resistant GNB, such as
ceftizoxime (Ck) (30), meropenem (Mr) (10), amoxycillin/ A. baumannii, P. aeruginosa, K. pneumoniae, E. coli.[7,9,10] In
clavulanic acid (Ac) (20/10), piperacillin/tazobactum our study, 97.4% isolates were GNB. P. aeruginosa (35%)
(TZP) (100/10). Zone diameter was measured and being the most common isolate followed by A. baumannii
interpreted as per the Clinical and Laboratory Standards (23.6%) and K. pneumoniae. In 10.75% cases, two isolates
Institute (CLSI) guidelines. For quality control of disc were recovered from a single specimen, in contrast to
diffusion tests ATCC control strains of E. coli ATCC
the other study that reported two to three isolates per
25922, S. aureus ATCC 25923 and P. aeruginosa ATCC
specimen in 16.3% cases.[5] Antibiotic resistance is a
27853 strains were used.
major problem in ICU admitted patients. We noticed
100%, 96.9%, and 68.4% resistance to ceftazidime against
Statistical analysis
A. baumannii, Klebsiella spp. and P. aeruginosa, respectively.
For retrospective analysis, SPSS software was used for
Similar observations were made by other investigators
calculation of percentage resistance of 95% confidence
that reported 96-100% resistance;[11,12] whereas, other
interval (CI).

Table 1: Different microorganisms isolated from the lower

Results respiratory tract specimen from intensive care unit patients
During the study period, laboratory data of 207 patients Organism Bronchioalveolr Tracheal Total
whose LRT specimens were received in our laboratory lavage (%) aspirate (%) (%)
was evaluated. Male to female ratio was 1.8:1. Out of P. aeruginosa 13 44 57 (35)
the 207 patients, 70 were from the surgical ward, 62 A. baumannii 1 37 38 (23.6)
K. pneumoniae 1 21 22(13.6)
from urology, 35 from medicine, 28 from nephrology, 12 Enterobacter spp. 0 17 17 (10.5)
from neuromedicine. Out of 207 specimens, 144 (69.5%) E. coli 0 12 12 (7.4)
were culture positive whereas, 63 (30.43%) specimens C. freundii 0 8 8 (4.9)
S. aureus 0 3 3 (1.8)
showed no growth. From the 144 culture positive Coagulase negative
specimens, 161 isolates were recovered. Out of 161 S. aureus 0 1 1 (0.6)
isolates, 154 (95.6%) were GNB, three (1.86%) were Candida spp. 0 3 3 (1.8)
Candida spp., and four (2.4%) were Gram positive cocci. Total 15 (9.3) 146 (90) 161

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Indian J Crit Care Med July-September 2009 Vol 13 Issue 3

Table 2: Antimicrobial resistance rates (%) for the gram negative bacilli recovered from lower respiratory tract secretions of
intensive care unit patients
Antimicrobials A. baumannii K. pneumoniae C. freundii E. coli Enterobacter P. aeruginosa
(38) (22) (8) (12) (17) (57)
Cotrimoxazole 79.5 90.9 100 100 100 ND*
Doxycycline 2.6 9.1 0 0 0 ND
Amikacin 87.2 63.6 75 41.7 72.2 61.4
Netilmicin ND ND ND ND ND 70.2
Ciprofloxacin 89.7 95.5 100 100 100 ND
Of loxacin ND ND ND ND ND 68.4
Ceftizoxime ND ND ND ND ND 68.4
Ceftazidime 100 96.9 87.5 91.7 100 68.4
Meropenam 25.6 9.1 12.5 0 11.1 22.8
Amoxyclav 97.4 100 100 91.7 100 ND
Ticarcillin/Tazobactam ND ND ND ND ND 49.1
Aztreonam ND ND ND ND ND 94.7
*ND - Not Done

Table 3: Bacterial resistance rates (%R 95%CI) to are required to evaluate the usefulness of doxycycline
doxycycline for various isolates recovered from lower for ICU admitted patients.
respiratory tract specimens
Organism (n) %R* %IS** %S*** %R 95%CI Limits and outcome
A. baumannii (38) 2.6 64.1 33.3 0.1-15.1 One of the potential limitations of this study is that
C. freundii (8) 0 75 25 0.0-40.2 epidemiologic analysis, ESBL phenotypic detection and
Enterobacter spp. (17) 0 94.4 5.6 0.0-21.9
E. coli (12) 0 83.3 16.7 0.0-30.1
MIC of doxycycline was not carried out. Despite this
K. pneumoniae (22) 9.1 77.7 13.6 1.6-30.6 limitation our data can be used for local therapeutic
*% R - Percentage resistance; **% IS - Percentage intermediate sensitive; choices.
***%S - Percentage sensitive

We conclude that nonfermenters are the most common

workers have reported lower rate of resistance (37-67.5%)
etiological agents of LRTIs in ICU. There is an alarmingly
to ceftazidime.[11,13] High rate of resistance at our center
high rate of resistance to cephalosporins, ␤ lactam-␤-
might be due to the selective influence of extensive
lactamase inhibitors, and carbapenem against predominant
usage of third generation cephalosporins. Carbapenems
organisms. We suggest that further studies should be
are frequently used as a last choice in treating serious
carried out to evaluate the usefulness of doxycycline
infections caused by GNB. In our study, 25.6% isolates of
against the ICU pathogens. Judicious use of older and
Acinetobacter spp., 22.8% isolates of P. aeruginosa, and 9%
newer antimicrobial agents is essential to prevent the
isolates of Klebsiella spp., were resistant to meropenem in
emergence of multi drug resistant bacteria in the ICU.
contrast to another study, where meropenem resistance
was found in 14.2% isolates of A. baumannii and 12-42.5%
isolates of P. aeruginosa, respectively.[4,14] Another study
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