Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi

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1. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi

2. Original Article Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi Manoj Kumar *, Sanjay Jain, Neetu Shree, Mukesh Sharma Department of Microbiology, Hindu Rao and NDMC Medical College, Delhi 110007, India 1. Introduction Antimicrobial resistance (AMR) in microorganisms is a growing public health concern globally, especially in developing countries. Number of organisms developing resistance to commonly used antibiotics is increasing ever since the discovery of first antibiotic Penicillin in 1928. Extended spectrum b-lactamase (ESBL) was first reported in 1987.1 Similarly, vancomycin resistance in Enterococci and Methicillin a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x a r t i c l e i n f o Article history: Received 3 June 2015 Accepted 20 July 2015 Available online xxx Keywords: Multidrug resistance E. coli Klebsiella spp. MRSA Pseudomonas aeruginosa a b s t r a c t Background/Objectives: Antimicrobial resistance to microorganisms is a growing public health concern globally, especially in developing countries. This study was conducted to study the incidence rate of multidrug-resistant organisms with their antibiotic sensitivity pattern. Methods: An observational retrospective study was conducted for a period of 1 year from Jan 2013 to Dec 2013 in a tertiary care hospital in North Delhi. Sample processing and identifi- cation of organisms up to species level were done as per standard protocol, and antibiotic sensitivity was done as per CLSI guidelines. Results: A total of 12,250 samples were received from OPDs (7000), wards (3025), and ICUs (2225) of various departments. Of these, 3080 showed significant growth of organisms. Among the 3080 isolates, 1838 were gram-negative bacilli, 1086 were gram-positive cocci and 156 were Candida spp. Escherichia coli (1080) was the most commonly isolated organism followed by Klebsiella spp. (446), MSSA (372), and Enterococcus (295). Amongst GNB, maximum resistance was seen with ceftazidime followed by ceftriaxone, ofloxacin, norfloxacin, and cotrimoxazole. Least resistance was observed with amikacin, nitrofurantoin, netilmicin, and carbapenems. Among the GPC, maximum resistance was seen with cefepime followed by cotrimoxazole, ciprofloxacin and gentamicin. Least resis- tance was seen with nitrofurantoin, linezolid, and chloramphenicol. Multidrug resistance was observed more from ward isolates, with E. coli (64.35%) topping the list followed by Acinetobacter (63.53%), Enterococcus (59.66%), Klebsiella (52.47%), MRSA (43.13%), Streptococcus (42.86%), and Pseudomonas (37.96%). Conclusion: There is an urgent need to employ strategies that will slow the development of resistance to the current armamentarium. # 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved. * Corresponding author. Tel.: +91 9873832875. E-mail address: drmanu_05@rediffmail.com (M. Kumar). APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme http://dx.doi.org/10.1016/j.apme.2015.07.006 0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. resistance in Staphylococcus aureus (MRSA) were identified in 1980 and 1990, respectively. Vancomycin-resistant Staphylococ- cus aureus (VRSA) was first reported from the US in 2002, Brazil in 2005, and Jordan and India in 2006.2 According to a 2011 report from Center for Disease Control and Prevention, an estimated 722,000 health-care-associated infections occurred in American hospitals and were associated with 75,000 deaths.3 Repeated courses of antimicrobial therapy are common in acutely ill, febrile patients, who frequently have endotracheal tubes, urinary catheters, and central venous catheters.4 In combination with host factors, indwell- ing devices are routes for transmission and colonization of resistant infections.5 Lengthy or inappropriate antimicrobial therapy allows microbes to mutate into new forms that help them survive antibiotics and quickly become new dominant strains.6 Social factors such as demographic changes, deficient hygienic practices, and overcrowding have also been enu- merated for the emergence of AMR. The multidrug-resistant (MDR) Escherichia coli has been isolated in carriers and in water samples in rural Tamil Nadu.2,7 Self medication, poor compliance, and inappropriate and irrational uses of anti- biotics in humans and animals for therapeutic and non- therapeutic use are the other factors for hospital and community-acquired resistant infections, as documented by World Health Organization (WHO). A study conducted in Odisha8 has witnessed the presence of MDR E. coli in cow dung and drinking water. A study conducted by Gruson et al. in France9 has documented an increased susceptibility to antibiotics by previously resistant gram-negative organisms by following antibiotic policy and antibiotic rotation in ventilator-associat- ed pneumonia among intensive care units (ICU) patients. The knowledge of national scenario of AMR is limited in India due to the absence of central monitoring agency. This study was undertaken in a tertiary care hospital in North Delhi to identify the multidrug-resistant organisms, their resistance pattern, and to develop antibiotic policy for the proper and effective use of antibiotics. 2. Material and methods 2.1. Type of study An observational retrospective study was conducted for a period of 1 year from Jan 2013 to Dec 2013 in a tertiary care hospital in North Delhi. 2.2. Study population Hospital-based population: Different clinical samples of patients such as blood, body fluids, CSF, female genital tract specimens, pus discharge, respiratory secretions, semen, stool, and urine were received in the Department of Microbiology from various OPDs and wards of Hindu Rao Hospital, a North Delhi tertiary care hospital. Relevant patient data, such as collection date, OPD/Ward, sex, culture results, and antimicrobial sensitivity results were collected and analyzed. A total of 12,250 non- repetitive samples were included during the study period. 2.3. Culture The various samples were cultured on different media using Blood Agar, MacConkey's Agar, Hichrome Media (for urine culture). Sample processing and identification of organisms to the species level were done as per standard microbiological protocol. 2.4. Bacterial identification and antimicrobial sensitivity test Appropriate biochemical tests were done on culture isolates to identify the organisms based on colony morphology and results of Gram staining. Antimicrobial sensitivity test was performed using Kirby Bauer disk diffusion method (HiMedia, Mumbai) and carried out as per the Clinical and Laboratory Standards Institute (CLSI) guidelines.10 A 0.5 McFarland's physiological saline suspension prepared by picking up a single colony from pure culture was used. AST was done by placing standard antimicrobial impregnated disk (HiMedia, India) on lawn cultured Mueller-Hinton agar followed by incubation for 18–24 h at 37 8C. Results were determined as sensitive and resistant based on diameter of zone of inhibition. The control strains used were E. coli (ATCC 25922), S. aureus (ATCC 25923), and Pseudomonas aeruginosa (ATCC 27853) and they were included in the study. Organisms resistant to at least one agent in three or more antimicrobial classes were considered as MDR.11 Antibiotics tested for the sensitivity against gram-negative bacteria (GNB) were amikacin (30 mg), amoxicillin-clavulanic acid (20/10 mg), carbenicillin (100 mg), cefepime (30 mg), cefta- zidime (30 mg), ceftriaxone (30 mg), chloramphenicol (30 mg), ciprofloxacin (5 mg), co-trimoxazole (23.75/1.25 mg), furazoli- done (100 mg) (only for stool specimens), gentamicin (10 mg), imipenem (10 mg), meropenem (10 mg), netilmicin (30 mg), nitrofurantoin (300 mg) (only for urine specimens), norfloxacin (10 mg), ofloxacin (5 mg), piperacillin-tazobactam (100/10 mg) and tigecycline (15 mg). For gram-positive bacteria (GPC), amikacin (30 mg), amoxicillin-clavulanic acid (20/10 mg), cefe- pime (30 mg), cefoxitin (30 mg), chloramphenicol (30 mg), cipro- floxacin (5 mg), co-trimoxazole (23.75/1.25 mg), gentamicin (10 mg), levofloxacin (5 mg), linezolid (30 mg), nitrofurantoin (300 mg) (only for urine specimens), oxacillin (30 mg), tetracy- cline (30 mg), and vancomycin (30 mg) were used. All data were tabulated and analyzed. After collection of data, it was verified twice in Microsoft Excel sheet. 3. Results During the study period, a total number of 12,250 samples were analyzed; of which, 7000 (57.14%), 3025 (24.69%), and 2225 (18.17%) samples were from OPDs, wards, and ICUs, respec- tively. Out of 12,250 samples, 3080 (25.14%) showed significant growth on culture. Of these 3080 samples, 1260 (40.91%) samples were from male patients and 1820 (59.09%) from female patients (Fig. 1a), and 995 (32.31%), 1705 (55.36%), and 380 (12.34%) were from OPD, ward, and ICU patients, respectively (Fig. 1b). Remaining samples either had no growth a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x2 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

4. or had insignificant growth. Urine was the predominant sample received from OPD, ward, and ICU patients (675, 517 and 53, respectively) followed by pus (OPD: 233, wards: 479, and ICU: 28), blood (OPD: 31, wards: 348, and ICU: 216), and female genital tract specimens (OPD: 36, wards: 270, and ICU: 10) (Table 1a). Out of 3080 significant positive cultures, gram-negative and gram-positive isolates constituted 1838 (59.68%) and 1086 (35.26%), respectively and Candida spp. comprised 156 (5.06%) of isolates (Candida albicans 46, non-albicans 110) (Fig. 1c). E. coli was the predominant organism accounting for 35.06% of the total isolates followed by Klebsiella (14.48%) and MSSA (12.08%). Other pathogens isolated were Proteus, P. aeruginosa, Acinetobacter, Citrobacter, Enterobacter, Morganella, Salmonella, and Shigella among gram-negative isolates and CONS, S. aureus, Enterococcus, and Streptococcus spp. among gram- positive isolates. Tables 1b–1d depict the distribution of various organisms isolated from various specimen types among OPD, wards, and ICU. AMR ranged anywhere from 0% to 90%. Many pathogens revealed high level of resistance for single and multiple antimicrobial agents. E. coli, the predominant pathogen isolated, showed high resistance toward cephalosporins (70.6–100%), fluoroquinolones (69.5–76.7%), and beta-lactams (81.95%) and lower resistance to carbapenems (3.8–32.7%). For aminoglycosides, 12.39% and 45.37% of E. coli isolates were resistant to amikacin and gentamicin, respectively. A high proportion of E. coli isolates were resistant to orally adminis- tered drugs such as ciprofloxacin (69.95%) and amoxicillin- clavulanic acid (81.95%). Among the other GNB, maximum resistance was seen with ceftazidime (35.7–83.33%) followed by ceftriaxone (20–96.3%) and least resistance was observed with amikacin (10–66.67%), tigecycline (33.33%), and imipenem (3.83–45.45%) (Table 2a, Fig. 2a). Among the gram-positive cocci, maximum resistance was seen with cefepime (100%) followed by cotrimoxazole (50–74.36%) and least resistance with linezolid (1.16–5.88%) (Table 2b, Fig. 2b). Multidrug resistance (MDR) was observed more among the isolates from ward samples as compared to OPD and ICU, with E. coli topping the list followed by Acinetobacter, Enterococcus, Klebsiella, MRSA, Streptococcus, and Pseudomonas (Table 3, Fig. 3). Organisms isolated from stool (90.90%) were most resistant followed by isolates from body fluids (84.62%), respiratory secretions (83.08%), semen (77.77%), urine (77.59%), pus (77.16%), female genital-tract specimens (76.27%), CSF (71.64%), oral secretions (62.5%), and blood (59.66%) (Table 4). 4. Discussion This observational study compiled valuable laboratory data regarding incidence of AMR of various pathogens from different clinical specimens. A continuous surveillance of AMR is very important in management of various bacterial infections. A little extra venture on AMR studies in a health care setting facilitates the prediction of extremely practical information about prevailing resistance pattern. All the organisms isolated from wards exhibited more resistance as compared to OPD. This similar pattern was observed by the WHO community surveillance study report on pathogenic organisms12 and Saravanan et al.13 Our study detected 59.68% isolates as GNB, 35.26% as GPC, and 5.06% as Candida. Behera et al.14 demonstrated the respective percentages as 68%, 11%, and 21% of the total isolates. In accord with the findings by Randrianirina et al.,15 our study also revealed E. coli as the most predominant organism followed by Klebsiella and MSSA. In accord with several global and regional studies, our study also revealed E. coli as the most dominant pathogen from Fig. 1 – (a) Distribution of samples gender wise. (b) Distribution of samples among OPD, wards, and ICU. (c) Organism-wise distribution of isolates. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 3 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

5. different clinical specimens. About 87.13% of E. coli isolates were resistant to different antibiotics. These isolates were mainly from urine, pus, and female genital tract secretions with 3.83% resistance for imipenem, 12.39% for amikacin, and 45.37% for gentamicin. About 73.99%, 69.59%, and 20.62% of these isolates were also resistant to cotrimoxazole, ciproflox- acin, and piperacillin-tazobactam, respectively. This was slightly higher as compared to a study by Shobha et al.16 which detected nil resistance for imipenem, 8.75% for amikacin, 39% for gentamicin, 50% for cotrimoxazole, and 63.2% for ciprofloxacin. In another study by Chaudhuri et al.,17 none of the E. coli isolates were resistant to imipenem, 8% to amikacin, 13.5% to piperacillin-tazobactam, and 67% to ciprofloxacin. Behera et al.14 detected low resistance levels to carbapenems (8%) and b-lactam-b-lactamase inhibitor combinations (11%) and high levels of resistance to aminogly- cosides (57%), cephalosporins (56%), and fluoroquinolones (47%). Klebsiella was the second most common isolate. In our study, high resistance was seen with carbenicillin (88.89%), cephalosporins (64–87.5%), ofloxacin (71.61%), and amoxicillin- clavulanic acid (77.64%) and low resistance with amikacin (27.85%), gentamicin (47.65%), carbapenems (imipenem 14.34%, meropenem 34.33%), piperacillin-tazobactam (38.39%), nitrofurantoin (18.55%), and netilmicin (26.92%). Shobha et al.16 detected antibiotic resistance of Klebsiella in urinary isolates as 0% for imipenem, 11.5% for amikacin, 39.5% for gentamicin, 62% for ciprofloxacin, 69% for norfloxacin, and 70% for nalidixic acid. Chaudhuri et al.17 observed 3% resistance to imipenem, 14.5% to amikacin, 22% to piper- acillin-tazobactam, 29.5% to ciprofloxacin, and 40.5% to levofloxacin. Behera et al.14 detected low resistance levels to carbapenems (24%) and high levels of resistance to cephalos- porins (88%), fluoroquinolones (72%), aminoglycosides (66%), and b-lactam-b-lactamase inhibitor combinations (47%). MSSA was detected in 12.08% of total isolates and showed nil resistance to vancomycin with fluoroquinolones showing higher resistance than amoxicillin. Saravanan et al.13 reported higher incidence rate (21%) with higher resistance to amoxi- cillin than fluoroquinolones and vancomycin (50%). Incidence of 9.58% isolation of Enterococcus was reported in our study with high resistance to aminoglycosides, cotrimox- azole, and fluoroquinolones and low resistance to vancomycin (3.21%). Incidence of 28% isolation has been reported by Table1b–Distributionofvariousspeciesofgram-negativebacteria(GNB)isolatedfromvariousspecimentypesamongOPD,Wards,andICU.(O–OPD,W–Ward,I–ICU,T– Total). SampleAcinetobacterCitrobacterE.coliEnterobacterKlebsiellaMorganellaProteusPseudomonasSalmonellaShigella OWITOWITOWITOWITOWITOWITOWITOWITOWITOWIT Blood312112615060212243010l338601010000011207073324390100 Bodyfluids0000000005160000011200000011000000000000 CSF041500000841200000951400000101010100000000 Femalegenital tractsecretions 16070202191426167000044525102020000131500000000 Oralsecretions0000000000000000121400000000000000000000 Pus52413036093414471850202217871060303610218502507500000000 Respiratory secretions 036900000189000037192900000011026800000000 Semen0000000050050000000000000000000000000000 Stool000000005150200000020200000000000000000000 Urine34l822043672442263300008549313723051264227321200000000 Total12532085615021430580701080030311723198446280101818945584191083324390l0l Table 1a – Distribution of various specimen types among OPD, wards, and ICU (O – OPD; W – Ward; I – ICU; T – Total). Sample 0 W I T Blood 31 348 216 595 Body fluids 0 10 3 13 CSF 0 46 21 67 Female genital tract secretions 36 270 10 316 Oral secretions 3 4 1 8 Pus 233 479 28 740 Respiratory secretions 3 14 48 65 Semen 9 0 0 9 Stool 5 17 0 22 Urine 675 517 53 1245 Total 995 1705 380 3080 a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x4 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

6. Chopra et al.18 but with low resistant levels to above drugs. Behera et al.14 displayed high resistance to aminoglycosides and 13% to vancomycin. A high resistance to cotrimoxazole (70%) and ciprofloxacin (69.6%) was noticed in MRSA isolates (which is 43% of total S. aureus isolated) followed by amoxicillin-clavulanic acid and only 5.88% resistance to linezolid. None of the MRSA strains were resistant to vancomycin. Most of the strains were from urine followed by blood and pus. Detection rates of MRSA observed by Tiwari et al.,19 Kamat et al.,20 and Behera et al.14 were 69.1%, 71.4%, and 58% respectively. Tiwari et al.19 observed higher resistance to amoxicillin-clavulanic acid, similar resistance to cotrimoxazole and vancomycin, and lower resistance to ciprofloxacin as compared to our study and maximum strains were isolated from pus swabs or aspirates. Table 1c – Distribution of various species of gram-positive cocci (GPC) isolated from various specimen types among OPD, Wards, and ICU (O – OPD; W – Ward; I – ICU; T – Total). Sample CONS Enterococcus MRSA MSSA Streptococcus O W I T O W I T O W I T O W I T O W I T Blood 10 78 51 139 1 11 7 19 3 35 25 63 6 97 28 131 0 7 3 10 Body fluids 0 0 0 0 0 2 0 2 0 2 0 2 0 0 0 0 0 0 0 0 CSF 0 2 2 4 0 3 3 6 0 2 2 4 0 14 2 16 0 1 2 3 Female genital tract secretions 2 13 0 15 1 15 0 16 3 12 1 16 1 14 0 15 0 0 0 0 Oral secretions 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 2 0 0 0 0 Pus 21 45 1 67 2 12 0 14 18 38 4 60 68 87 5 160 3 2 0 5 Respiratory secretions 0 0 0 0 0 0 0 0 0 0 4 4 0 0 0 0 0 1 0 1 Semen 3 0 0 3 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 Stool 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Urine 6 3 0 9 124 111 3 238 3 8 0 11 32 14 1 47 2 0 0 2 Total 43 141 54 238 128 154 13 295 27 97 36 160 109 227 36 372 5 11 5 21 Table 1d – Distribution of Candida isolated from various specimen types among OPD, Wards, and ICU (O – OPD; W – Ward; I – ICU; T – Total). Sample 0 W I T Blood 1 2 4 7 Body fluids 0 0 0 0 CSF 0 1 0 1 Female genital tract secretions 4 16 0 20 Oral secretions 0 1 0 1 Pus 2 3 1 6 Respiratory secretions 0 0 4 4 Semen 0 0 0 0 Stool 0 0 0 0 Urine 30 70 17 117 Total 37 93 26 156 Table 2a – Antibiotic resistance profile of GNB (all values are in percentages). Antimicrobial tested Acinetobacter Citrobacter E. coli Enterobacter Klebsiella Morganella Proteus Pseudomonas Salmonella Shigella Amikacin 60.24 28.57 12.39 66.67 27.85 10 20 21.36 21.21 100 Amoxicillin- clavulanic acid 64.58 50 81.95 100 77.64 60 28 83.33 3.33 100 Carbenicillin 88.89 33.33 85.71 – 88.89 – – 28.57 20 – Cefepime 50 – 100 – 87.5 – 0 100 0 – Ceftazidime 83.33 71.43 78.37 – 77.36 62.5 35.71 75.27 37.5 100 Ceftriaxone 96.3 36.36 70.66 100 64 50 20 50 0 100 Chloramphenicol 12.5 33.33 33.33 0 19.05 – 50 100 0 – Ciprofloxacin 46.67 27.27 69.59 50 51.43 33.33 35.29 34.48 30 – Cotrimoxazole 50 50 73.99 – 48.91 60 83.33 75 11.11 – Furazolidone – – 94.44 – 50 – – – – – Gentamicin 57.89 47.62 45.37 66.67 47.65 20 40 40 19.35 100 Imipenem 45.45 0 3.83 0 14.34 0 6.9 11.43 8.57 – Meropenem 36.67 0 32.71 0 34.33 100 0 38.1 10 0 Netilmicin 45.45 28.57 19.13 0 26.92 0 70 20.37 33.33 – Nitrofurantoin 77.78 50 3.19 0 18.55 20 58.82 57.14 – – Norfloxacin 70 100 76.74 – 47.73 75 26.32 28.57 – – Ofloxacin 100 71.43 76.67 50 71.61 0 66.67 63.33 71.43 – Piperacillin- tazobactam 57.58 28.57 20.62 – 38.39 – 0 12.77 20 – Tigecycline 0 – 33.33 – 100 – – – 0 – a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 5 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

7. The rates of MDR MRSA isolates were similar in both studies (43.13% in our study and 41% by Tiwari et al.19 ). Our study identified 3.51% of the total isolates as P. aeruginosa while Saravanan et al.13 detected 8%, Behera et al.14 22%, and Kamat et al.20 detected 27.56%. Of the total GNB isolated, 5.87% were Pseudomonas in our study as compared to 9% by Chaudhuri et al.,17 43.2% by Jamshidi et al.,21 and 53.8% by Malini et al.22 No significant difference in number of isolates from OPD and wards was noted in our study, whereas Joseph et al.23 noted more number of isolates from wards. Pus was the major source of isolation similar to Saravanan13 and Malini et al.22 Pseudomonas showed high resistance to cefepime and chloramphenicol (100%), amoxicillin-clavulanic acid (83.33%), ceftazidime (75.27%), cotrimoxazole (75%), ofloxacin (63.33%), and nitrofurantoin (57.14%) in our study; low resistance levels were seen with imipenem (11.43%), piper- acillin-tazobactam (12.77%), amikacin (21.36%), norfloxacin (28.57%), ciprofloxacin (34.48%), meropenem (38.1%), and gentamicin (40%). In the study from Kolar,22 Pseudomonas Table 2b – Antibiotic resistance profile of GPC (all values are in percentages). Antimicrobial tested CONS Enterococcus MRSA MSSA Streptococcus Amikacin 14.67 69.05 21.57 6.08 50 Amoxicillin-clavulanic acid 33.1 41.29 64.86 19.46 16.67 Cefepime 100 100 100 100 0 Chloramphenicol 39.58 31.82 22.73 6.12 0 Ciprofloxacin 39.23 70.1 69.62 33.52 31.58 Cotrimoxazole 66.67 74.36 70 58.06 50 Gentamicin 37.23 63.73 47.68 18.61 52.94 Levofloxacin – 100 – – – Linezolid 4.26 0 5.88 1.16 0 Nitrofurantoin 15 16.83 21.43 7.14 0 Oxacillin 26.53 50 95.12 10.53 – Tetracycline – 100 – – – Vancomycin 0 3.21 0 0 6.67 Fig. 2 – (a) Antibiotic resistance profile of GNB. (b) Antibiotic resistance profile of GPC. a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x6 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

8. showed 5.8% resistance to imipenem, 30.2% to amikacin, 57% to ciprofloxacin, 75% to cefepime, 79.4% to ceftazidime, and 96% to cotrimoxazole. A study from Bangalore24 showed 60–70% resistance to amikacin, ceftazidime, and ciprofloxacin. In a study from Chandigarh,25 42% isolates were found to be resistant to imipenem. Jamshidi et al.21 found Pseudomonas to be mostly resistant to cefepime (96.6%) and gentamicin (66.6%) and less resistant to amikacin (15.4%) and imipenem (53.3%). Joseph et al.23 observed similar levels of resistance to imipenem, meropenem, and amikacin as in our study but low levels to ceftazidime. Randrianirina et al.15 also observed low resistance to ceftazidime (0%) and piperacillin (12.8%). In contrast to our study, approximately 40% resistance was seen with ceftazi- dime, imipenem, and levofloxacin in a study from Mexico by Amábile-Cuevas26 and by Brink et al.27 in South Africa. Our study identified 2.76% of the total isolates as Acineto- bacter while Saravanan et al.13 detected 1.6%, Behera et al.14 16.59%, and Kamat et al.20 detected 13.27%. Of the total GNB isolated, 4.62% were Acinetobacter in our study as compared to 6% by Chaudhuri et al.,17 12.68% by Jamshidi et al.21 , and 25.39% by Malini et al.22 Maximum isolates were from wards, with pus being the major source of isolation in our study like in a study by Malini et al.22 High resistance was seen with ofloxacin (100%), cephalos- porins (83.33–96.3%), carbenicillin (88.89%), nitrofurantoin (77.78%), amoxicillin-clavulanic acid (64.58%), amikacin (60.24%), gentamicin (57.89%), and piperacillin-tazobactam Table 3 – Species-wise distribution of resistant and multidrug-resistant organisms among OPD, wards, and ICU. Organism Total isolated R MDR OPD Wards ICU Total Percentage OPD Wards ICU Total Percentage Acinetobacter 85 12 41 19 72 84.7 8 29 17 54 63.53 Citrobacter 21 4 12 0 16 76.19 2 7 0 9 42.86 CONS 238 29 85 37 151 63.45 11 29 9 49 20.59 E. coli 1080 366 512 63 941 87.13 264 380 51 695 64.35 Enterobacter 3 0 2 0 2 66.67 0 2 0 2 66.67 Enterococcus 295 106 145 10 261 88.47 61 107 8 176 59.66 Klebsiella 446 84 192 76 352 78.92 50 124 60 234 52.47 Morganella 10 2 7 0 9 90 1 4 0 5 50.00 MRSA 160 23 89 35 147 91.88 12 42 15 69 43.13 MSSA 372 66 89 18 173 46.51 9 28 11 48 12.90 Proteus 45 12 15 7 34 75.56 5 8 1 14 31.11 Pseudomonas 108 49 31 8 88 81.48 20 14 7 41 37.96 Salmonella 39 1 14 3 18 46.15 0 5 1 6 15.38 Shigella 1 0 1 0 1 100 0 1 0 1 100.00 Streptococcal 21 5 4 4 13 61.9 2 3 4 9 42.86 Total 2924 759 1239 280 2278 77.91 445 783 184 1412 48.29 Fig. 3 – Species-wise distribution of multidrug-resistant organisms among OPD, wards, and ICU. Table 4 – Distribution of various resistant and multidrug-resistant specimens among OPD, wards, and ICU. Specimen Total samples R S OPD Wards ICU Total Percentage OPD Wards ICU Total Blood 595 16 185 154 355 59.66 15 163 62 240 Body fluids 13 0 8 3 11 84.62 0 2 0 2 CSF 67 0 29 19 48 71.64 0 17 2 19 Female genital tract secretions 316 24 207 10 241 76.27 12 63 0 75 Oral secretions 8 3 2 0 5 62.5 0 2 1 3 Pus 740 174 373 24 571 77.16 59 106 4 169 Respiratory secretions 65 3 9 42 54 83.08 0 5 6 11 Semen 9 7 0 0 7 77.77 2 0 0 2 Stool 22 5 15 0 20 90.9 0 2 0 2 Urine 1245 527 411 28 966 77.59 148 106 25 279 Total 3080 759 1239 280 2278 236 466 100 802 a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) x x x – x x x 7 APME-302; No. of Pages 9 Please cite this article in press as: Kumar M, et al. Incidence rate of multidrug-resistant organisms in a tertiary care hospital, North Delhi, Apollo Med. (2015), http://dx.doi.org/10.1016/j.apme.2015.07.006

9. (57.58%). Resistance levels to ceftazidime, cefepime, piper- acillin-tazobactam, ciprofloxacin, amikacin, imipenem, and meropenem were higher in our study as compared to Brink et al.27 Acinetobacter showed higher rate of resistance to amikacin, ceftazidime, ceftriaxone, imipenem, and piperacil- lin-tazobactam, and lower rate to cefepime, ciprofloxacin, and cotrimoxazole in the present study when compared to the study in Kolar.22 Jamshidi et al.21 observed higher rates of resistance to imipenem, amikacin, cefepime, ciprofloxacin, and gentamicin than in our study. Chaudhuri et al.17 and Behera et al.14 detected very high resistance levels to imipenem (74–100%) and carbapenems (74%), respectively. Antibiotic resistance in Acinetobacter was overall higher than in Pseudomonas in our study in contrast to results by previous studies done by Brink et al.27 Carbapenem resistance in Acinetobacter was 36.67% and 45.45% for meropenem and imipenem, respectively, compared to 38.10% and 11.43% in Pseudomonas. 5. Conclusion Antibiotics have played an indispensable role in decreasing illness and death associated with infectious diseases in animals and humans. However, selective pressure exerted by antimicrobial drug use also has been the major driving force behind the emergence and spread of drug resistance traits among pathogenic and commensal bacteria. In addition, resistance has developed after advent of every major class of antimicrobial drugs, varying in time from as short as 1 year (penicillin) to >10 years (vancomycin). There is an urgent need to develop and strengthen antimicrobial policy, standard treatment guidelines, national plan for containment of AMR, and research related to public health aspects of AMR at community and hospital levels. Behavioral pattern of health care providers and consumers is of paramount importance in preventing emergence of AMR. There is an urgent need to employ strategies that will slow the development of resistance to the current armamentarium, such as judicious use of antibiotics, avoiding prolonged antibiotic use or under-dosing, using pharmacokinetic and pharmacodynamic principles to choose dosing regimens, encouraging early and aggressive empirical therapy, followed by de-escalation and narrowing the antimicrobial spectrum when culture results become available, strict hand-hygiene protocols, and implementation of appropriate infection control measures in the hospital, especially while treating high-risk patients. Conflicts of interest The authors have none to declare. r e f e r e n c e s 1. Lee JH, Bae IK, Lee SH. New definitions of extended- spectrum b-lactamase conferring worldwide emerging antibiotic resistance. Med Res Rev. 2012;32:216–232. 2. Raghunath D. Emerging antibiotic resistance in bacteria with special reference to India. J Biosci. 2008;33(4):593–603. 3. Magill SS, Edwards JR, Bamberg W, et al. Multistate point- prevalence survey of health care-associated infections. N Engl J Med. 2014;370:1198–1208. 4. Fish DN, Ohlinger MJ. Antimicrobial resistance: factors and outcomes. Crit Care Clin. 2006;22(2):291–311. 5. Davis KA. Ventilator-associated pneumonia: a review. J Intensive Care Med. 2006;21(4):211–226. 6. National Institute of Allergy and Infectious Diseases. The problem of antimicrobial resistance. 2006. http://www.niaid.nih. gov/factsheets/antimicro.htm. 7. Seidman JC, Anitha KP, Kanungo R, Bourgeois AL, Coles CL. 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