1. Pattern of Hospital-Acquired Pneumonia in Intensive Care Unit of Suez Canal University Hospital By Nermine El-Maraghy Associate Professor of Medical Microbiology & Immunology FOMSCU, Egypt. Consultant of Medical Immunology FOMSCU, Egypt. Consultant of Infection control FOMSCU, Egypt.

2. Introduction

3. Hospital acquired pneumonia (HAP) occurs more than 48 hours after hospital admission, ventilator associated pneumonia (VAP) occurs after 48-72 hours of endotracheal intubation HAP is the second most common nosocomial infection and accounts for approximately 25% of all infections in the Intensive Care Unit worldwide

4. Aim To identify the etiology, initial evaluation, prevention, and treatment of adult patients with ICU HAP, and VAP in Suez Canal University (SCU) hospital and their management strategies.

5. Methodology

6. Methods This study was conducted in the department of ICU, Suez Canal University Hospital; Ismailia, Egypt in the period from May to October 2013. All the patients were subjected to clinical and radiological assessment, Endotracheal aspirate samples for culture, and sensitivity to determine the causative organisms, Clinical Pulmonary Infection Score (CPIS) was done in order to determine the severity of HAP

7. Table( 1) Modified Clinical Pulmonary Infection Score (CPIS) chart CPIS points Diagnostic feature012 Tracheal secretionsRareAbundantAbundant and purulent Chest radiograph infiltrate NoneDiffuseLocalized Temperature (°C)≥36.5 and ≤38.4≥38.5 and ≤38.9≥39 or ≤36 White blood cells (×10 9 /L) ≥4.0 or ≤11.0 11.0 11.0 plus band forms ≥0.5 PaO 2 /FiO 2 mmHg>240 or ARDS≤240 and no ARDS MicrobiologyNegativePositivePositive plus positive Gram stain

8. Results

9. Table (2): Demographic data of the studied patients. Specification Freq. n=100 % Age ≤ 65 years7777% > 65 years2323% sex Male7373% Female2727%

10. Table (3): The relation between the isolated organisms and the mechanical ventilation P value = 0.88 Isolated organisms Total No. Mechanical ventilation (n=100) Ventilated (VAP) Non ventilated (HAP) Freq. % of column Freq. % of column MRSA363235.9436.35 Klebsiella pneumoniae 292528.1436.35 Pseudomonas aeruginosa 655.719.1 Proteus spp.666.800.0 E. coli555.600.0 Strept. viridans322.219.1 Methicillin sensitive Staph.aureus(MSSA) 222.200.0 No growth131213.519.1 Total1008910011100

11. Table (4): Relation between the isolated organisms and the onset of pneumonia among the studied patients P value = 0.32 Isolated organisms Total No. Onset of pneumonia (n=100) EarlyLate Freq.% of columnFreq. % of column MRSA 36529.43137.3 Klebsiella pneumoniae 29423.42530.2 Pseudomonas aeruginosa 600.067.2 Proteus spp. 6211.844.7 E. coli 515.944.7 Strept. viridians 3211.811.3 Methicillin sensitive Staph.aureus(MSSA) 200.022.6 No growth 13317.71012.0 Total 10017100.083100.0

12. Table (5): The relation between the detected organisms and the severity of pneumonia P value = 0.007 Isolated organisms Total No. Severity of pneumonia (n=100 ) Mild ModerateSevere Freq. % of colum n Freq. % of column Freq. % of column MRSA36211.11838.31645.7 Klebsiella pneumoniae29633.31736.2617.1 Pseudomonas aeruginosa 615.612.1411.4 Proteus spp.6422.212.112.9 E. coli5316.700.025.8 Strept. viridians300.036.400.0 Methicillin sensitive Staph.aureus(MSSA) 200.024.200.0 No growth13211.1510.8617.1 Total10018100.047100.035100.0

13. Table (6): The relation between the detected organisms and the age P value = 0.29 Isolated organisms Total No Age ≤ 65 years> 65 years Freq. % of column Freq. % of column MRSA363039626.3 Klebsiella pneumoniae 292025.9939.3 Pseudomonas aeruginosa 656.514.3 Proteus spp.656.514.3 E. coli545.114.3 Strept. viridans311.328.6 Methicillin sensitive Staph. aureus(MSSA) 222.600.0 No growth131013.1312.9 Total10077100.02323.0

14. Table (7): The relation between concomitant illness and the severity of pneumonia (N=100) P value = 0.04 Concomitant illness Total No. Severity of pneumonia MildModerateSevere Freq. % of column Freq. % of column Freq. % of column DM41211.12348.91851.4 COPD7316.736.412.9 OTHERS21316.71021.3720.0 NONE311055.51123.4925.7 Total10018100.047100.035100.0

15. Table (8): The relation between the isolated organisms and the sensitivity to the tested antibiotics P value = 0.32 Isolated organisms Tested antibiotic Vancomycin Imipenem Levofloxacin Ceftriaxone Cefoperazone Cefotaxime Amoxicillin MRSA44.4%27.8%11.1%8.3%19.4%8.3%0% Klebsiella spp.3.4%75.9%44.8%13.8%3.4%0% P. aeruginosa66.7%50%66.7%0% Proteus spp.50%16.7%33.3%83.3%16.7%33.3%0% E. coli0%80%40%20% 0% Strept. Viridians0%66.7%33.3% 0% Methicillin sensitive Staph.aureus (MSSA) 0%

16. Table (9): The relation between used antibiotics before ICU admission, and the isolated organisms (N=29). Used antibioticNumber% Isolated organism Ceftriaxone 321.4% MRSA Cefotaxime 321.4% MRSA Levofloxacin 321.4% Klebsiella spp. Ciprofloxacin 214.4% MRSA Azithromycin 321.4% MRSA Total 14 100% Unknown antibiotics 15 46.7%MRSA 40%Klebsiella spp 13.3%P. aeruginosa Total 15 100%

17. Table (10): Relation between causative organisms and fate of the patients P value =0.004 Isolated organismsNo. Fate (n=100) DischargedDied Freq. % of column Freq. % of column MRSA36616.23047.7 Klebsiella pneumoniae291232.41726.9 P. aeruginosa612.757.9 Proteus spp.6513.511.6 E. coli5410.911.6 Strept. viridans325.411.6 Methicillin sensitive Staph. aureus (MSSA) 225.400 No growth13513.5812.7 Total1003710063100

18. Conclusion

19. Gram-negative organisms were isolated in 46% of cases, gram-positive organisms in 41% and the isolated organisms showed high resistance to most of the tested antibiotics.

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