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PREVALENCE of ACINETOBACTER in PATIENTS ADMITTED INTO INTENSIVE CARE UNIT of the UNIVERSITY COLLEGE HOSPITAL, IBADAN a Disserta

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PREVALENCE of ACINETOBACTER in PATIENTS ADMITTED INTO INTENSIVE CARE UNIT of the UNIVERSITY COLLEGE HOSPITAL, IBADAN a Disserta PREVALENCE OF ACINETOBACTER IN PATIENTS ADMITTED INTO INTENSIVE CARE UNIT OF THE UNIVERSITY COLLEGE HOSPITAL, IBADAN A Dissertation SUBMITTED TO NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE PART II FELLOWSHIP EXAMINATION OF THE FACULTY OF PATHOLOGY (MEDICAL MICROBIOLOGY) BY DR. NWADIKE VICTOR UGOCHUKWU MBBSIBADAN Faculty: Pathology MAY 2012 Training Institution: University College Hospital CERTIFICATION This is to certify that this project titled: “Prevalence of Acinetobacter in patients admitted into the Intensive Care Unit of the University College Hospital was supervised by us”. Name: Prof. R. A. Bakare MBBS, FMCPath, FWACP (laboratory medicine) Address: Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan. Signature:……………………………………………… Date:………………………. Name: Dr. S A. Fayemiwo.B.Sc (Hons), MBBS, MSc (Epid), FMCPath Address: Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan. Signature:……………………………………………… Date:.………………………. DECLARATION I hereby declare that this work is original and has not been presented to any other college for a degree or fellowship award or submitted elsewhere for publication. DR VICTOR UGOCHUKWU NWADIKE MBBS (IBADAN) Acknowledgement I give all the glory to God almighty for the successful completion of this work. I am eternally grateful to Prof RA Bakare, my first supervisor who is my teacher and mentor for his unflinching assistance, guidance and invaluable sense of direction in every step of the project and for the golden opportunity to do residency training in Medical Microbiology. I am also deeply grateful to Dr Fayemiwo SA my second supervisor for his unwavering support the patience taken from his very busy schedule to provide guidance and tutelage, I remain grateful. I also wish to appreciate the other consultants (Dr Oni, Dr Okesola, Dr Dada- Adegbola and Dr Kehinde) in the department for their immeasurable contribution to my training and also for their encouragement and constructive criticism throughout the course of this work. I am also grateful to Dr Fowotade (Consultant clinical virologist) for all her support and kindness. Also for her patience in going through the book at every stage. I must also acknowledge the HOD Anaesthesia and residents in the department of Anaesthesia for their support throughout the course of this work. I want to acknowledge staff of Medical Microbiology Department College of Medicine (Tony, Tina, Kuburat, Mr Ojo ) for their assistance in the course of the study. Special thanks to my colleagues (Drs Olusanya, Olugbeminiyi, Okoye,Manga, Tayo, Tuta and Ajani) for their support. My sincere appreciation also goes to the management of University College Hospital for allowing me to carry out the project in the Hospital. Lastly but by no means the least, I wish to acknowledge my friend and partner Oluwatoyin Nwadike for all her support and encouragement, for being there when it mattered the most. To my lovely kids Amarachi, Nkechi and Chidiebere thank you for the patience, tolerance and home support. I wish to also express my gratitude to my Mother (Mrs Comfort Nwadike) for her unwavering and timeless support ,Thank you ma. I also say thank you to my mother and father in law, my uncles; Supol Ifeanyi Ohuruzo, Endy Ohuruzo , My one and only Brother Chijioke. Finally I say thank you to a host of other people too numerous to mention but who also gave their support. With heart full of gratitude I say thank you all. Dedication To Jesus Christ for his divine favor and interventions in my life. I say from a heart full of gratititude Thank you sir. To my Mother (Mrs Nwadike Comfort) who took on life and raised two boys, who taught me not just to be a man but a good man, Thank you. LIST OF TABLE Table 1; Distribution of socio-demographic data and selected variables Table 2; Relationship between selected Risk factors and Acinetobacter infection Table 3; Relationship between selected Risk factors and Acinetobacter infection Table 4; Logistic Regression Analysis for independent risk factors Figure 1; Antibiotics susceptibility profiles Figure 2; plasmids analysis of isolates ABSTRACT Acinetobacter plays an important role in the infection of patients admitted to hospitals. Acinetobacter are free living gram-negative coccobacilli that emerge as significant nosocomial pathogens in the hospital setting and are responsible for intermittent outbreaks. The aim of this study was to determine the prevalence of Acinetobacter in patients admitted into the Intensive Care Unit, identify risk factors associated with infection, the antibiotic susceptibility profile of the isolates and determine the relatedness of the Acinetobacter isolates. A cross sectional study was carried out in the Intensive Care Unit of the University College Hospital Ibadan. Samples collected were tracheal aspirate, catheter specimen of urine, wound biopsy, and blood all for microscopy, culture and sensitivity. The isolates were tested against various antibiotics and the plasmid profile done to determine their relatedness. All data were analyzed using the statistical package for Social Sciences version 15.0 program. Fourteen (14%) of the 100 patients recruited into the study, developed Acinetobacter infection, it consisted of 9% of the total number of isolates isolated. Twelve (86%) of the isolates were recovered from tracheal aspirate, 1(7%) from urine and 1(7%) from blood. Only duration of endotracheal intubation specifically an 8-14day period was an independent risk factor for Acinetobacter. All the isolates were resistant to Ceftriaxone, Ciprofloxacin, Ofloxacin, and gentamicin. Nine (64.3%) of the isolates were susceptible to Meropenem, seven (50%) were susceptible to amikacin and five (35.7%) susceptible to levofloxacin. All of the isolates harbor plasmids of varying molecular sizes. Ten of the fourteen Acinetobacter were isolated at about the same period of time in the ICU with 6(42.7%) having plasmid size in the 23.1kb band and show similar pattern revealing that the isolates exhibit some relatedness. The clonal nature of the isolates suggest that strict infection control practices must be adopted in ICU, also an antibiotic policy must be developed for the ICU to prevent abuse of antibiotics that may lead to selection of resistant bacteria. CHAPTER ONE 1.0 INTRODUCTION In the last 20years the control of hospital-acquired infection caused by multidrug resistant Gram-negative bacilli has proved to be a peculiar problem. An increasing incidence during the 1970s of resistant members of the family Enterobacteriaecea involved in nosocomial infections was followed by the therapeutic introduction of newer broad spectrum antibiotics in hospitals and a subsequent increase in the importance of aerobic Gram-negative bacilli, including Pseudomonas aeruginosa and Acinetobacter spp. Of the newer pathogens, Acinetobacter plays an important role in the colonization and infection of patients admitted to hospitals1. Acinetobacter is ubiquitous, free-living and fairly stable in the environment2. Members of the genus Acinetobacter are Gram-negative cocco-bacilli that emerge as significant nosocomial pathogens in the hospital setting and are responsible for intermittent outbreaks.2 Due to their distinct adhesive ability to epithelial cells; they have a predilection to colonize skin, especially in the areas of the perineum, inguinal region, axillae, mucous membranes and upper respiratory airway.3 Acinetobacter species have also been associated with human infections which include pneumonia, septicemia, wound sepsis, urinary tract infection, endocarditis and meningitis.4 Over the past two decades, Acinetobacter infections have become an increasingly common nosocomial problem.3,4 In addition to hospitalized patients, community acquired Acinetobacter infection is increasingly reported in studies.5,6Acinetobacter infections are increasingly implicated in infections in intensive care units and have been cited in up to 17% of Ventilator Associated Pneumonias, second only to Pseudomonas, which was responsible for 19% of Ventilator Associated Pneumonia in an ICU.3 In a review from the CDC, 7% of ICU-acquired pneumonias were due to Acinetobacter in 2003 compared to 4% in 1986.7 Infections caused by Acinetobacter are difficult to control due to multi-drug resistance,2 this limits therapeutic options in critically ill and debilitated patients especially from intensive care units where their prevalence is most noted.2 The incidence of outbreak is much more in the regions where temperature is hot and humid.2,3,8 Acinetobacter outbreaks have been traced to contamination of respiratory-therapy and ventilator equipment from cross-infection by the hands of health care workers who have cared for colonized, infected patients or touched contaminated fomites.5,9 A. baumannii, A. calcoaceticus and A. lwoffii are the Acinetobacter species most frequently reported in clinical literature.3 There is some data to suggest that the proportion of intensive care unit (ICU)-acquired pneumonia cases being found to be due to A. baumannii is actually increasing. In large surveillance studies from the United States between 5 and 10% of cases of ICU-acquired pneumonia were due to A. baumanniii8. Data on Acinetobacter in Africa is largely limited to South Africa at the present time, although there are scattered reports from other countries in Africa.10 In addition to lengthy stay in the ICU, risk factors for colonization and infection are recent surgery,
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