Changing Antimicrobial Susceptibility and Resistance Pattern of Acinetobacter Species Over the Last Eight Years in a Tertiary Care Hospital in Lahore, Pakistan

Open Access ORIGINAL ARTICLE Changing Antimicrobial Susceptibility and Resistance Pattern of Acinetobacter Species over the Last Eight Years in a Tertiary Care Hospital in Lahore, Pakistan Fareeha Imran1, Muna Malik1, Amina Asif1, Gulnaz Akhtar2, Sidra Zaman3, Aasma Noveen Ajmal4 1Assistant Professor, Department of Pathology, Ameer-ud-Din Medical College/PGMI/LGH, Lahore, Punjab Pakistan 2Associate Professor, Department of Pathology, Ameer-ud-Din Medical College/PGMI/LGH, Lahore, Punjab Pakistan 3Demonstrator, Department of Pathology, Avicenna Medical College, Lahore, Punjab Pakistan 4Senior Demonstrator, Department of Pathology, Ameer-ud-Din Medical College/PGMI/LGH, Lahore, Punjab Pakistan ABSTRACT Background: Acinetobacter spp. is a highly resistant nosocomial pathogen that leads to a broad range of human infections resulting in high morbidity and mortality. Due to unpredictable MDR patterns of Acinetobacter spp., it is imperative to know the institutional prevalent susceptibility profiles of these residing pathogens. The objective of this study was to determine the antimicrobial susceptibility pattern of Acinetobacter species over the last 8 years in a tertiary care hospital in Lahore, Pakistan. Material and Methods: A retrospective study was carried out in Lahore General Hospital, a tertiary care hospital in Lahore, Pakistan. Eight-year data was gathered from January 2012 to December 2019. All specimens were handled according to standard operating procedures in the microbiology laboratory of the Pathology department of Lahore General Hospital. The Acinetobacter spp. were identified in the laboratory by Gram staining, oxidase test, catalase test and Triple sugar iron fermentation and their antibiotic sensitivity pattern was noted. Results: The highest yield of Acinetobacter spp. from the clinical specimen was isolated from pus followed by tracheal secretion, blood, and urine in the last three years (from 2017 to 2019). Most of the isolates were multi-drug resistant (MDR). There was a progressive increase in resistance of Acinetobacter spp. The highest progression in resistance was observed among the cephalosporin and quinolone group of antibiotics. Conclusions: Increased resistance to commonly used antimicrobials against Acinetobacter species has been observed with the highest resistance to quinolones and cephalosporins. Key words: Acinetobacter, Antibiotic stewardship, Multidrug resistance, Nosocomial infections. Authors’ Contribution: Correspondence: Article info: 1Conception; Literature research; Fareeha Imran Received: October 5,2020 manuscript design and drafting; 2,3 Critical Email: fareehaimran536@hotmail.com Accepted: June 15, 2021 analysis and manuscript review; 4-6 Data analysis; Manuscript Editing. Cite this article. Imran F, Malik M, Asif A, Akhtar G, Zaman S, Ajmal A N. Changing Funding Source: Nil Antimicrobial Susceptibility and Resistance Pattern of Acinetobacter Species over the Last Eight Conflict of Interest: Nil Years in a Tertiary Care Hospital in Lahore, Pakistan. J Islamabad Med Dental Coll. 2021; 10(2): 83-88. Doi: 10.35787/jimdc.v10i2.615 Introduction Acinetobacter species is one of the most important with hospital-acquired infections with almost 20% of opportunistic non-fermenting bacteria associated infections occurring in intensive care units.1 It is a J Islamabad Med Dental Coll 2021 83 major cause of urinary tract infection, surgical site simplified phenotypic identification protocol and to infection, septicemia, pneumonia, and ventilator- determine the changing antibiotic susceptibility associated pneumonia. In the past, they were pattern of these isolates. This is essential for proper considered contaminants but now they are an antimicrobial stewardship, which is the key to important cause of healthcare-associated effective control of infections. infections.2 Hospital-acquired infections are the sixth leading cause of death in the USA.3 Invasive M a t e r i a l and Methods procedures and misuse of broad-spectrum This retrospective study was carried out in Lahore antibiotics are the major risk factors for the General Hospital, Lahore, a tertiary care hospital. acquisition of infection with Acinetobacter species. Approval was obtained from the Ethical Review Increased resistance leads to treatment failure, Committee of Postgraduate Medical Institute/ prolonged hospital stays, financial burden and Ameer-ud-Din Medical College/ Lahore General increased mortality.4,5 Hospital, Lahore, Pakistan. This study comprised of Multidrug efflux pumps, target modification, eight-year data from January 2012 to December permeability defects, and enzymatic degradation of 2019. drugs are important mechanisms of acquired Samples from both indoor and outdoor patients resistance against a wide range of antibiotics.6 were collected and processed according to standard Acinetobacter species have been declared by WHO protocols of the microbiology laboratory of the as one of the most serious organisms among ESKAPE Pathology department, Lahore General Hospital, pathogens (Enterococcus faecium, Staphylococcus Lahore, Pakistan. These samples included blood, aureus, Klebsiella pneumoniae, Acinetobacter CSF, pus, wound swabs, tips, tracheal secretion, species, Pseudomonas aeruginosa, and fluid, sputum, bronchial wash, pleural tap, Enterobacter species).6 tissue/biopsy, and urine. All Acinetobacter spp. It is very difficult to eradicate Acinetobacter from isolated and identified after biochemical tests were the environment due to its ability to survive on dry included in this study. surfaces for a longer period and resistance to most Clinical samples from patients already taking of the disinfectants.7 About 48-85% of the clinical antibiotics and repeat isolates from the same isolates have shown multidrug resistance.1 patient were excluded. Acinetobacter spp. are emerging as one the most resistant pathogens in Pakistan as well as globally All clinical specimens were initially inoculated on a and are a great burden to human health.8,9 Blood agar and MacConkey agar, while the urine specimens were inoculated on Cystine Lactose Increased incidence of MDR strains of Acinetobacter Electrolyte Deficient (CLED) medium. The inoculated species is due to a lack of compliance with basic plates were incubated aerobically at 37°C and infection control measures.8 Due to unpredictable checked for bacterial growth after 24 hours. The MDR patterns of Acinetobacter spp., it is imperative morphology of bacterial colonies was examined with to know the institutional prevalent susceptibility a hand lens. The bacteria were identified first by profiles of these residing pathogens. Hence, this Gram staining, catalase test, oxidase tests, and study was conducted to observe the antibiogram of hanging drop method for motility. The the last eight years of various clinical samples from Acinetobacter spp. were identified as Gram- which Acinetobacter spp. was isolated by a negative or Gram variable coccobacilli, oxidase J Islamabad Med Dental Coll 2021 84 negative and catalase positive. Each strain was D i s c u s s i o n inoculated on the Triple sugar iron (TSI) slant for the identification of its ability to ferment sugars. Despite rigorous endeavors, nosocomial multi-drug resistant (MDR) Acinetobacter spp. is still a major The antimicrobial susceptibility pattern was problem owing to its great capability to propagate evaluated by the Kirby-Bauer disc diffusion method and colonize human and environmental reservoirs. 10 according to respective CLSI guidelines. A bacterial Acinetobacter spp. is a highly resistant nosocomial suspension of 0.5 McFarland turbidity standard was pathogen that leads to a broad range of human made and inoculated on Muller Hinton agar plate for infections resulting in high morbidity and mortality each Acinetobacter spp. isolate. Aminoglycosides, rates.12 Over the years Acinetobacter species are Carbapenem, Quinolones, Cephalosporins. increasingly being isolated from a broad array of Ampicillin / Sulbactam, Cotrimoxazole, Piperacillin / clinical specimens. It is the need of the day to Tazobactam, and Doxycycline discs were inoculated periodically analyze the antimicrobial susceptibility on plates and incubated for further 24 hours of and resistance pattern of this common pathogen so aerobic incubation at 37°C. that appropriate antibiotic policy can be formulated for empirical as well as a targeted treatment. ATCC 19606 strain of Acinetobacter species was used as a quality control strain in all standard The variations in the antibiogram of Acinetobacter 11 operating procedures. Frequencies and spp. demands periodic surveillance of these percentages were calculated for the qualitative pathogens for an appropriate selection of therapy.13 variables like Acinetobacter species isolated from clinical samples and percentage resistance pattern Acinetobacter species has attained a foothold in the to various antibiotics. ICU settings, causing nosocomial pneumonia which accounts for around 36% of hospital-acquired R e s u l t s pneumonia in Asian countries.14,15 This is in concordance with this study, which shows The results were tabulated according to each year. A Acinetobacter species infections on the rise over the total number of clinical samples were tabulated past eight years, especially in the ICUs. This is an from which Acinetobacter species were isolated imminent threat for the spillover of this organism in according to the specimen. the general wards, highlighting the importance of keeping a strict eye over its prevalence and

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