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Ventilator Associated Pneumonia in the Critical Care Unit in a Tertiary Care Hospital by Burkholderia Cepacia by an Unusual Mode of Infection

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Ventilator Associated Pneumonia in the Critical Care Unit in a Tertiary Care Hospital by Burkholderia Cepacia by an Unusual Mode of Infection International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571 Original Research Article Ventilator Associated Pneumonia in the Critical Care Unit in a Tertiary Care Hospital by Burkholderia Cepacia by an Unusual Mode of Infection Saurabh Mitra1, Swagnik Roy1, Rajat Dasgupta2 1Assistant Professor, 2Demonstrator, Department of Microbiology, K P C Medical College and Hospital, Kolkata. Corresponding Author: Saurabh Mitra Received: 27/08/2015 Revised: 29/09/2015 Accepted: 03/10/2015 ABSTRACT The present study was carried out on suspected cases of ventilator associated pneumonia in the critical care unit over a period of eleven months in a tertiary care hospital in West Bengal. A total number of 128 suspected cases of respiratory tract infection were reported. Samples were collected from the above cases and cultured for bacterial growth. Out of the 128 samples a total of 45 were culture positive. Of the culture positive cases, 14 were Burkholderia cepacia. Unexpectedly high number of, Burkholderia cepacia isolated for the first time from this unit prompted extensive searching. This led to isolation of Burkholderia cepacia from the chlorhexidine gluconate mouthwash used in the ward. Prompt action was taken leading to control of the situation. Keyword: Ventilator - associated pneumonia, endotracheal tube aspirates, microscan system, nonfermenters, nosocomial infections. INTRODUCTION (e.g. prior antibiotic therapy, contaminated Ventilator associated pneumonia ventilator circuits, decreased gastric (VAP) is an infection of lung parenchyma acidity), (ii) increased possibility of occurring 48-72 h or more after intubation aspiration of oropharyngeal contents into due to organisms incubating at the time the lower respiratory tract (e.g. intubation, mechanical ventilation (MV) was decrease level of consciousness, presence commenced. [1] It is the most common of nasogastric tube) and (iii) reduced host nosocomial infection encountered in the defense mechanism in the lung and permit intensive care unit (ICU), with 9-28% of overgrowth of aspirated pathogen (e.g. all intubated patients developing VAP. [2,3] chronic obstructive pulmonary disease, old Intubation independently increases the risk age, upper abdominal surgery). Aspiration of developing nosocomial pneumonia at of oropharyngeal secretions into the least seven‑fold, with a peak in incidence bronchial tree is a major factor in the [5] occurring around day 5 of ventilation. [4] development of VAP. Most cases seem to result from aspiration Burkholderia cepacia or the of pathogenic microorganisms that Burkholderia cepacia complex (BCC) is a commonly colonizes the oropharyngeal catalase-producing, non-lactose- airway of the critically ill patient. Risk fermenting, gram- negative bacterium. B factor of VAP includes: (i) Increase the cepacia is an important human pathogen risk of colonization by potential pathogens which often causes pneumonia in immune- International Journal of Health Sciences & Research (www.ijhsr.org) 125 Vol.5; Issue: 11; November 2015 compromised individuals with underlying Pseudomonas aeruginosa, and lung disease or malignancies. Apart from Acinetobacter baumannii pneumonia (especially in patients with Extensive search was carried out to cystic fibrosis), they also cause a wide locate the source, this included variety of infections ranging from investigation of care givers, paramedical superficial to deep-seated and staffs and other hospital personnel and disseminated infections, meningitis, instruments like suction apparatus, peritonitis (in patients undergoing humidifiers, and ventilator circuits. peritoneal dialysis), [6] septicaemia and Samples were taken from nebulizer drugs bronchiectasis. BCC survives and especially from batches that were used in multiplies in aqueous hospital those patients who were subsequently environments where it may persist for long infected. All these samples were subjected periods. Due to high intrinsic resistance of to culture by conventional method. Finally the BCC to antibiotics and antimicrobial Burkholderia cepacia was isolated from compounds, all of these infections can the chlorhexidine gluconate which was prove very difficult to treat and may be used on the bedside for oral care in patient fatal. Nosocomial infections caused by with endotracheal tube in -situ. BCC include blood stream infections (BSI), pneumonias, and surgical wound RESULTS infections. Out breaks of nosocomial During an 11-month period, patients infections due to BCC have been admitted to the critical care unit were commonly reported in literature and evaluated. Among those requiring MV generally linked to contamination of with a CPIS score >6 were evaluated for various fluid used in hospitals. VAP. Bacteriological culture was done on the endotracheal aspirate by conventional MATERIALS AND METHODS method on blood agar and nutrient agar The present study was carried out medium. on critically ill immunologically Most cases of VAP were caused by debilitated patients because the study Gram-negative bacteria, which accounted population consists of patients on for majority of causative organisms. mechanical ventilator in the critical care Pseudomonas aeruginosa 9, (20 %), ward of a tertiary care hospital in West Acinetobacter baumannii 8, (17.7%), E. Bengal. coli 3, (6.6%), citrobacter 4(8.8%), Patients receiving treatment for Klebsiella pneumoniae 4 (8.8%) but respiratory failure on mechanical Burkholderia cepacia, BCC 14, (31.1%) ventilator presenting with features of VAP was the most common Gram-negative were investigated for causative organism. bacteria associated with VAP and The endotracheal tube aspirates samples Staphylococcus aureus 3(6.6%) was the were cultured under aerobic condition most common Gram-positive bacteria culture by conventional method and among patients with VAP. causative organisms were identified by Burkholderia cepacia comprised of automated method (microscan system maximum number of cases, 31.1 %. The Siemens). The organism isolated were organisms isolated from the patients and Burkholderia cepacia in a significant those isolated subsequently from the number of cases along with other mouth wash sample showed identical organisms like Klebsiella pneumoniae, sensitivity pattern on automated method Staphylococcus aureus, Escherichia coli, (microscan system Siemens) indicating and other nonfermenters like their origin from same source. International Journal of Health Sciences & Research (www.ijhsr.org) 126 Vol.5; Issue: 11; November 2015 Clinical Microbiology, Gazi University School of Medicine, Ankara, Turkey [7] BCC is implicated as the causative agent of various type of infection e.g. pneumonia (included VAP), Bloodstream (included catheter related BSI) urinary tract ,surgical site and skin-soft tissue. Of these pneumonia was the most frequent infection due to BCC and Oropharyngeal bacterial colonization during intubation, poor cough reflex, and direct inhalation of Figure 1 contaminated aerosols into the lower 1) Pseudomonas aeruginosa 9 20%) 2) Acinetobacter baumannii 8, (17.7%) respiratory tract have been involved in the 3) E. coli 3,(6.6%) higher risk for pneumonia of patients 4) Citrobacter 4(8.8%), 5) Burkholderia cepacia BCC 14, (31.1%) receiving mechanical ventilation. 6) Klebsiella pneumonia 4 (8.8%) A study named The Pathogenesis 7) Staphylococcus aureus 3(6.6%) of Ventilator-Associated Pneumonia: Its Relevance to Developing Effective DISCUSSION Strategies for Prevention, [8] carried out by Non-fermentative Gram negative Nasia Safdar MD MSc, Christopher J rods occupy the second position after Crnich MD MSc, and Dennis G Maki MD, enterobacteriaceae as opportunistic the author has mentioned BCC as a major pathogens responsible for nosocomial etiological agent for epidemic VAP caused infections. Pseudomonas aeruginosa, by caused by contamination of inhaled Acinetobacter baumannii and medication nebulizer reservoirs. Stenotrophomonas maltophilia are the In 2012 an original article most frequently encountered non- published in 2012 Jan by Martin M, [1] fermentative agents of nosocomial Winterfeld I, Kramme E, Ewert I, infections in intensive care units. Sedemund-Adib B, Mattner F. [9] 12 cases Multidrug resistance exhibited by these were identified whereby the first detection species can cause serious problems in the of BCC was in respiratory specimens of 11 clinical setting. B. cepacia with its high patients and 1 in a wound swab from the transmissibility between hospitalized oral cavity. Of these patients six developed patients and multiple drug resistance can ventilator-associated pneumonia (VAP). now be added to this list. B. cepacia Investigations revealed that five different though usually nonpathogenic in healthy batches of an alcohol-free mouthwash hosts, is commonly associated with containing hexetidine were highly colonization and pulmonary infection in contaminated. Isolates of BCC from CF patients However, the pathogenicity of patients and mouthwashes were B. cepacia is not always limited to genetically indistinguishable proving to be individuals with CF, infection occurs the suspected source. through exposure to contaminated solutions in hospitalized patients. CONCLUSION In the study, Nosocomial In hospitals, B. cepacia has been Burkholderia cepacia infections in a found to contaminate antiseptics, Turkish university hospital: a five-year disinfectants, nebulizer solution, and surveillance, by Murat Dizbay, Ozlem dextrose solution in the present study B Guzel Tunccan, Busra Ergut Sezer, cepacia
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