An overview of resistance profiles ESKAPE pathogens from 2010-2015 in a tertiary respiratory center in Romania.

Lower respiratory tract infections (LRTIs) is an umbrella term that covers a wide spectrum of diseases, comprising mild and severe, acute and chronic conditions. A wide spectrum of pathogens can be implicated, from viruses to pyogenic and atypical bacteria. A special place should be reserved for slow growing bacteria (Mycobacteria spp., Nocardia spp.) and parasites (i.e., hydatic cysts caused by Echinococcus granulosus). OBJECTIVE: The objective of this study is to observe, analyze and establish the drug susceptibility patterns for Enterococcus spp., Staphylococcus aureus, Klebsiella spp., Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp. (the ESKAPE pathogens) in the "Marius Nasta" Institute for Pulmonary Medicine (MNIPM), Bucharest, Romania. MATERIALS AND METHODS: A retrospective healthcare record based study was undertaken to establish the drug susceptibility patterns. We assessed all antibiograms of the ESKAPE pathogens isolated from respiratory samples from adult inpatients hospitalized between 2010-2015 at the MNIPM. RESULTS: We analyzed 2859 isolates (61% of the 4683 ESKAPE isolates). P. aeruginosa was the most frequent pathogen, while Enterococcus spp. and Enterobacter spp. were practically non-present. The antibiotic profile of P. aeruginosa isolates presented more resistance in the Intensive Care Unit (ICU)÷Surgery wards, probably resulting from antibiotic pressure. The other non-fermenter, A. baumannii, while less frequent (and the only pathogen more frequent in the surgery department) had an even more resistant profile, to almost all antibiotics, with the exception of Colistin. Methicillin-resistant S. aureus (MRSA) accounted for about 60% of all isolates, more in the ICU÷Surgery ward. K. pneumoniae presents a less resistance and shows more stability when analyzing the antibiogram pattern in the Medical wards. DISCUSSION: For methodological or procedural reasons, Enterococcus spp. and Enterobacter spp. were underrepresented in the study. Interventional programs comprising antibiotic stewardship and active surveillance need to be implemented to alleviate the antibiotic profile. Further research needs to focus on more detailed characterization of the molecular mechanisms leading to the high resistance detailed herein. CONCLUSIONS: This study adds to the body of literature reporting the antibiotic resistance landscape in Romania, for these highly resistant pathogens.

Resistance pattern of multi-drug resistant strains of Mycobacterium tuberculosis and characteristics of patients with multi-drug resistant tuberculosis.

Introduction: Multi-drug resistant tuberculosis (MDR-TB) is a major concern in the medical community. Knowledge about the drug resistance pattern of Mycobacterium tuberculosis strains plays an essential role in the management of the disease. Material and methods: We conducted a retrospective, 3-year study (2009-2011), in an urban area. We collected data on the drug resistance for 497 M. tuberculosis strains, isolated from patients with pulmonary TB. Among the 497 strains, we identified 158 MDR strains. Eighty medical recorders of patients infected with MDR strains were available and we included those patients in the study group. Results: Of the 497 analysed strains, 8% were resistant to a single anti-TB drug. We identified 5.2% polyresistant drug strains, the most frequent combination being INH+EMB (1.4%). Of the 158 MDR strains identified (31.8%), over 60% were resistant to all first line anti-TB drugs tested. Most of them presented resistance to STM (86.1%) and EMB (67.7%). With respect to second line anti-TB drugs resistance to KM (23.4%) was the most common, followed by OFX (8.2%). With respect to the patients with MDR-TB, a percentage of 61.2% of them had a history of anti-TB treatment. Regarding lifestyle habits, 61.2% of the patients were smokers and 18.8% were abusing alcohol. Out of 51 patients, for whom information was available regarding their occupation, only 33.3 % were employees. Conclusion: MDR strains of Mycobacterium tuberculosis display an increased resistance to first line anti-TB drugs. Extension of resistance to second line anti-TB drugs narrows the therapeutic options. Knowledge of MDR-TB risk factors is imperative for the correct and rapid initiation of the treatment.

[Antibiotic resistance of Acinetobacter baumannii strains isolated from clinical specimens in the "Marius Nasta" Pneumology Institute, Bucharest]. / Rezistenta la antibiotice a tulpinilor de Acinetobacter baumannii izolate din specimene clinice in Institutul de Pneumoftiziologie "Marius Nasta", Bucuresti.

Acinetobacter baumannii (A. baumannii) is one of the leading causes of morbidity and mortality in patients who are in critical condition in hospitals and especially in intensive care units (ICU). Long time considered a bacterium with low virulence, A. baumannii has more recently become a cause for major concern in clinical practice due to its high level of antimicrobial resistance. The extend of infections with Acinetobacter baumannii in ICU is caused by multiple factors, such as mechanical ventilation, invasive procedures, the use of a large number of broad spectrum antibiotics and transmission through the hands of medical staff In this study we evaluated the resistance to antibiotics of 213 non-duplicated strains of A. baumannii isolated in the bacteriology laboratory of the "Marius Nasta" lnstitute of Pneumophtisiology (IPMN) from January 2012 to December 2013. These strains originated from patients in medical wards (56), ICU (143) and surgery (14). Strains identification was performed by classical methods on multitest media and with API kits (Bio Merieux). The antibiotic sensitivity was performed on Mueller-Hinton media in accordance with CLSI2013. Analysis of the resistance to antibiotics was the following: carbenicilin (87.3%), ceftriaxone (87.3%), cefoperazone with sulbactam (84.9%), ceftazidime (79.3%), carbapenems (imipenem and/or meropenem--75.1%), fluoroquinolones (ciprofloxacin and/orlevofloxacin--73.7%), cefepime (66.6%), piperacilin with tazobactam (62.4%), amikacin (50.2%), netilmicin (45%), gentamicin (42.7%) and tobramycin (35.6%). In our study, we only found two strains of Acinetobacter baumannii with resistance to colistin and 70 (32.8%) strains sensitive only to colistin, but resistant to all other antibiotics tested. A. baumannii is a pathogen with rapid spread and extended resistance to even newer antimicrobial agents. Due to its ability to survive in the hospital environment, A. baumannii has the immense potential to cause nosocomial infections. We did not find significant differences between the antibiotic resistance of strains isolated from ICU patients and those obtained from medical or surgical wards. This study has also shown that there is a high number of A. baumannii strains with resistance to almost all antibiotics tested, notably with the exception of colistin, wich therefore becomes the antibiotic of choice in the treatment of these infections. The marked increase in the number of multidrug resistant A. baumannii strains highlights the need for a more rational use of broad spectrum antibiotics, as well as for an immediate review of infections control protocols, so as to limit the spread of this pathogen.

Mortality Risk and Etiologic Spectrum of Community-acquired Pneumonia in Hospitalized Adult Patients.

BACKGROUND: The etiology of community-acquired pneumonia (CAP) is specific to each region, as proved by numerous studies conducted so far. Knowledge of these data is essential in developing guidelines for antibiotic prescription. Assessment of severity of CAP patients is crucial in determining the risk of mortality and the site of care. Unusual bacterial etiologies may increase the risk of mortality. OBJECTIVE: First outcome was the identification of pathogens in CAP patients requiring hospitalization and secondary to determine factors that correlate with increased risk of mortality. MATERIAL AND METHODS: A prospective study of patients over 18 years of age hospitalized with CAP from whom pathological products were taken (mainly sputum) for bacteriological analysis (microscopy and culture). RESULTS: 120 patients were evaluated over a period of three years (2008-2010); we could identify a bacterial etiology in 33 cases (27.5%). The most commonly isolated were S. pneumoniae (11 cases), H. influenzae (9 cases) and Gram-negative enteric bacilli (12 cases). The mortality rate was 9.2%, significantly higher in the age group over 65 years and in patients with hypoxemia, impaired consciousness and high CURB 65 score, but the only independent factor for the mortality risk prediction was the presence of confusion on admission. CONCLUSIONS: S. pneumoniae, H. infuenzae and enteric Gram negative bacilli remain the most frequent cause of CAP in hospitalized patients in Romania and the first line of antibiotic treatment should be targeted. The only independent risk factor for mortality risk was the presence of disorders of consciousness on admission.

[Incidence and resistance patterns of pathogens from lower respiratory tract infections (LRTI)]. / Incidenta si pattern-ul de rezistenta bacteriilor patogene izolate din tractul respirator inferior.

The aim of present study was to evaluate the incidence and antibiotic susceptibility of pathogens in LRTI for patients in ICU/Surgery and pneumological wards from Marius Nasta Institute. A number of 938 strains isolated between September 1st 2004 and September 1st 2005 were identified by standard procedures and antimicrobial resistance was determined following CLSI approved standard. Imipenem-EDTA Double Disk Synergy test and Etest were used for detection of metallo-beta-lactamase producing isolates of P.aeruginosa. There were isolated 744 Gram-negative strains: H. influenzae 34.6%, P. aeruginosa 17.7%, H. parainfluenzae 15.9%, K. pneumoniae 8.6% and another spp. and 194 Gram-positive strains: 54.1% S.aureus and 45.9% S.pneumoniae. Among H. influenzae and H. parainfluenzae isolates, the highest resistance rate was to trimethoprim/sulfametoxazole (SXT 30.9% and 31.1%), followed by ampicillin (AMP 11.6% and 13.4%), chloramphenicol (C 4.5% and 5.1%) and clarithromycin (1.6% and 13.6%). P. aeruginosa strains showed a resistance rate between 7.9% to amikacin and 38.3% to cefoperazone. The resistance to imipenem (IPM) and meropenem (MEM) was close: 28.2% and 26.0%. From 36 P. aeruginosa IPM and multidrug resistant strains tested, 8 were probably producing metallo-beta-lactamase. For S. aureus the highest resistance rate was to penicillin 93.3% followed by erythromycin (E 45.7%), oxacillin 41.9% and CIP (33.3%); all strains were susceptible to vancomycin, teicoplanin and linezolid. From S. pneumoniae strains 13.4% were high resistant to penicillin and 39.3% were intermediate resistant. The resistance rate for other antibacterial agents was 64.0% to SXT, 18.8% to E, 8.3% to C and all strains were susceptible to levofloxacin. K. pneumoniae strains were resistant to cefepime (11.3%), CIP (7.8%) and there was no resistant strain to IPM and MEM.

[Bacteria isolated from pleural fluid and their resistance to antimicrobials]. / Bacterii izolate din lichidul pleural si rezistenta lor la antibiotice.

The aim of this study is to evaluate the frequency of microorganisms isolated from pleural fluids and their resistance to antimicrobial agents. A total of 272 pleural fluids were studied between July 2004 - July 2005 from the patients hospitalized in ICU/surgery (127) and respiratory diseases wards (145) at Marius Nasta Institute. The laboratory investigations included: direct microscopy, cultures for aerobic and anaerobic bacteria, identification, disk diffusion method according with CLSI recommendations for resistance and Etest for detection of metallo-beta-lactamase producing isolates of Pseudomonas aeruginosa. Microorganisms were isolated from 159 samples (58.4%), 48 pleural fluids were positive only in microscopy (17.6%). The most frequent isolated strain was P. aeruginosa (49.6%), followed by Staphylococcus aureus (12.8%) and Enterobacteriaceae (11.2%) polymicrobial infections were mostly due to combinations of Pseudomonas with Enterobacteriaceae. For P. aeruginosa the resistance rate was higher than 71% for all beta-lactams. For aminoglycosides the lower resistance rate was to amikacin (18.0%). For quinolones, resistance of P. aeruginosa was 67.8% to ciprofloxacin. P. aeruginosa isolated from patients hospitalized in ICU/surgery were more resistant to some antimicrobials than the strains isolated in the respiratory diseases wards: resistance to amikacin was 24.5% versus 10% respectively. From 21 P. aeruginosa imipenem and multidrug resistant strains tested, 3 were probably producing of metallo-beta-lactamase. S. aureus showed 47.1% oxacillin resistance, 38.9% resistance to gentamicin and ciprofloxacin and 27.7% to erythromycin. All S.aureus strains were susceptible to linezolid, teicoplanin and vancomycin. The resistance of Enterobacteriaceae strains was high to ampicillin (80.0%), amoxicillin/clavulanic acid and trimethoprim/sulfamethoxazole e(57.6%); the lowest resistance rate was to cefoperazone/sulbactam (7.7%) and to imipenem and ciprofloxacin (10.8%).