Study of gram-negative bacteris resistance to antibiotics causing nosocomial pneumonia in patients with stroke at 103 Military Hospital

Journal of military pharmaco-medicine no2-2018

STUDY OF GRAM-NEGATIVE BACTERIA RESISTANCE TO
ANTIBIOTICS CAUSING NOSOCOMIAL PNEUMONIA IN
PATIENTS WITH STROKE AT MILITARY HOSPITAL 103
Dang Phuc Duc*; Nguyen Minh Hien*
Mai Xuan Khan*; Nguyen Thai Son*
SUMMARY
Objectives: To evaluate the antibiotic resistance of Gram-negative bacteria causing
pneumonia in stroke patients. Methods: Descriptive study. Results: P. aeruginosa resistance
> 80% was observed in most antibiotics (14/20 patients), 100% was resistant to imipenem,
norfloxacin; sensitivity to polymycin (100%). K. pneumoniae strains 100% with 8/20 antibiotics,
including ciprofloxacin, cefpirome, cefuroxime. K. pneumoniae strains were sensitivity 100% to
doxycylins and carbapenem antibiotics. A. baumannii strains resist 100% to 5 antibiotics,
including piperacillin + tazobactam; 50% of A. baumannii strains resist to the carbapenem group.
* Keywords: Nosocomial pneumonia; Antibiotic resistance; Stroke.

INTRODUCTION
Stroke patients have many potential
risk factors for nosocomial pneumonia
such as: poor mobility due to paralysis,
swallowing disorders, immuno-depression,
mechanical ventilation... Most causes of
pneumonia are Gram-negative bacteria.
Antibiotic resistance of bacteria, especially
Gram-negative bacteria is increasing
and causing difficulties in treatment. We
conducted this study aiming at: Assessment
of antibiotic resistance of Gram-negative
bacteria causing nosocomial pneumonia
in stroke patients at 103 Military Hospital.

SUBJECTS AND METHODS
1. Subjects.
215 patients were diagnosed with stroke
at Department of Stroke, 103 Military

Hospital, divided into two groups: pneumonia
and non-pneumonia.
* Inclusion criteria:
- American Thoracic Society's 2005
nosocomial pneumonia diagnostic criteria:
- Pneumonia appears after hospitalization
> 48 hours.
- The presence of a new or progressive
radiographic infiltrate plus at least two of
three clinical features.
- Fever greater than 38oC.
- Leukocytosis or leukopenia.
- Purulent secretions.
- For patients who do not meet new
pulmonary radiographic criteria, clinical
signs and sputum cultures are pathogenic,
we also classify pneumonia.

* 103 Military Hospital
Corresponding author: Dang Phuc Duc ()
Date received: 08/12/2017
Date accepted: 18/01/2018

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Journal of military pharmaco-medicine no2-2018
* Exclusion criteria:
- Patients died or discharged within 48 hours after hospitalization.
- Pneumonia within 48 hours after admission.
- Tuberculosis, lung tumors.
2. Method.
Descriptive research with analysis. Statistical processing using SPSS 15.0 software.
RESULTS AND DISCUSSION
We studied 215 stroke patients who were divided into two groups: pneumonia group
(n = 29); non pneumonia group (n = 186), we obtained the following results:
1. Patients’ characteristics.
Table 1: Stroke characteristics.
Stroke type

Pneumonia
(n = 186)

Non pneumonia
(n = 29)

Total
(n = 215)

n

%

n

%

n

%

Ischemia

125

67.2%

11

37.9%

136

63.3%

Hemorrhage

61

32.8%

18

62.1%

79

36.7%

Total

186

29

p

< 0.05

215

Out of 215 stroke patients, 136 patients (63.3%) suffered from ischemia and 79
patients had hemorrhage (36.7%). 29 patients (13.5%) caught pneumonia.
According to the research by Phan Nhut Tri, the proportion of stroke patients
accquired pneumonia was 19.1% [9].
2. The bacteria that cause nosocomial pneumonia in stroke patients.
Table 2: Types of bacteria in pneumonia group.
Bacteria
Do not grow bacteria
Gram negative

Gram positive

Pseudomonas aeruginosa

n = 29

%

5

17.2

7

24.1

Klebsiella pneumoniae

4

13.8

Acinetobacter baumannii

2

6.9

Klebsiella oxytoca

1

3.4

Klebsiella ozaenae

1

3.4

Staphylococcus aureus

3

10.3

Streptococcus.d

1

3.4

Streptococcus viridans

5

17.2

Of 29 patients with nosocomial pneumonia, 5 patients had sputum culture without
bacterial growth (17.2%). Of the 24 samples cultured with bacteria, 15 samples had
Gram-negative bacteria (62.5%), only 37.5% had Gram-positive bacteria.
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Journal of military pharmaco-medicine no2-2018
According to data from the Vietnamese Ministry of Health, the leading cause of
hospital-acquired pneumonia is Gram-negative bacteria [1].
In our study, the most common bacterial cause of nosocomial pneumonia was
S. aeruginosa (24.1%). The results were consistent with those by Huynh Thi Ngoc Chi
et al (2012) [2]; Doan Ngoc Duy et al [3]: P. aeruginosa accounted for the highest
rate (16.7%).

3. Antibiotic resistance characteristics of some Gram-negative bacteria cause
nosocomial pneumonia in stroke patients.
Table 3: Antibiotic resistant characteristics of Pseudomonas aeruginosa.
Sensitive

Antibiotics

Resistant

Intermediate

Total

n

%

n

%

n

%

Gatifloxacin

0

0.0%

5

100%

0

0.0%

5

Gentamycin

0

0.0%

2

100%

0

0.0%

2

Imipenem

0

0.0%

3

100%

0

0.0%

3

Netilmycin

0

0.0%

4

100%

0

0.0%

4

Norfloxacin

0

0.0%

2

100%

0

0.0%

2

Ofloxacin

0

0.0%

3

100%

0

0.0%

3

Ticar/clavulanic

0

0.0%

6

100%

0

0.0%

6

Ticarcillin

0

0.0%

2

100%

0

0.0%

2

Tobramycin

0

0.0%

3

100%

0

0.0%

3

Trime/sulfamethoxazole

0

0.0%

1

100%

0

0.0%

1

Cefepime

1

14.3%

6

85.7%

0

0.0%

7

Levofloxacin

0

0.0%

5

83.3%

1

16.7%

6

Meropenem

1

16.7%

5

83.3%

0

0.0%

6

Ceftazindin

1

20.0%

4

80.0%

0

0.0%

5

Ciprofloxacine

1

33.3%

2

66.7%

0

0.0%

3

Aztreonam

0

0.0%

2

50.0%

2

50.0%

4

Piperacillin

1

25.0%

1

25.0%

2

50.0%

4

Pipe/tazobactam

5

83.3%

1

16.7%

0

0.0%

6

Amikacine

2

50.0%

0.0%

2

50.0%

4

Polymycin

3

100%

0

0.0%

0

0.0%

3

15

19.0%

57

72.2%

7

8.9%

79

Total

P. aeruginosa was resistant to > 80% with most antibiotics (14/20), 100% was
resistant to imipenem, norfloxacin. P. aeruginosa was sensitive to polymycin (100%),
piperacillin/tazobactam (83.3%) and amikacine (50%)
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Journal of military pharmaco-medicine no2-2018
Multidrug resistant P. aeruginosa is common in both domestic and international
studies [1, 3, 8, 12].
The carbapenem resistance leads to a return to colistin, an antibiotics of the
polymicin family. Many domestic and international studies have shown that
P. aeruginosa are highly susceptible to colistin: Tran Thi Thanh Nga (2010), Labarca et
al (2016) [11], Yayan (Germany, 2015).
Table 4: Characteristics of Klebsiella pneumoniae antibiotic resistant.
Antibiotics

Sensitive

Resistant

Intermediate
Total

n

%

n

%

n

%

Cefepime

0

0.0%

1

100%

0

0.0%

1

Cefpirome

0

0.0%

1

100%

0

0.0%

1

Cefurocime

0

0.0%

3

100%

0

0.0%

3

Ciprofloxacine

0

0.0%

2

100%

0

0.0%

2

Chloramphenicol

0

0.0%

1

100%

0

0.0%

1

Fosfomycin

0

0.0%

2

100%

0

0.0%

2

Tobramycin

0

0.0%

1

100%

0

0.0%

1

Amo + clavulanic acid

0

0.0%

3

75.0%

1

25.0%

4

Ceftriaxone

1

25.0%

3

75.0%

0

0.0%

4

Gatifloxacin

1

25.0%

3

75.0%

0

0.0%

4

Levofloxacin

1

33.3%

2

66.7%

0

0.0%

3

Cefotaxim

1

50.0%

1

50.0%

0

0.0%

2

Ceftazindin

1

25.0%

2

50.0%

1

25.0%

4

Ofloxacin

1

50.0%

1

50.0%

0

0.0%

2

Amikacine

2

66.7%

1

33.3%

0

0.0%

3

Aztreonam

1

33.3%

1

33.3%

1

33.3%

3

Doxyxylin

1

100%

0

0.0%

0

0.0%

1

Ertapenem

2

100%

0

0.0%

0

0.0%

2

Imipenem

1

100%

0

0.0%

0

0.0%

1

Meropenem

4

100%

0

0.0%

0

0.0%

4

Total

17

35.4%

28

58.3%

3

6.3%

48

In our study, K. pneumoniae was 100% resistant to 8/28 antibiotics, including
ciprofloxacin, cefpirome, cefuroxime. The bacterial had sensitivity 100% to doxycylin
and carbapenem antibiotics.
The antibiotic resistance of K. pneumoniae in our study was higher than in previous
studies. Le Thi Kim Nhung (Thong Nhat Hospital, 2008 - 2010) [7]: K. pneumoniae was
resistant to empiric antibiotics, including third generation cephalosporins, with levels of
resistance ranging from 18 - 38%. Ngo The Hoang (2012) studied the resistance of
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Journal of military pharmaco-medicine no2-2018
K. pneumoniae in nosocomial pneumonia indicating that P. pneumoniae was resistant

to most quinolones generation I - II and third generation cephalosporine 54.8 - 64.3%;
sensitivity to carbapenem antibiotics (imipenem sensitivity 90.5%; meropenem
sensitivity 97.6%) [5].
Many studies also show that K. pneumoniae is relatively sensitive to carbapenem
antibiotics [5, 7, 8].
Table 5: Antibiotic resistant characteristics of Acinetobacter baumannii.
Antibiotics

Sensitive

Resistant

Intermediate

Total

n

%

n

%

n

%

Aztreonam

0

0.0%

1

100%

0

0.0%

1

Doxyxylin

0

0.0%

1

100%

0

0.0%

1

Gentamycin

0

0.0%

1

100%

0

0.0%

1

Pipe/tazobactam

0

0.0%

1

100%

0

0.0%

1

Ticarcillin

0

0.0%

1

100%

0

0.0%

1

Cefepime

1

50.0%

1

50.0%

0

0.0%

2

Ceftazindin

1

50.0%

1

50.0%

0

0.0%

2

Ciprofloxacine

1

50.0%

1

50.0%

0

0.0%

2

Imipenem

1

50.0%

1

50.0%

0

0.0%

2

Levofloxacin

1

50.0%

1

50.0%

0

0.0%

2

Amikacine

1

100%

0

0.0%

0

0.0%

1

Cefotaxim

0

0.0%

0

0.0%

1

100%

1

Ceftriaxone

0

0.0%

0

0.0%

1

100%

1

Meropenem

1

50.0%

0

0.0%

1

50.0%

2

Piperacillin

0

0.0%

0

0.0%

1

100%

1

Rifampin

0

0.0%

0

0.0%

1

100%

1

Tobramycin

2

100%

0

0.0%

0

0.0%

2

Trime/sulfamethoxazole

1

100%

0

0.0%

0

0.0%

1

10

40.0%

10

40.0%

5

20.0%

25

Total

A. baumannii was resistant 100% to 5 antibiotics, including piperacillin/tazobactam.
For carbapenem antibiotics, A. baumannii was resistant 50%.
The rapid emergence of multidrug-resistant A. baumannii strains is becoming a
challenge for treatment. Multidrug-resistant status of this bacterium has been reported
in several studies [4, 12].
A. baumannii was resistant to the carbapenem group, which is one of the widest
spectrum of antibiotics currently available [4, 6, 8]. Not only in Vietnam, there are many
international reports about A. baumannii resistance to carbapenem [10, 11].
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Journal of military pharmaco-medicine no2-2018
CONCLUSION
In our study on 215 patients with stroke
at Department of Stroke, 103 Military
Hospital, we drew some conclusions:
- The incidence
pneumonia was 13.5%.

of

nosocomial

- Of 24 bacterial strains, 62.5% of
Gram-negative bacteria were cultured.
- P. aeruginosa was resistant to > 80%
with most antibiotics (14/20), resistance 100%
to imipenem, norfloxacin. P. aeruginosa was

sensitive to polymycin (100%); piperacillin/
tazobactam (83.3%) and amikacine (50%).
- K. pneumoniae was resistant 100%
to 8/21 antibiotics, including ciprofloxacin,
cefpirome, cefuroxime. K. pneumonia
sensitivity 100% to doxycylins and carbapenem
antibiotics.
A. baumannii was resistant 100% to
5 antibiotics, including piperacillin +
tazobactam. For carbapenem antibiotics,
A. baumannii was resistant to 50%.
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