Antimicrobial Resistance Patterns of Gram-Negative Bacilli Bloodstream Isolates - Research Paper Example

Antimicrobial Resistance Patterns of GNB Bloodstream Isolates Name Institution Table of Contents Table of Contents 2 1.0 Introduction 3 2.0 Methodology 4 3.0 Study Ranking 5 4.0 Critical Appraisal 6 4.1 Validity 6 4.2 Results 8 4.3 Clinical relevance 9 5.0 Conclusion 10 6.0 References 10 1.0 Introduction Antimicrobial resistance is the prime public health problem, particularly in developing nations, where there is relatively easy access to antibiotics and high medicine consumption (Kumar et al, 2013; Spellberg et al, 2013). As established by Khalili et al (2012), incidences of antibiotic resistance have risen rapidly over the past decade, with between 50 and 80 percent of the hospital-acquired infections resulting from the resistant strains. The contributing factors to the infections from the resistant microorganisms include the use of antibiotics (Mushi, 2013). Indeed, studies have established that antibiotic resistance are triggers for comorbidity, mortality, as well as higher cost of treatment (Magnet et al 2013; Tan et al, 2012; Gupta, 2011). Among the most significant causes of hospital infections are Gram-negative bacilli (GNB), which is a cause of early- and late-onset neonatal sepsis that has a high mortality rate (Toroglu et al, 2005). Apart from the innate and chromosomally mediated methods of resistance, the advancement of drug resistance in GNB is also encouraged by the acquisition of integrons, plasmids, and transposons that transmit resistance genes (Soge et al, 2009- Paterson, 2008). These genes are characteristically an outcome of selective antimicrobial strain compelled by long-term use of antibiotics. Hence, averting the increase of resistant organisms is vital for mitigating hospital infections. The incidence of antimicrobial resistance ranges in varied settings (Navaneeth & Belwadi, 2002). At the same time, past and current studies have indicating that information on the patterns of antimicrobial resistance is critical, specifically in hospitals (Paramythiotou et al, 2004; Velasco et al, 2012). To this end, the proposed question is: “what are the antimicrobial resistance patterns of GNB bloodstream isolates in a hospital and their potential causes to patients when significant changes take place?” The research question directs an inquiry into the antimicrobial resistance patterns in hospitals as this will help the healthcare practitioners to select appropriate antibiotic therapy that can improve reduce mortality and morbidity, reduce treatment care and improve treatment outcomes. 2.0 Methodology Data was mainly collected using Google search engine and search into open-access databases such as Google Scholar and Medline. The keywords employed for the search included antibiotic resistance, antimicrobial resistance, Gram-negative bacilli (GNB) among others. Articles targeted were those that combined observational and randomised controlled trial (RCTs), systematic review as well as those supporting, and not supporting the hypothesis. The search was primarily performed for relevant information within the context of developing countries, based on the assumption that health-care associated and nosocomial infections are associated with high mortality and morbidity rates among patients in hospitals in developing nations, as established by Kumar et al (2013). The articles searched were those that primarily published within the last ten years. The criterion was based on the assumption that antibiotic resistance has increased rapidly over the last decade. Accordingly, articles searched were peer-reviewed scholarly literature published between 2004 and 2014. As expected, the critical research barrier comprised the limited number of publications relevant to the research question. Overall, the search yielded 17 articles, out of which 5 were selected from critical appraisal. Evaluation of the articles for appropriateness was through Hillier’s et al (2011) FORM framework. In using the framework, the areas explored included the level of evidence in the literature, the level of evidence base, the validity of the findings, the generalisability of the results and the applicability of the results. Critical Appraisal Skills Program (CASP) was applied to critically appraise the five articles (Oxman et al, 1994; Burls, 2009). 3.0 Study Ranking Table 1: Studies ranked based on FORM Studies selected Rank Evidence base Consistency Clinical Impact Generalisability Applicability Godebo et al (2014) 1 A A A A A Wong et al (2012) 2 A A A B A Sharif et al (2013) 3 B B A B A Khalili et al (2012) 4 B B A B A Sani et al (2012) 5 B B A B A Table 2: Definition of grades (Hillier et al, 2011) 4.0 Critical Appraisal Critical Appraisal Skills Program (CASP) framework was used to examine the validity, results, and clinical relevance of the five selected articles. 4.1 Validity Sharif et al (2013) studied Gram-negative bacterial resistance of, ceftazidime and imipenem in patient samples at Shahid Beheshti Hospital between in the period 2011-2012. Data from 1041 patients were examined. The large number of patients explored makes the study generalisable. Sharif et al (2013) used only current research data published between 2009 and 2011. Only 28 articles were reviewed in the study. These limit the comprehensiveness and objectivity of the study. While there is a link between the research question and hypothesis, there may be a level of bias as only positive articles were used. Khalili et al (2012) examined antibiotic resistance of Gram-negative bacteria from nosocomial infections during a 6-month period. The study was conducted at Shariati teaching hospital in Tehran, Iran. Khalili et al (2012) also performed systematic review of literature to substantiate the validity of his research. However, unlike Sharif et al (2013), Khalili et al (2012) used both current and past research data of between the years 1996 and 2010. This gives the study a deeper insight into antibiotic resistance of Gram-negative bacteria. Still, Sharif et al (2013) used on 18 peer-reviewed articles, which gives it limited neutrality and comprehensiveness. Still, the articles reviewed are relevant to the research topic. Wong et al (2012) examined antimicrobial co-resistance patterns of GNB isolated from bloodstream infections of hospitalised patients in three hospitals: hospitals in Greater Vancouver, Canada. Like Khalili et al (2012) and Sharif et al (2013), systematic review of literature was used to substantiate the validity of his research. Only 17 past and current peer-reviewed articles were reviewed, which gives the study limited neutrality and comprehensiveness. Sani et al (2012) investigated antibiotics resistance profiles of bacteria from surgical wounds in four hospitals in Niger State. Sani et al (2012) also used systematic review of literature just like Sharif et al (2013) and Khalili et al (2012). Only 15 peer-reviewed articles were examined published between 1987 and 2009. Despite the limited number of articles, this gave the study a deeper insight into antibiotic resistance of Gram-negative bacteria. The articles reviewed are also relevant to the research topic. Godebo et al (2014) investigated multidrug-resistance rates of gram-positive and gram-negative bacteria isolates that cause wound infections. The researchers reviewed 35 peer-reviewed literatures, both current and past, spanning 1976-2012. These gave the study broader scope of review, greater objectivity and deeper insight into antibiotic resistance of Gram-negative bacteria. 4.2 Results Sharif et al (2013) established that the resistance rates of ceftazidime and cefepime exceeded 50 percent in a majority of the organisms. Sharif et al (2013) also found that Gram-negative bacteria were greatly resistant to three broad-spectrum antibiotics. Sharif’s et al (2013) results are valid as they are consistent with the studies reviewed and the hypothesis. Still, the fact that there was a risk of bias implies that the results may not be absolutely valid. At any rate, Sharif et al (2013) conducted a follow-up study, which validate his results. Khalili et al (2012) performed susceptibility tests on 570 Gram-negative isolates acquired from clinical samples of patients infected after at stay in hospital for more than 72 and established Escherichia coli as the most highly frequently isolated Gram-negative organism. They further established that patients in Intensive Care Units had the highest rates of resistance in Gram-negative isolates. Acinetobacter spp. was found to be the most resistant organisms. Khalili’s et al (2012) findings reflect findings from literature review. These shows the results are valid. The research design used was also appropriate for the study, which gives the results empirical basis. Wong et al (2012) did a 10-year retrospective study between 2002 and 2011 to analyse bloodstream infections with GNB. Wong et al (2012) established increased resistance to antibiotics (for E. cloacae, K. pneumoniae, E. coli, P. Aeruginosa and K. Oxytoca) partly be linked to antimicrobial consumption. For instance, E. coli resistance to Ciprofloxacin resistance started in 2002 peaked in 2006 at 40 before stabilizing at 29 percent in 2011. The longitudinal method of studies and use of controlled group imply that Wong’s et al (2012) results are more valid compared to Khalili et al (2012) and Sharif et al 92013. Sani et al (2012) used 800 samples from hospitalised patients and established that E. coli, S. aureus and Strept. pyogenes had high resistance to antibiotics. The limited number of literature reviewed and the short-term research design used imply that Sani et al (2012) results are less valid compared to Wong’s et al (2014), Khalili et al (2012) and Sharif et al (2013). Godebo et al (2014) used cross-sectional study to investigate 322 wound samples of hospitalised patients. Godebo et al (2014) found that the rate of MDR bacterial pathogens causing infection were prevalent, with many isolates identified as resistant to multiple classes of antimicrobials. Overall, proteus species were the leading isolates followed by P.aeruginosa and S.aureus in that order. The results are valid as they are consistent with the studies reviewed and the hypothesis. There cross-sectional study limits occurrence of bias, which indicates the results are absolutely valid. 4.3 Clinical relevance Sharif’s et al (2013) results are applicable for the decisions being made for the patients who may develop antibiotic resistance. This means that there is no difference exists between participation in trial and the patients targeted for the results. Ultimately, Sharif’s et al (2013) results have high clinical relevance. Wong’s et al (2012), Sani et al (2012) and Khalili’s et al (2012) results, like Godebo et al (2014), relate to the decisions to be made regarding the patients who develop antibiotic resistance in hospital settings. The researchers also indicated the population of study. Therefore, means that there is no clear difference between participants in trial and the patients surveyed by the study for the results. Therefore, the results have clinical relevance. 5.0 Conclusion Godebo et al (2014) is the highest ranked study, as it has high evidence base, high consistent, highly generalisable and high clinical relevant or applicability. The same applies for Wong et al (2012) study, except that it is less generalisable. Responding to the research question, it is concluded that increased resistance to antibiotics (for E. cloacae, K. pneumoniae, E. coli, P.aeruginosa, S.aureus, P. Aeruginosa and K. Oxytoca) is linked to antimicrobial consumption. These isolates are also resistant to multiple classes of antimicrobials. The findings can be applied in policing to determine appropriate antibiotics for use, reduce mortality and morbidity, reduce treatment care, and improve treatment outcomes. An underlying research gap is the limited generalisability of the studies used due to limited geographical scope. Therefore, there is a need for cross-sectional and longitudinal studies that examine antimicrobial resistance patterns of GNB bloodstream isolates in a hospital and their potential causes to patients when significant changes take place. 6.0 References Burls. A. (2009). What is Critical Appraisal? Oxford: Hayward Group Godebo, G., Kibru, G. & Tassew, H. (2014). Multidrug-resistant bacterial isolates in infected wounds at Jimma University Specialized Hospital, Ethiopia. Annals of Clinical Microbiology and Antimicrobials, 12(1), 17 Gupta, K., Hooton T., Naber K., Wullt, B., Colganm R., Miller L.,, Moran G., Nicolle L., Raz, R,, Schaeffer A., Soper, D. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Disease, 52(5):e103-120. Hillier, S., Grimmer-somer, K., Merlin, T. et al. (2011). FORM: An Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology 11(23), 1-11 Khalili, H., Soltani, R., Afhami, S., Dashti-Khavidaki, S. & Alijani, B. (2012). Antimicrobial resistance pattern of Gram-negative bacteria of nosocomial origin at a teaching hospital in the Islamic Republic of Iran. 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