Int J Biol Med Res.

2012; 3(2):1651-1654
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Original article
A clinico-microbiological study of ventilator-associated pneumonia in a tertiary
care hospital
R.M. Saldanha Dominic*a, H.V. Prashanth b , Shalini Shenoy c , Shrikala Baliga d
*
a Associate Professor, Dept. of Microbiology, Kasturba , Medical College, Mangalore- 575001
b
Professor, Dept. of Microbiology, Sri Siddhartha Medical College, Tumkur- 572107
c
Professor, Dept. of Microbiology, Kasturba Medical College, Mangalore- 575001
d
Professor and Head, Dept. of Microbiology, Kasturba Medical College, Mangalore- 575001

ARTICLE INFO ABSTRACT

Keywords: Ventilator-associated pneumonia (VAP) is one of the commonest nosocomial infection

Ventilator-associated pneumonia occurring in mechanically ventilated patients in the ICU. It continues to complicate the course
Pseudomonas
Acinetobacter of 7% to 41% of patients receiving continuous mechanical ventilation.This prospective study
was done to determine the etiological agents of VAP and assess their antibiotic susceptibility
patterns. Semi-quantitative culture of endotracheal aspirates of patients with VAP was done. In
our study, 59 patients of 153 mechanically ventilated patients developed VAP. Among the
causative agents, Pseudomonas, Acinetobacter and Staphylococcus aureus were found to be the
commonest etiological agents in patients with VAP. Ninety-two isolates in patients with VAP
were found to be multi-drug resistant pathogens. Early and appropriate antimicrobial therapy
is an important goal in the setting of life-threatening infections, taking into account factors that
modulate bacterial ecology and the susceptibility of causative organisms which is crucial for
optimal management.

c Copyright 2010 BioMedSciDirect Publications IJBMR -ISSN: 0976:6685. All rights reserved.

1. Introduction
Ventilator-associated pneumonia (VAP) is defined as
pneumonia occurring more than 48 hours after the initiation of
endotracheal intubation and mechanical ventilation (MV)
including pneumonia developing even after extubation [1]. Inspite
of the advances in the diagnosis, treatment and prevention of VAP, it
continues to complicate the course of 7% to 41% of patients
receiving continuous mechanical ventilation and is a major cause of
morbidity and mortality among critically ill patients [2, 3, 4].
Accurate data on etiologic agents and the epidemiology of VAP are
limited by the lack of a 'gold standard' for diagnosis. However,
regardless of the diagnostic technique used, there have been
dramatic variations in the distribution of pathogens and drug
resistance patterns. Because early and appropriate antimicrobial
therapy is an important goal in the setting of life-threatening
infections, taking into account factors that modulate bacterial
ecology and the susceptibility of causative organisms is crucial for
optimal management [5]. Prompt distribution of appropriate
antibiotics seems to be the only intervention that alters outcome
* Corresponding Author : Dr. R.M. Saldanha Dominic
Associate Professor,
Dept. of Microbiology, Kasturba
Medical College, Mangalore- 575001
Mobile: +919845278907
E.mail: drdoms@hotmail.com
c
Copyright 2010 BioMedSciDirect Publications. All rights reserved.
once the diagnosis is established. The aims of this prospective
study were to study the bacterial agents associated with VAP and
their antibiotic sensitivity patterns in the intensive care unit (ICU).
2. Materials and Methods:
The study was conducted at the Diagnostic Laboratory,
Kasturba Medical College (K.M.C.) Hospital, Ambedkar Circle,
Mangalore. The study population included the patients admitted
for ventilator care in the ICU of K.M.C. Hospital, Ambedkar Circle
and Attavar, and the neonatal intensive care unit of Government
Lady Goschen Hospital, Mangalore. All the adult and newborn
patients on mechanical ventilation for more than 48 hours were
included in the study. Data collection at the time of admission to the
ICU included admission date to ICU, age, gender, primary
diagnosis, date of initiating mechanical ventilation, underlying
diseases and surgical procedures. Other data collected included
details of antibiotic therapy, steroid usage, duration of hospital
stay, neurological disorders and impaired consciousness. Other
clinical criteria for diagnosis of VAP included modified clinical
pulmonary infection score (CPIS) > 6 (Table 1) [6] and
microbiological criteria included a positive Gram stain (> 10
polymorphonuclear cells/ low power field and > 1 bacteria/ oil
immersion field with or without the presence of intracellular
bacteria) and quantitative endotracheal aspirate culture showing
 R.M. Saldanha Dominic et.al / Int J Biol Med Res. 2012; 3(2):1651-1654
1652

> 105 CFU/ ml [7, 8, 9].Based on the clinical and microbiological criteria, 59 out of 153 patients admitted were diagnosed with VAP. The
organisms isolated by quantitative culture of endotracheal aspirate [10] (EA) from VAP patients were isolated and identified by standard
microbiological techniques [11]. Antimicrobial susceptibility of the clinical isolates to routinely used antibiotics was determined by Kirby-
Bauer disk diffusion method [12]. The oxacillin screen agar test [13] and the combination disk method [14] using cefotaxime and ceftazidime
alone and in combination with clavulanic acid were used to detect methicillin resistant Staphylococcus aureus (MRSA) and extended
spectrum β- lactamase (ESBL) producing members of the family Enterobacteriaceae. VAP pathogens, such as Pseudomonas spp.,
Acinetobacter spp. Enteric gram negative bacilli expressing ESBL and MRSA were defined as multi-drug resistant (MDR) pathogens [15].
Statistical analysis was carried out using the Chi-square test and the level of significance was set at P < 0.05.

3. Results
A total of 153 patients comprising 69 in the adult age group and 84 in the pediatric age group who were on ventilator therapy were taken
up for the study.
3.1. Incidence
Fifty nine patients fulfilled the criteria for the diagnosis of VAP and the growth obtained by culture fulfilled the cut-off threshold of 105
CFU/ml, showing an overall incidence of 38.56% (59 cases). In the pediatric category, 33 (55.93%) cases and in the adult category 26
(44.07%) cases developed VAP. Neonates accounted for 25 (40.32%) cases of VAP (Table 2). Males accounted for 37 (62.71%) cases and
females 22 (37.29%) cases of VAP.

Table 1: Modified Clinical Pulmonary Infection Score (CPIS) [6]

CPIS points 0 1 2
Temperature (°C) ≥36.5 and ≤38.4 ≥38.5 and ≤38.9 ≥39 and ≤36

Leucocyte count (per mm3) 4000- 11000 < 4000 or > 11000 < 4000 or > 11000
+ band forms ≥500
Tracheal secretions Rare Abundant Abundant + Purulent
PaO2/ FiO2 mm Hg >240 or ARDS -

Chest radiograph No infiltrate Diffuse infiltrate

Culture of tracheal aspirate
≤240 and no ARDS
Light growth Moderate or heavy growth
Localized infiltrate
or no growth of pathogenic bacteria
Moderate or heavy growth of
pathogenic bacteria
and presence of the same
bacteria in Gram stain

Table 2: Age incidence and sex distribution of VAP

Age group Total patients Patients Males Females Incidence

on ventilator with VAP number (%) number (%) (%)
0 – 1 month 62 25 19 (76.00) 6 (24.00) 40.32

>1 month-<1 year> 81 2

2 (100.00) 0 (0.00) 25.00
1 year- <18 years> 45 6

18 years-< 65 years> 61 23 3 (50.00) 3 (50.00) 42.86

65 years 31 3
11 (47.83) 12 (52.17) 41.07
53 59
Total (%) 2 (66.67)62.71 1 (33.33) 23.08

37.29

Under 3.1.Incidence- ≥symbol to be included before 105

 R.M. Saldanha Dominic et.al / Int J Biol Med Res. 2012; 3(2):1651-1654
1653

Table 3: Bacterial isolates from endotracheal aspirates in VAP 3.6.Outcome:

patients
A total of 19 patients in our study with VAP expired accounting
for a mortality rate of 32.2%. Among 25 neonates with VAP, 9
Bacterial isolates* Number Percentage (%)
(36%) expired.
Gram negative bacilli 33 18.86 4. Discussion
-Staphylococcus aureus 23 13.14 VAP is an important nosocomial infection in patients on
mechanical ventilation in ICUs. The overall incidence of VAP in our
- Staphylococcus epidermidis 2 1.1
study was 38.56%.This was marginally higher than the incidence
Streptococcus pneumoniae 4 2.2 of 37% reported by Gadani et al [16] in a study of 37 patients on
- Enterococcus spp. 4 2.2 ventilator therapy. This could be due to the fact that our study
Gram positive cocci : 142 81.14
included patients in the pediatric age group as well as adults. A
probable reason for the marginally higher incidence of VAP in our
- Klebsiella spp 27 15.43
study could be that new born patients (neonates) constituted the
Acinetobacter spp 18 10.28 majority of cases of VAP among the pediatric age group with an
Citrobacter spp 13 7.43 incidence of 40.32%. The immune systems and immune
mechanisms are not well developed in neonates thereby placing
-Escherichia coli, 6 3.43
them at a higher risk of infection.
- Haemophilus influenzae 4 2.29
In our study, duration of mechanical ventilation and prior
Streptococcus pneumoniae 2 1.14
antibiotic therapy were statistically significant risk factors for
- Pseudomonas 72 41.14 development of VAP. Studies on VAP [16, 17] have also highlighted
similar findings. Reducing the duration of mechanical ventilation
* Total number of bacterial isolates – 175 significantly shortens hospital stay and hence subsequent risk of
3.2.Risk factors exposure of patients to MDR pathogens. A proper weaning
protocol effectively administered can reduce the duration of
Statistical analysis revealed duration of mechanical ventilation
ventilation. A once-daily trial of spontaneous breathing and a
and administration of prior antibiotic therapy as significant risk
prolonged period of rest may be the most effective methods of
factors for VAP caused particularly by multi-drug resistant (MDR)
weaning to recondition respiratory muscles that may have been
pathogens.
weakened during mechanical ventilation [18 ,19]. The judicious
3.3.Microbial etiology selection of patients for antibiotic therapy needs to be emphasized.
A total of 175 bacterial isolates (Table 3) were obtained from Use of antibiotics as a prophylactic measure against VAP is not
the endotracheal aspirate of VAP patients in which the commonest recommended as prior exposure to antibiotics is a significant risk
bacterial isolates were gram negative bacilli (81.14%). factor for colonization and infection with nosocomial MDR
Pseudomonas accounted for 41.14% followed by Klebsiella species pathogens as observed in other studies [1, 20, 21]. The rational use
(15.43%), Acinetobacter species (10.28%) and E. coli (3.43%). of appropriate antibiotics may reduce patient colonization and
Staphylococcus aureus (13.14%) was the commonest among the subsequent VAP with MDR pathogens. Hospitalization needn't be
gram positive isolates. prolonged if deemed unnecessary.

3.4.Antibiotic sensitivity patterns:
Pseudomonas was found to be most sensitive to Amikacin
(52.78%) and Ceftazidime (47.22%), Klebsiella was most sensitive
to Amikacin (66.67%) and Ciprofloxacin (59.26%), Acinetobacter
was most sensitive to Chloramphenicol (50%) and Amikacin
(38.89%), E. coli was most sensitive to Amikacin and Ciprofloxacin
(50% each). Staphylococcus aureus was found to be most sensitive
to Vancomycin and Rifampicin (100% each).
3.5.MDR pathogens
Ninety two (52.57%) of the 175 isolates from VAP patients
were found to be MDR pathogens. These included 16 isolates
(59.26%) of ESBL producing Klebsiella, 5 isolates (83.33%) of
ESBL producing E. coli, 43 isolates (59.72%) of multi-drug
resistant Pseudomonas, 12 isolates (66.67%) of multi-drug
resistant Acinetobacter and 16 isolates of MRSA.
The majority of bacterial isolates in our study were gram
negative bacilli-81.14%; Pseudomonas species accounted for
41.14%, Klebsiella species (15.43%), Acinetobacter species
(10.28%), E. coli (3.43%). Staphylococcus aureus (13.14%) was
predominant among gram positive isolates. Pseudomonas species
which common nosocomial pathogens have been identified in the
respiratory therapy equipment, disinfectants, sinks, etc. Because
of its hardiness and ability to capitalize on breakdowns in human
antimicrobial defences, it is a common nosocomial pathogen.
Our findings with reference to etiology of VAP are on similar lines
to various other studies [22, 23, 24]. Airway intubation is
associated with increased frequency of gram negative bacterial
colonisation of upper and lower respiratory tract followed by rapid
growth of these gram negative bacteria and pneumonia. Several
studies have reported that more than 60% of nosocomial
 R.M. Saldanha Dominic et.al / Int J Biol Med Res. 2012; 3(2):1651-1654
pneumonias are caused by aerobic gram negative bacilli. P.
aeruginosa and other gram negative bacterial species adhere five
times better to buccal cells of severely ill patients than to cells of
normal and similar level of increased adherence has been
demonstrated for critically ill patients' tracheal epithelial cells
[25]. These gram negative aerobes also reflect in organisms with
drug resistance and their ability to survive in the hospital
environment.
In our study, 92 isolates (52.57%) from VAP patients were
found to be MDR pathogens. These included Pseudomonas,
Acinetobacter and MRSA. In addition, ESBL producing strains of
Klebsiella and E. coli were also isolated. Though our findings are
significantly lower than other studies17, the etiology of VAP by
MDR pathogens remains the same. This reinforces the need for
vigilance in taking preventive measures against VAP.
The mortality rate in our study on VAP was 32.2% with neonates
and elderly above 65 years accounting for a majority of deaths. A
poorly developed immune system and waning of immune defence
mechanisms in the neonates and elderly respectively could explain
t h e r e a s o n s f o r p o o r r e c o v e r y f r o m V A P.
5. Conclusions
Vigilance is required for patients admitted in the ICU and on
mechanical ventilation. The endotracheal aspirate of patients on
mechanical ventilation should be sent for routine culture and
sensitivity. In case the patient develops VAP, antibiotic to be used
needs to be changed as per sensitivity reports. It should also be
kept in mind that VAP can be caused by MDR pathogens. Therefore,
in addition to aseptic precautions while handling ventilated
patients and adequate preventive measures to minimize risk
factors, the choice of antibiotics should be guided by the sensitivity
patterns of the involved pathogens. This can significantly improve
the outcome for mechanically ventilated patients.
Acknowledgements
The authors acknowledge the assistance provided by Dr. T.V.
Shenoy, Professor, Department of Anaesthesia, K.M.C. Mangalore
in providing the necessary inputs during the conduct of the study.
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