High antibiotic resistance and mortality with Acinetobacter species in a tertiary hospital, Nepal

A nursing and midwifery training program in Kathmandu on antimicrobial resistance and stewardship and infection prevention and control: a qualitative and quantitative outcomes and process evaluation

Background

Low- and middle-income countries (LMICs) are disproportionately affected by antimicrobial resistance (AMR). Nurses and midwives are essential to a holistic approach to AMR stewardship (AMS) and IPC within LMICs.

Objective

(1) Adapt AMS and IPC training programs and practice guidelines for community- and hospital-based nurses and midwives in Nepal; (2) pilot and conduct training outcome and process evaluations.

Design

A one-day training was developed through partnerships between Henry Ford Health and nursing and midwifery organizations and teaching facilities in Nepal. Quantitative outcome and process evaluations were conducted. Qualitative process evaluation interviews were conducted with purposefully selected trainees.

Settings

Trainees worked in healthcare facilities in Kathmandu Valley.

Participants

A total of 126 nurses and midwives participated in the training and the quantitative evaluation. Eighteen trainees participated in the process evaluation interviews.

Methods

The 10-module program was adapted from AMS and IPC materials from the World Health Organization and the Nepal Ministry of Health and Population, and curricula from previous AMS studies in Nepal. Key outcomes were AMS and IPC knowledge, and decision-making about empirical dispensing of antibiotics. The process evaluation focused on training content, integration into practice, implementation barriers, and recommendations for dissemination. Quantitative data analysis included descriptive and bivariate analysis. Qualitative data analysis included coding, searches, review of coded texts, and identification of patterns and themes.

Results

AMS and AMR knowledge increased at immediate [1.40 (1.06-1.74) CI 95%] and six-month post-training [0.71 (0.35-1.08) CI 95%]. IPC knowledge also increased at immediate [0.79 (0.55-1.03) CI 95%] and six-month post-training [0.72 (0.49-0.96) CI 95%]. At immediate post-training, an increasing number of respondents indicated that they would not dispense antibiotics for adults [14.74% (4.88, 24.60%) CI 95%] and children [8.13% (-1.88, 18.14%) CI 95%] with fever and sore throats, and for non-pregnant women with burning sensation when urinating [10.69% (0.68%, 20.71%) CI 95%]. Process evaluation data indicated positive responses to the training content and relevancy to practice.

Conclusion

The AMS-IPC training increased knowledge and decreased intentions for dispensing antibiotics. Participants provided concrete examples of implementation of learnings into practice. Trainings will be adapted to address identified content needs and challenges to implementation.

Antibiotic resistance: a global crisis, problems and solutions

Healthy state is priority in today's world which can be achieved using effective medicines. But due to overuse and misuse of antibiotics, a menace of resistance has increased in pathogenic microbes. World Health Organization (WHO) has announced ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) as the top priority pathogens as these have developed resistance against certain antibiotics. To combat such a global issue, it is utmost important to identify novel therapeutic strategies/agents as an alternate to such antibiotics. To name certain antibiotic adjuvants including: inhibitors of beta-lactamase, efflux pumps and permeabilizers for outer membrane can potentially solve the antibiotic resistance problems. In this regard, inhibitors of lytic domain of lytic transglycosylases provide a novel way to not only act as an alternate to antibiotics but also capable of restoring the efficiency of previously resistant antibiotics. Further, use of bacteriophages is another promising strategy to deal with antibiotic resistant pathogens. Taking in consideration the alternatives of antibiotics, a green synthesis nanoparticle-based therapy exemplifies a good option to combat microbial resistance. As horizontal gene transfer (HGT) in bacteria facilitates the evolution of new resistance strains, therefore identifying the mechanism of resistance and development of inhibitors against it can be a novel approach to combat such problems. In our perspective, host-directed therapy (HDT) represents another promising strategy in combating antimicrobial resistance (AMR). This approach involves targeting specific factors within host cells that pathogens rely on for their survival, either through replication or persistence. As many new drugs are under clinical trials it is advisable that more clinical data and antimicrobial stewardship programs should be conducted to fully assess the clinical efficacy and safety of new therapeutic agents.

Carbapenem Resistance in Acinetobacter calcoaceticus-baumannii Complex Isolates From Kathmandu Model Hospital, Nepal, Is Attributed to the Presence of bla OXA-23-like and bla NDM-1 Genes

The Acinetobacter calcoaceticus-baumannii (ACB) complex, also known as ACB complex, consists of four bacterial species that can cause opportunistic infections in humans, especially in hospital settings. Conventional therapies for susceptible strains of the ACB complex include broad-spectrum cephalosporins, β-lactam/β-lactamase inhibitors, and carbapenems. Unfortunately, the effectiveness of these antibiotics has declined due to increasing rates of resistance. The predominant resistance mechanisms identified in the ACB complex involve carbapenem-resistant (CR) oxacillinases and metallo-β-lactamases (MBLs). This research, conducted at Kathmandu Model Hospital in Nepal, sought to identify genes associated with CR, specifically blaNDM-1, blaOXA-23-like, and blaOXA-24-like genes in carbapenem-resistant Acinetobacter calcoaceticus-baumannii (CR-ACB) complex. Additionally, the study is aimed at identifying the ACB complex through the sequencing of the 16s rRNA gene. Among the 992 samples collected from hospitalized patients, 43 (approximately 4.334%) tested positive for the ACB complex. These positive samples were mainly obtained from different hospital units, including intensive care units (ICUs); cabins; and neonatal, general, and maternity wards. The prevalence of infection was higher among males (58.14%) than females (41.86%), with the 40-50 age group showing the highest infection rate. In susceptibility testing, colistin and polymyxin B exhibited a susceptibility rate of 100%, whereas all samples showed resistance to third-generation cephalosporins. After polymyxins, gentamicin (30.23%) and amikacin (34.88%) demonstrated the highest susceptibility. A substantial majority (81.45%) of ACB complex isolates displayed resistance to carbapenems, with respiratory and pus specimens being the primary sources. Polymerase chain reaction (PCR) revealed that the primary CR gene within the ACB complex at this hospital was bla OXA-23-like, followed by bla NDM-1. To ensure the accuracy of the phenotypic assessment, 12 samples were chosen for 16s rRNA sequencing using Illumina MiSeq™ to confirm that they are Acinetobacter species. QIIME 2.0 analysis confirmed all 12 isolates to be Acinetobacter species. In the hospital setting, a substantial portion of the ACB complex carries CR genes, rendering carbapenem ineffective for treatment.

Assessment of Antibiotic Resistance among Clinical Isolates of Enterobacteriaceae in Nepal

Clinicians face a global challenge treating infections caused by Enterobacteriaceae because of the high rate of antibiotic resistance. This cross-sectional study from the Nepal Armed Police Force Hospital, Kathmandu, Nepal, characterized resistance patterns in Enterobacteriaceae across different antimicrobial classes and assessed incidences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) infections. Enterobacteriaceae from clinical samples were isolated on blood and MacConkey agar, except for urine samples on cysteine lactose electrolyte-deficient agar. To determine antimicrobial susceptibility patterns, including MDR and XDR, the Kirby-Bauer disc diffusion method was used. Statistics were performed using SPSS, v. 17.0. Members of the family were identified in 14.5% (95% CI: 16.2-12.8%) of the total samples (N = 1,617), primarily in urine (54.7%, 128/234), blood (19.7%, 46/234), and sputum (15.0%, 35/234). Escherichia coli (n = 118, 44.2%) was the most predominant bacteria, followed by Citrobacter freundii (n = 81, 30.3%). As much as 95.6% (392/410) of the isolates were penicillin-resistant, whereas only 36.2% (290/801) were carbapenem-resistant. A total of 96 (36.0%) MDR and 98 (36.7%) XDR Enterobacteriaceae were identified. Proteus mirabilis (44.4%, 8/18) predominated MDR cultures, whereas C. freundii (53.1%, 43/81) predominated XDR cultures. Multidrug resistant (38.4%, 71/154) and XDR Enterobacteriaceae (22.7%, 35/154) were chiefly uropathogens. Fluoroquinolone resistance rates in non-MDR, MDR, and XDR isolates were 19.9%, 63.2%, and 96.2%, respectively, whereas cephalosporin resistance rates were 28.6%, 72.9%, and 95.4% and penicillin resistance rates were 67.0%, 97.4%, and 98.0%. One-seventh of patients visiting the hospital were found to be infected with Enterobacteriaceae, and of these patients, at least one-fourth were infected with MDR strains.