Prevalence and risk factors for drug resistance in patients with lower respiratory infections in Healthcare Associated Infection: a single centre study from Eastern India

C. Mohan Rao, Saswat Subhankar, Sujit Pradhan, Debee Prasad Dash


Background: Healthcare Associated Infections (HCAI) are associated with longer hospitalisations and increased morbidity and mortality. Lower respiratory infections including Pneumonia is an entity among healthcare associated infections mostly witnessed in nursing home residents, patients on long term care and patients receiving home or hospital based intravenous therapy and undergoing dialysis. Aim of the study to assess the prevalence and risk factors of resistance among the patients developing lower respiratory infections as a consequence of Healthcare Associated Infection.

Methods: The study was conducted as a prospective cohort model. All the eligible patients were subjected to detailed history taking, clinical examination, laboratory and radiological investigations. All the categorical parameters were compared using Fisher’s exact test. Continuous parameters were compared using independent t-test. All the statistical analysis was carried out using the software Stata 15.1.

Results: Majority of the patients were older than 60 yrs (73%). Death was significantly seen in persons under 60 years and associated pulmonary consolidation equal to or more than three zones (p<0.05). Klebsiella spp (20.95%), and Acinetobacter (6.1%) were most commonly isolated. Multi-drug and extensive drug resistance were encountered among these organisms. Male gender, immune-compromised patients, bilateral pulmonary involvement and hospitalisation for at least 48 hours in preceding 90 days were associated with isolation of MDR organism.

Conclusions: Lower respiratory infection is an important component of healthcare associated infections. It needs targeted antibiotic therapy covering MDR organisms prevalent in the local population. Data from different institutions to corroborate findings regarding antibiotic resistance pattern of the microbes is recommended.


Extensive drug resistance, Healthcare, Infections, Klebsiella, Acinetobacter, Multi-drug resistance

Full Text:



American Thoracic Society. Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416.

Ewig S, Welte T, Chastre J, Torres A. Rethinking the concepts of community-acquired and health-care-associated pneumonia. Lancet Infect Dis. 2010 Apr 1;10(4):279-87.

Brito V, Niederman MS. Healthcare-associated pneumonia is a heterogeneous disease, and all patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial pneumonia. Curr Opinion Infect Dis. 2009;22(3):316-25.

World Health Organization. Antimicrobial resistance: global report on surveillance. World Health Organization; 2014.

Mohan B, Prasad A, Kaur H, Hallur V, Gautam N, Taneja N. Fecal carriage of carbapenem-resistant Enterobacteriaceae and risk factor analysis in hospitalised patients: A single centre study from India. Ind J Med Microbiol. 2017;35(4):555.

Infectious Diseases Society of America (IDSA), Spellberg B, Blaser M, Guidos RJ, Boucher HW, Bradley JS, et al. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis. 2011. 52(Suppl 5):S397-S428.

Sievert DM, Ricks P, Edwards JR, Schneider A, Patel J, Srinivasan A, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010. Infect Control Hospital Epidemiol. 2013 Jan;34(1):1-4.

Rosón B, Carratala J, Fernández-Sabé N, Tubau F, Manresa F, Gudiol F. Causes and factors associated with early failure in hospitalized patients with community-acquired pneumonia. Archi Internal Med. 2004;164(5):502-8.

Slinin Y, Foley RN, Collins AJ. Clinical epidemiology of pneumonia in hemodialysis patients: the USRDS waves 1, 3, and 4 study. Kidney Intern. 2006;70(6):1135-41.

Guo H, Liu J, Collins AJ, Foley RN. Pneumonia in incident dialysis patients-the United States renal data system. Nephrol Dialysis Transplant. 2007;23(2):680-6.

Shindo Y, Sato S, Maruyama E, Ohashi T, Ogawa M, Hashimoto N, et al. Health-care-associated pneumonia among hospitalized patients in a Japanese community hospital. Chest. 2009 Mar 1;135(3):633-40.

Micek ST, Kollef KE, Reichley RM, Roubinian N, Kollef MH. Health care-associated pneumonia and community-acquired pneumonia: a single-center experience. Antimicrob Agents Chemoth. 2007;51(10):3568-73.

Falcone M, Venditti M, Shindo Y, Kollef MH. Healthcare-associated pneumonia: diagnostic criteria and distinction from community-acquired pneumonia. Intern J Infect Dis. 2011;15(8):e545-50.

Carratala J, Mykietiuk A, Fernandez-Sabe N, Suarez C, Dorca J, Verdaguer R, et al. Health care-associated pneumonia requiring hospital admission. Arch Intern Med. 2007;167:1393-9.

Venditti M, Falcone M, Corrao S, Licata G, Serra P, and the Study Group of Italian Society of Internal Medicine. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med. 2009;150:19-26.

Kollef MH, Shorr A, Tabak YP, Gupta V, Liu LZ, Johannes RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005 Dec 1;128(6):3854-62.

D'Agata EM. Rapidly rising prevalence of nosocomial multidrug-resistant, Gram-negative bacilli: a 9-year surveillance study. Infect Control Hospital Epidemiol. 2004;25(10):842-6.

Centers for Disease Control and Prevention. Antibiotic resistance threats in the united states, 2013. Available at: Accessed 29 Mar 2016.

Calfee D, Jenkins SG. Use of active surveillance cultures to detect asymptomatic colonization with carbapenem-resistant Klebsiella pneumoniae in intensive care unit patients. Infect Control Hospital Epidemiol. 2008;29(10):966-8.

Papadimitriou-Olivgeris M, Marangos M, Fligou F, et al. Risk factors for KPC-producing Klebsiella pneumoniae enteric colonization upon ICU admission. J Antimicrob Chemother. 2012;67:2976-81.

Wattal C, Goel N, Oberoi JK, Raveendran R, Datta S, Prasad KJ. Surveillance of multidrug resistant organisms in tertiary care hospital in Delhi, India. J Assoc Physicians India. 2010;58:32-6.

Yigit H, Queenan AM, Anderson GJ, Domenech-Sanchez A, Biddle JW, Steward CD, et al. Novel carbapenem-hydrolyzing β-lactamase, KPC-1, from a carbapenem-resistant strain of Klebsiella pneumoniae. Antimicrob Agents Chemoth. 2001;45(4):1151-61.

Hossain A, Ferraro MJ, Pino R, Dew RB, Moland ES, Lockhart TJ, Thomson KS, Goering RV, Hanson ND. Plasmid-mediated carbapenem-hydrolyzing enzyme KPC-2 in an Enterobacter sp. Antimicrob Agents Chemother. 2004;48(11):4438-40.

van Duin D, Doi Y. The global epidemiology of carbapenemase-producing Enterobacteriaceae. Virulence. 2017;8(4):460-9.

Quale JM, Landman D, Bradford PA, Visalli M, Ravishankar J, Flores C, et al. Molecular epidemiology of a citywide outbreak of extended-spectrum β-lactamase–producing Klebsiella pneumoniae infection. Clin Infect Dis. 2002;35(7):834-41.

Manikal VM, Landman D, Saurina G, Oydna E, Lal H, Quale J. Endemic carbapenem-resistant Acinetobacter species in Brooklyn, New York: citywide prevalence, interinstitutional spread, and relation to antibiotic usage. Clin Infect Dis. 2000;31(1):101-6.

Tacconelli E, Magrini N, Kahlmeter G, Singh N. Global priority list of antibiotic-resistant bacteria to guide research, discovery, and development of new antibiotics. World Health Organization. 2017;27.

Chalmers JD, Taylor JK, Singanayagam A, Fleming GB, Akram AR, Mandal P, et al. Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study. CliniInfect Dis. 2011;53(2):107-13.

Aliberti S, Di Pasquale M, Zanaboni AM, Cosentini R, Brambilla AM, Seghezzi S, et al. Stratifying risk factors for multidrug-resistant pathogens in hospitalized patients coming from the community with pneumonia. Clini Infect Dis. 2011;54(4):470-8.

Durlach R, McIlvenny G, Newcombe R, Reid G, Doherty L, Freuler C, et al. Prevalence survey of healthcare-associated infections in Argentina; comparison with England, Wales, Northern Ireland and South Africa. J Hospital Infect. 2012;80:217-23.

Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SA, Leblebicioglu H, Mehta Y, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control. 2016;44(12):1495-504.

Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Prediction of infection due to antibiotic-resistant bacteria by select risk factors for health care-associated pneumonia. Archiv Inter Med. 2008;168(20):2205-10.

Han JH, Nachamkin I, Zaoutis TE, Coffin SE, Linkin DR, Fishman NO, et al. Risk factors for gastrointestinal tract colonization with extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella species in hospitalized patients. Infect Control Hospital Epidemiol. 2012;33(12):1242-5.

Warren DK, Guth RM, Coopersmith CM, Merz LR, Zack JE, Fraser VJ. Epidemiology of methicillin-resistant Staphylococcus aureus colonization in a surgical intensive care unit. Infect Control Hospital Epidemiol. 2006;27(10):1032-40.

Mathur P. Prevention of healthcare-associated infections in low- and middle-income Countries: the Bundle approach. Indian J Med Microbiol. 2018;36:155-62.