Risk factors and profile of antimicrobial use among patients with urinary tract infection at an intensive care unit
DOI:
https://doi.org/10.33448/rsd-v10i3.13516Keywords:
Urinary tract infections; Intensive Care Units; Antimicrobial; Escherichia coli; UTI; ICU; Acinetobacter baumannii.Abstract
Urinary Tract Infections (UTI) affecting patients at Intensive Care Units (ICU) is a preoccupant reality, further aggravated by inadequate antimicrobial use and the alarming antimicrobial resistance in microorganisms. We evaluated the level of assertiveness regarding the use of antimicrobials during the empirical antibiotic-therapy (EA), in patients with UTI, comparing the empiric pharmacological treatments (EA) and those ones performed after the antibiogram (guided therapy). Moreover, we estimated the prevalence of the causative agents and analyzed the risk factors associated. This is an observational and cross-sectional study, undertaken in 2015, in which patients (both gender and all ages) with UTI and underwent antimicrobial therapy, enrolled at an ICU in a hospital in the southern region of the Brazilian state of Minas Gerais, Brazil, were evaluated. Among the 49 patients evaluated (28 females [F] and 21 males [M]), the mean age was 55±19 years (CI(95) 49-61) and the predominant age range was ≥70 years. Fourteen different microorganisms were identified. 28.3% (CI(95%) 16.2-40.4) of the UTI had Escherichia coli as causative agent (33.3% M and 28.6% F); 18.9% (CI(95%) 8.3-29.4) Acinetobacter baumannii (33.3% M and 10.7% F); 15.1% (CI(95%) 5.5-24.7) Klebsiella pneumoniae (19% M and 14.3% F); 11.3% Pseudomonas aeruginosa (9.5% M and 14.3% F); 5.7% Enterobacter aerogenes (14.3% M); 3.8% Klebsiella oxytoca; 3.8% Staphylococcus aureus (7.1% F); and 2% for each of the microorganisms as follows: Enterococcus faecalis (4.8% M); Proteus mirabilis (3.6% F); Enterobacter cloacae (3.6% F); Providencia rettgeri (4.8% M); Citrobacter koseri (3.6% F); Citrobacter freundii (3.6% F); and Yeasts (4.8% M). The prevalence of UTI caused by A. baumannii and P. aeruginosa in the ITUs were influenced by the patients’ sex (χ² with p<0.001). In the male sex, it there was “substantial” positive correlations between the most increased ages (in years) and the prevalence of UTI caused by E. coli (r = 0.69) or between the decreased ages and the prevalence of UTI caused by A. baumannii (r = -0.7). In the female sex, it there was an “extremely” positive correlation between the most increased ages and the prevalence of UTI caused by E. coli (r = 0.94; CI(95) 0.66-0.99; p<0.0014). The most used antimicrobials in an empirical fashion (EA) were: Ciprofloxacin (14.3% CI(95%) 4.7-24.1), Cefepime (14.3%), and Vancomicin (10%); and after antibiogram (guided therapy): Ceftazidime (16.3% CI(95%) 6-26.7), Ciprofloxacin (14.3% CI(95%) 4.5-24.1), Polymyxin B (10.2%), Imipenem (10.2%), and Ampicillin/sulbactam (8.2%). In 20% of cases, the EAs were considered “inappropriate/not correct”. However, we must also be aware of the clinical need and the immediacy for the treatment of UTIs in an ICU, since the disease can be fatal if a therapy is not instituted, therefore, we advise more detailed assessments, both of the rationality of use antibiotics, as well as the risk factors for the development of UTIs in ICUs.
References
Aarestrup, F. M., Agerso, Y., Gerner-Smidt, P., et al. (2000). Comparison of antimicrobial resistance phenotypes and resistance genes in Enterococcus faecalis and Enterococcus faecium from humans in the community, broilers and pigs in Denmark. Diagn Micr Infec Dis, 37, 127-137.
Agência Nacional de Vigilância Sanitária – Anvisa, a. Microbiologia Clínica Aplicada ao Controle de Infecção Relacionada à Assistência à Saúde. Brasília: Ministério da Saúde, 2013.
Agência Nacional de Vigilância Sanitária – Anvisa, b. Medidas de Prevenção de Infecção Relacionada à Assistência à Saúde. Brasília: Ministério da Saúde, 2013.
Agência Nacional de Vigilância Sanitária – Anvisa. Resolução da diretoria colegiada – RDC Nº 44, de 26 de outubro de 2010. Brasília: Ministério da Saúde, 2010.
Agersø, Y., Pedersen, A. G., & Aarestrup, F. M. (2006). Identification of Tn5397--like and Tn916-like transposons and diversity of the tetracycline resistance gene tet (M) in enterococci from humans, pigs and poultry. J Antimicrob Chemoth, 57, 832-839.
Aliberti, L. C. (1995). Enterococcal nosocomial infection: epidemiology and practice. Gastroenterol Nursing, 18, 177–181.
Anderl, J. N., Franklin, M. J., Stewart, P. S. (2000). Role of antibiotic penetration limitation in Klebsiella pneumonia biofilm resistance to ampicillin and ciprofloxacin. Antimicrob Agents Chemother, 44(7), 1818-1824.
Baum, K. R., Ahmad, Z., Singh, V. K. (2015). Regulation of Expression of Oxacillin-Inducible Methionine Sulfoxide Reductases in Staphylococcus aureus. International Journal of Microbiology, 2015Article ID 617925, 9.
Behzadi, P., Behzadi, E., Yazdanbod, H., et al. (2010). A survey on urinary tract infections associated with the three most common uropathogenic bacteria. A Journal of Clinical Medicine, 5(2), 111-15.
Bennett, J. W., Murray, C. K., Holmes, R. L., et al. (2008) Di-minished vancomycin and daptomycin susceptibility during prolonged bacteremia with methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis, 60(4), 437-440.
Betsy, F. (2002). Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. The American Journal of Medicine, 113(1, Supplement 1), 5–13.
Biavasco, F., Foglia, G., Paoletti, C., et al. (2007) Van A-type enterococci from humans, animals, and food: species distribution, population structure, Tn1546 typing and location, and virulence determinants. Appl Environ Microb, 73, 3307-3319.
Brasil. Ministério da Saúde. Uso Racional de Medicamentos: temas selecionados. Brasília: Ministério da Saúde, 2012.
Centers for Disease Control (CDC), Antibiotic Resistant Threats in the United States, 2013. 114 p., 2013.
Cha, H. Y., Kim, H. O., Jin, J. S., et al. (2010). Emergence of Vancomycin-Intermediate Staphylococcus aureus from Predominant Methicillin-Resistant S. aureus Clones in a Korean Hospital. The Journal of Microbiology, 48(4), 533-535
Chai, W. L., Hamimah, H., Cheng, S. C., et al. (2007). Susceptibility of Enterococcus faecalis biofilm to antibiotics and calcium hydroxide. Journal of Oral Science, 49(2), 161-166.
Choi, H. K., Kim, Y. K., Kim, H. Y., et al. (2015). Clinical and microbiological features of Providencia bacteremia: experience at a tertiary care hospital. Korean J Intern Med, 30, 219-225.
Cole, S. J., Records, A. R., Orr, M. W., et al. (2014). Catheter-Associated Urinary Tract Infection by Pseudomonas aeruginosa Is Mediated by Exopolysaccharide-Independent Biofilms. Infection and Immunity, 82(5), 2048–2058.
Costerton, J. W., Lewandowski, Z., DeBeer, D., et al. (1994). Biofilms, the customized microniche. J Bacteriol, 176(8), 2137-2142.
Cunha, B. A., Schoch, P. E., Hage, J.R. (2011). Nitrofurantoin: Preferred Empiric Therapy for Community-Acquired Lower Urinary Tract Infections. Mayo Clin Proc, 86(12), 1243-1248.
Davin-Regli, A., & Pagès, J-M. (2015). Enterobacter aerogenes and Enterobacter cloacae; versatile bacterial pathogens confronting antibiotic treatment. Frontiers in Microbiology, 6(392), 10.
Ejrnæs, K. (2011). Bacterial Characteristics of Importance for Recurrent Urinary Tract Infections Caused by Escherichia coli. Dan Med Bull, 58(4), B4187.
European Association of Urology - EAU. Guidelines on Urological Infections. 2015.
European Medicines Agency – EMA. The bacterial challenge: time to react. Disponível em: <http://www.ema.europa.eu/docs/en_GB/document_library/Report/2009/11/WC500008770.pdf>. Acesso em: 17 Mai. 2016.
Fisher, J. F., Chew, W. H., Shadomy, S., et al. (1982). Urinary tract infections due to Candida albicans. Rev Infect Dis, 4(6), 1107-18.
Flores-Mireles, A. L., Walker, J. N., Caparon, M., et al. (2015). Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol, 13(5), 269–284.
Food and Drug Administration – FDA. Fighting the Impact of Antibiotic-Resistant Bacteria. Disponível em: <http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm349953.htm>. Acesso em: 16 Mai. 2016.
França, L. C. Principais antibióticos utilizados em hospitais brasileiros nos últimos 10 anos. 2012. 24 f. Monografia (Especialização em Saúde Pública) – Universidade Federal de Santa Catarina, Florianópolis.
Furtado, G. H. C., Martins, S. T., Coutinho, A. P., et al. (2005). Incidence of vancomycin-resistant Enterococcus at a university hospital in Brazil. Revista Saúde Pública, 39(1), 1-5.
Grumach, A. S., & Ferraroni, N. R. (2006). O papel da penicilina na medicina moderna. DST – Jornal Brasileiro Doenças Sexualmente Transmissíveis, 18(1), 7-13.
Howden, B. P., Ward, P. B., Charles, P. G., et al. (2004). Treatment outcomes for serious infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility. Clin Infect Dis, 38(4), 521-528.
Ibrahim, E. H., Sherman, G., Ward, S., et al. (2000). The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest, 118(1), 146-155.
Ita, P. H., & Schor, N. (2003). Abordagem diagnóstica e terapêutica na infecção do trato urinário – ITU. Rev Ass Med Brasil, 49(1), 109-16.
Jacoby, T. S. Associação Entre Consumo de Antimicrobianos e Multirresistência Bacteriana em Centro de Terapia Intensiva de Hospital Universitário Brasileiro, 2004-2006. 2008. 97 f. Dissertação de Mestrado em Ciências Médicas – Universidade Federal do Rio Grande do Sul, Porto Alegre.
Johnson, J. R. (1991). Virulence Factors in Escherichia coli Urinary Tract Infection. Clinical Microbiology Reviews, 4(1), 80-128.
Johnson, L., Sabel, A., Burman, W. J., et al. (2008). Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates. Am J Med, 121(10), 876-884.
Khatri, B., Basnyat, S., Karki, A., et al. (2012). Etiology and antimicrobial susceptibility pattern of bacterial pathogens from urinary tract infection. Nepal Med Coll J, 14(2), 129-32.
Kollef, M. H., Sherman, G., Ward, S., et al. (1999). Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest, 115(2), 462-474.
Kuehnert, M. J., Kruszon-Moran, D., Hill, H. A., et al. (2006). Prevalence of Staphylococcus aureus nasal colonization in the United States, 2001–2002. The Journal of Infectious Diseases, 193(2), 172.
Leekha, S., Terrell, C. L., & Edson, R. S. (2011). General Principles of Antimicrobial Therapy. Mayo Clin Proc, 86(2), 156-167.
Leigh, D. A., & Emmanuel, F. X. (1984). The treatment of Pseudomonas aeruginosa urinary tract infections with norfloxacin. J Antimicrob Chemother, 13(Suppl.B), 85-8.
Manchanda, V., Sanchaita, & S., Singh, N. P. (2010). Multidrug resistant Acinetobacter. J Glob Infect Dis, 2(3), 291-304.
Marques, T. C., Reis, A. M. M., Silva, A. E. B. C., et al. (2008). Erros de administração de antimicrobianos identificados em estudo multicêntrico brasileiro. Revista Brasileira de Ciências Farmacêuticas, 44(2), 305-314.
McCaig, L. F., & Hughes, J. M. (1995). Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA, 273(3), 214-219.
Metri, B. C., Jyothi, & P., Peerapur, B. V. (2013). Antibiotic resistance in Citrobacter spp. isolated from urinary tract infection. Urol Ann, 5(4), 312-313.
Milo, G., Katchman, E. A., Paul, M., et al. (2005). Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database Syst Rev, 2, CD004682.
Murder, R. R., Brennen, C., Rihs, J. D., et al. (2006). Isolation of Staphylococcus aureus from the Urinary Tract: Association of Isolation with Symptomatic Urinary Tract Infection and Subsequent Staphylococcal Bacteremia. Clin Infect Dis, 42, 46–50.
Murray, T., & Comeau, L. L. (2001). Hyperammonemic coma caused by Providencia rettgeri infection in a child with prune belly syndrome. Pediatr Crit Care Med, 2(2), 178-80.
Onanuga, A., & Awhowho, G. O. (2012). Antimicrobial resistance of Staphylococcus aureus strains from patients with urinary tract infections in Yenagoa, Nigeria. J Pharm Bioallied Sci, 4(3), 226–230.
Pascale, S. G., Hannan, T. J., Ford, B., et al. (2013). Enterococcus faecalis Overcomes Foreign Body-Mediated Inflammation to Establish Urinary Tract Infections. Infection and Immunity, 81(1), 329–339.
Podschun, R., & Ullmann, U. (1998). Klebsiella spp. as Nosocomial Pathogens: Epidemiology, Taxonomy, Typing Methods, and Pathogenicity Factors. Clinical Microbiology Reviews, 11(4), 589–603.
Rodrigues-Barros, I. C. A. R., Ribeiro, A. U, Costa, A. C. V., et al. (2011). Microorganisms prevalent in urinary tract infections and antimicrobial sensitivity profile: analysis of patients attended at the Military Police Hospital of the State of Goiás, Brazil, in the period from 1998 to 2008. J Health Sci Inst, 29(4), 243-7.
Schafferand, J. N., Pearson, M. M., Jessica, N. et al. (2015). Proteus mirabilis and Urinary Tract Infections. Microbiol Spectr, 3(5), 66.
Silva, J. J., Cerdeira, C. D., Chavasco, J. M., et al. (2014). In vitro screening antibacterial activity of Bidens pilosa Linné and Annona crassiflora Mart. against Oxacillin Resistant Staphylococcus aureus (ORSA) from the aerial environment at the dental clinic. Rev Inst Med Trop Sao Paulo, 56(4), 333-40.
Sistema Nacional de Gerenciamento de Produtos Controlados – SNGPC. Disponível em: <http://www.anvisa.gov.br/sngpc/apresenta.htm>. Acesso em: 17 Mai. 2016.
Sousa, P. C. P., et al. (2011). Utilização de antibacterianos em Unidade de Terapia Intensiva. Revista Científica Internacional, 4(18).
Stamm, A. M. N. F., & Coutinho, M. S. S. A. (1999). Infecção do trato urinário relacionada ao cateter vesical de demora: incidência e fatores de risco. Rev Ass Med Brasil, 45(1), 27-33.
Tilahun, A. Y., Karau, M., Ballard, A., et al. (2014). The Impact of Staphylococcus aureus-Associated Molecular Patterns on Staphylococcal Superantigen-Induced Toxic Shock Syndrome and Pneumonia. Mediators of Inflammation, 2014;article ID 468285, 13.
Trajano, H. B. P., & Caldas, C. P. (2008). Uso de antibióticos em idosos hospitalizados com infecção do trato urinário. Revista do Hospital Universitário Pedro Ernesto, UERJ, 7, 116-126.
Vincent, J. L., Bihari, D., Suter, P. M., et al. (1995). The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) Study. JAMA, 274(8), 639-644.
Wagenlehner, F. M., & Naber, K. G. (2005). Fluoroquinolone antimicrobial agents in the treatment of prostatitis and recurrent urinary tract infections in men. Curr Infect Dis Rep, 7(1), 9-16.
Wong, E. S., & Hooton, T. M. (1981). Guideline for prevention of catheter-associated urinary tract infections Center for Diseases Control and Epidemiology. Infect Control, 2, 125-30.
World Health Organization – WHO. Medicines: rational use of medicines. Disponível em: <http://www.who.int/mediacentre/factsheets/fs338/en/index.html>. Acesso em: 16 Mai. 2016.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Lucas Harasim; Olibio Lopes Fiebig da Silva; Luiz Felipe Soares Pinheiro; Elber José Assaiante dos Santos; Cláudio Daniel Cerdeira; Gérsika Bittencourt Santos Barros
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
1) Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
2) Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
3) Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
