الفهرس 
titleOnly 14 pages are availabe for public view
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Abstract
Critically ill patients with malignancy are among the most vulnerable patients with high risk for developing MDR infection. In Alexandria, there are no studies about the frequency and epidemiology of antimicrobial resistance in the mentioned population. The objective of the study is to identify the prevalence and characteristics of antimicrobial resistance and to determine the factors that may enhance developing antimicrobial resistance among infecting pathogens in the intensive care department.
The study presented is a retrospective cross sectional study conducted by reviewing all medical records of patients admitted to critical care department of a referral tertiary care hospital with 50 ICU beds in Alexandria, Egypt. Study period was 4 years, starting from January 2017 to December 2020, to identify epidemiology, determinants, and AMR characteristics among adult patients with malignancy in ICU. Multivariate logistic regression model was used to identify risk factors associated with developing antimicrobial resistance.
The total number of patients reviewed in the study was 497 patients with malignancy and documented infections, while the total number of culture reports reviewed was 1249 samples collected.
The most common organisms isolated from the cultures were Klebsiella pneumoniae, E. coli, followed by, Acinetobacter baumanii, and Pseudomonas aeruginosa. The resistant cultures (MDR, XDR, PDR) were 380 (82.8%) among gram negative bacterial isolates, while 70 (93.3%) was the frequency of resistance among gram positive isolates.
Based upon multivariate logistic regression, the independent risk factors associated with developing MDR were neutropenia, recent use of antibiotics within 3 months, chemotherapy treatment, metastasis and prolonged hospital stay.
Local bacterial organisms‘ epidemiology and characteristics should guide the empirical choice of antimicrobial treatment.
6.2 Conclusions
Among ICU patients with malignancy, high prevalence of MDR was shown in our study. Frequency of reported Gram-negative bacilli were greater than Gram positive bacterial and fungal infections. K. pneumoniae was the most commonly encountered pathogen in this study.
Incidence of MDR-GNB resistant to higher generation cephalosporins and even carbapenems was rising over the study years, limiting antibiotic treatment options only to older classes of antibiotics as colistin and aminoglycosides with potential side effects as nephrotoxicity.
Summary, Conclusions and Recommendations
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Estimating AMR probability using the clinical prediction model of risk factors as neutropenia and previous antibiotics use, maybe functional in stratifying higher risk patients. This may guide critical care physicians in their empirical antimicrobial selection.
This study may provide valuable data for national surveillance of MDR and for comparisons with other countries. This could be a steppingstone to generate a robust local antibiotic policy.
6.3 Recommendations
1- Local prevalence and epidemiology of pathogens through previous research in addition to clinical status of the patients and their history should be used to guide antimicrobial selection.
2- When antibiotic culture and sensitivity results are available, they should be used to guide antimicrobial therapy.
3- Regular close monitoring and reporting the ever-changing dynamic microbiological resistance pattern should be performed for prompt administration of adequate empirical treatment specifically among special population as malignancy and pregnancy.
4- Implementing infection control measures, as well as antimicrobial stewardship programs (ASP) and recommendations to improve antibiotic prescribing may assist in optimizing communicable diseases management.
5- Future research may be needed to gather detailed information about AMR problem in special population.
6- Available social media with health education for health care professionals and patients are advised to defeat antimicrobials resistance threat caused by using improper antibiotics.
7- National robust data about AMR maybe generated through gathered local hospital antibiograms.
6.4 Clinical implications
First, cultures should be taken from the suspected sites of infection of critically ill patients suffering of sepsis rapidly in order to target antibiotic medication.
Upon initiation of an empirical treatment, the highly expected type and resistance of microorganisms, along with the patient clinical status, comorbidities and site of infection should both be considered when selecting empirical antimicrobials.
According to the results of the present study, the most frequently isolated organisms were Klebsiella pneumonia, E. coli, Acinetobacter baumanii, and Pseudomonas aeruginosa.
Based on resistance patterns recorded in the present study, initial appropriate empirical therapy in ICU cancer patients can be guided by the following strategy:
a- For suspected gram-negative infection as in cases of urinary tract and respiratory tract infection, best empirical choice includes colistin or aminoglycosides or carbapenems,
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b- For suspected gram-positive infection as in cases of catheter associates blood stream infection, skin, and soft tissue infection: best empirical choice includes vancomycin or linezolid or teicoplanin
Combination therapy should be considered for broad coverage, potential for synergy and avoiding emergence of resistance.
As general rules which control choice of antibiotics, consider adequate penetration to site of infection and well tolerated therapy. In patients with renal impairment, either aminoglycosides or colistin do not present a good choice for treatment due to their nephrotoxicity.
History of recent antibiotic exposure, neutropenia, local antimicrobial resistance prevalence, drug interactions and toxicity, antibiotics cost and availability are important factors to be considered upon selection of empirical antimicrobial therapy.