Blood Stream Infection in Stroke Patients: Spectrum of Microbial Isolates and Antimicrobial Resistance
Background: Bloodstream infection (BSI) is frequent in stroke, with poorer outcomes when microbial isolates are multi-drug resistant. There is a shortage of published data on BSI amongst stroke patients in Nigeria.
Objective: To describe the microbial isolates and the antimicrobial resistance pattern among microbial isolates in BSI in stroke patients.
Methods: This retrospective study of all hospitalized stroke patients with BSI at the University of Benin Teaching Hospital, Benin City, Nigeria covered July 2018 to June 2022. The demographics, stroke type, microbial isolates and antimicrobial resistance patterns were studied.
Results: Blood culture studies were conducted among 834 stroke patients with infections; 410 (49.2%) had positive growth for microbial organisms. Amongst those with positive blood cultures, 53% (217/410) were females, while 56% had a haemorrhagic stroke. The mean age was 76.9±13.9 years, with about 80% of them aged ≥ 65. Infections of the respiratory tract (45%) and the urinary tract (33%) were the possible primary sources of BSI. The leading isolates included Enterococcus faecalis (18.5%), Klebsiella oxotyca (12.9%), Proteus mirabilis (12.9%), Staphylococcus aureus (11.5%), and Escherichia coli (11.2%). Approximately 88% of the isolates were multi-drug resistant, with 100% resistance to cefuroxime, ceftazidime, and co-trimoxazole, 83.3% to erythromycin and 75% resistance to ampicillin. The elderly patients were significantly more likely to acquire multi-drug resistant micro-organisms (p = 0.007).
Conclusion: Stroke patients, especially the older ones, are susceptible to bloodstream infection from multi-drug-resistant micro-organisms, contributing to increased morbidity and mortality among stroke patients.
Verway M, Brown KA, Marchand-Austin A, Diong C, Lee S, Langford B, et al. Prevalence and Mortality Associated with Bloodstream Organisms: A Population-Wide Retrospective Cohort Study. J Clin Microbiol 2022;60:e02429-21. https://doi.org/10.1128/jcm.02429-21.
van Gemmeren T, Schuppner R, Grosse GM, Fering J, Gabriel MM, Huber R, et al. Early post-stroke infections are associated with an impaired function of neutrophil granulocytes. J Clin Med 2020;23:9:872. https://doi.org/10.3390/jcm9030872.
Kern WV, Rieg S. Burden of bacterial bloodstream infection—a brief update on epidemiology and significance of multidrug-resistant pathogens. Clin Microbiol Infect 2020;26:151-157. https://doi.org/10.1016/j.cmi.2019.10.031.
Shao IY, Elkind MS, Boehme AK. Risk factors for stroke in patients with sepsis and bloodstream infections. Stroke 2019;50:1046-1051. https://DOI.org/10.1161/STROKEAHA.118.023443
Marchello CS, Dale AP, Pisharody S, Rubach MP, Crump JA. A systematic review and meta-analysis of the prevalence of community-onset bloodstream infections among hospitalized patients in Africa and Asia. Antimicrob Agents Chemother 2019;64:e01974-19. https://doi.org/10.1128/AAC.01974-19.
Horan T. C., Andrus M., Dudeck M. A. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309–332. https://doi.org/10.1016/j.ajic.2008.03.002.
Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268-281. https://doi.org/10.1111/j.1469-0691.2011.03570.x.
Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: An expert statement. Intensive Care Med 2020;46:266-284. https://doi.org/10.1007/s00134-020-05950-6.
Schechner V, Wulffhart L, Temkin E, Feldman SF, Nutman A, Shitrit P, et al. One-year mortality and years of potential life lost following bloodstream infection among adults: A nation-wide population-based study. The Lancet. 2022;23:100511. https://doi.org/10.1016/j.lanepe.2022.100511.
Angioni D, Hites M, Jacobs F, De Breucker S. Predictive factors of in-hospital mortality in older adults with community-acquired bloodstream infection. J Frailty Aging 2020;9:232-237. https://doi.org/10.14283/jfa.2019.45.
Smith C, Almallouhi E, Feng W. Urinary tract infection after stroke: a narrative review. J Neurol Sci 2019;403:146-152. https://doi.org/10.1016/j.jns.2019.06.005.
Mukapa N, Mataruse A, Ngwende GW, Robertson V. Incidence, risk factors and microbiological aetiology of urinary tract infections in admitted stroke patients at a teaching hospital in Zimbabwe: A prospective cohort study. J Infect Prev 2022;4:100210. https://doi.org/10.1016/j.infpip.2022.100210.
Grossmann I, Rodriguez K, Soni M, Joshi PK, Patel SC, Shreya D, et al. Stroke and Pneumonia: Mechanisms, Risk Factors, Management, and Prevention. Cureus 2021;13:e19912. https://doi.org/10.7759/cureus.19912.
Yuan M, Li Q, Zhang R, Zhang W, Zou N, Qin X, et al. Risk factors for and impact of poststroke Pneumonia in patients with acute ischemic stroke. Medicine 2020;100:e25213. https://doi.org/10.1097/MD.0000000000025213
Pop-Vicas A, Tacconelli E, Gravenstein S, Lu B, D'Agata EM. Influx of multidrug-resistant, gram-negative bacteria in the hospital setting and the role of elderly patients with bacterial bloodstream infection. Infect Control Hosp Epidemiol 2009;30:325-331. https://doi.org/10.1086/596608.
Cabiltes I, Coghill S, Bowe SJ, Athan E. Enterococcal bacteraemia ‘silent but deadly’: a population‐based cohort study. Intern Med J 2020;50:434-440. https://doi.org/10.1111/imj.14396.
Billington EO, Phang SH, Gregson DB, Pitout JD, Ross T, Church DL, et al. Incidence, risk factors, and outcomes for Enterococcus spp. bloodstream infections: a population-based study. Int J Infect Dis 2014;26:76-82. https://doi.org/10.1016/j.ijid.2014.02.012
Youssef D, Hooshmand B, Riederer KM, Johnson LB, Khatib R. Klebsiella pneumoniae and K. oxytoca Bacteremia: Differences in Host, Source, and Antibiotic Susceptibility. Open Forum Infect Dis 2019;6:S112-S112. https://doi.org/10.1093/ofid/ofz360.255
Xu M, Fu Y, Kong H, Chen X, Chen Y, Li L, et al. Bloodstream infections caused by Klebsiella pneumoniae: prevalence of bla KPC, virulence factors and their impacts on clinical outcome. BMC Infect Dis 2018;18:1-9. https://doi.org/10.1186/s12879-018-3263-x.
Kwiecińska-Piróg J, Skowron K, Gospodarek-Komkowska E. Primary and Secondary Bacteremia Caused by Proteus spp.: Epidemiology, Strains Susceptibility and Biofilm Formation. Polish J Microbiol 2018;67:471-478. https://doi.org/10.21307/pjm-2018-055.
Korytny A, Riesenberg K, Saidel-Odes L, Schlaeffer F, Borer A. Bloodstream infections caused by multi-drug resistant Proteus mirabilis: Epidemiology, risk factors and impact of multi-drug resistance. Infect Dis 2016;48:428-431. https://doi.org/10.3109/23744235.2015.1129551.
Kwiecinski JM, Horswill AR. Staphylococcus aureus bloodstream infections: pathogenesis and regulatory mechanisms. Curr Opin Microbiol 2020;53:51-60. https://doi.org/10.1016/j.mib.2020.02.005.
Loftus MJ, Young-Sharma TE, Wati S, Badoordeen GZ, Blakeway LV, Byers SM, et al. Epidemiology, antimicrobial resistance and outcomes of Staphylococcus aureus bacteraemia in a tertiary hospital in Fiji: A prospective cohort study. Lancet 2022;22:100438. https://doi.org/10.1016/j.lanwpc.2022.100438.
MacKinnon MC, McEwen SA, Pearl DL, Lyytikäinen O, Jacobsson G, Collignon P, et al. Mortality in Escherichia coli bloodstream infections: a multinational population-based cohort study. BMC Infect Dis 2021;21:1-10. https://doi.org/10.1186/s12879-021-06326-x.
Bonten M, Johnson JR, van den Biggelaar AH, Georgalis L, Geurtsen J, de Palacios PI, et al. Epidemiology of Escherichia coli bacteremia: a systematic literature review. Clin Infect Dis 2021;72:1211-1219. https://doi.org/10.1093/cid/ciaa210.
Wesevich A, Sutton G, Ruffin F, Park LP, Fouts DE, Fowler Jr VG, et al. Newly named Klebsiella aerogenes (formerly Enterobacter aerogenes) is associated with poor clinical outcomes relative to other Enterobacter species in patients with bloodstream infection. J Clin Microbiol 2020;58:e00582-20. https://doi.org/10.1128/JCM.00582-20
Álvarez-Marín R, Navarro-Amuedo D, Gasch-Blasi O, Rodríguez-Martínez JM, Calvo-Montes J, Lara-Contreras R, et al. A prospective, multicenter case-control study of risk factors for acquisition and mortality in Enterobacter species bacteremia. J Infect 2020;80:174-181. https://doi.org/10.1016/j.jinf.2019.09.017.
Liu LH, Wang NY, Wu AY, Lin CC, Lee CM, Liu CP. Citrobacter freundii bacteremia: Risk factors of mortality and prevalence of resistance genes. J Microbiol Immunol Infect 2018;51:565-572. https://doi.org/10.1016/j.jmii.2016.08.016.
Maraki S, Vardakas KZ, Mavromanolaki VE, Kyriakidou M, Spais G, Kofteridis DP, et al. In vitro susceptibility and resistance phenotypes in contemporary Citrobacter isolates in a University Hospital in Crete, Greece. Infect Dis 2017;49:532-539. https://doi.org/10.1080/23744235.2017.1297896.
Alkharashi N, Aljohani S, Layqah L, Masuadi E, Baharoon W, Al-Jahdali H, et al. Candida bloodstream infection: changing pattern of occurrence and antifungal susceptibility over 10 years in a tertiary care Saudi hospital. Canadian J Infect Dis Med Microbiol 2019;34:38. https://doi.org/10.1155/2019/2015692.
Zhong L, Zhang S, Tang K, Zhou F, Zheng C, Zhang K, et al. Clinical characteristics, risk factors and outcomes of mixed Candida albicans/bacterial bloodstream infections. BMC Infect Dis 2020;20:1-1. https://doi.org/10.1186/s12879-020-05536-z.
Murray CJ, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022; 399(10325):629-55 DOI: 10.1016/S0140-6736(21)02724-0
Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2019. US Department of Health and Human Services, Centres for Disease Control and Prevention; 2019. https://doi.org/10.1097/CCM.0000000000004371
Iskandar K, Molinier L, Hallit S, Sartelli M, Hardcastle TC, Haque M, et al. Surveillance of antimicrobial resistance in low- and middle-income countries: A scattered picture. Antimicrob Resist Infect Control 2021;10:1-9. https://doi.org/10.1186/s13756-021-00931-w.
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