Incidence of bacterial infections and colonisation in patients admitted to a tuberculosis hospital

Abstract

Patients with drug resistant tuberculosis (TB) are treated with multiple antibiotics including moxifloxacin, linezolid, and meropenem, which puts them at greater risk for colonisation by multi-drug resistant (MDR) bacteria. The objectives of this study were to: (i) assess the antimicrobial prescribing patterns practiced within the hospital by retrospective patient file review; (ii) determine the spectrum of bacterial colonisation in TB patients upon admission and during hospitalisation; (iii) identify bacterial isolates and evaluate antimicrobial susceptibility profiles; (iv) detect antimicrobial resistance genes in the bacterial isolates by PCR and DNA sequencing; and (v) investigate genetic relatedness of Klebsiella pneumoniae isolates using Multi Locus Sequence Typing. Nasal, groin and rectal swabs [for the detection of extended spectrum beta lactamases (EBSLs), carbapenem-resistant Enterobacteriaceae (CRE), vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)] were analysed from a cohort of patients (n=37) admitted either from the community (n = 28) or from other healthcare facilities (n=9) to a TB hospital. Swab samples were collected at admission and at four week intervals thereafter during hospitalization. Identification and antimicrobial susceptibility testing of bacterial isolates (n=62) were determined at the National Health Laboratory Services (NHLS) by the VITEK-MS and Vitek 2 systems respectively. Additional antimicrobial susceptibility testing was conducted by Sensititre Gram Negative Xtra (GNFX2) MIC plates. PCR and DNA sequencing were used for detection of resistance genes. Patients (n=13/37; 35%) were colonized by MDR bacteria (ESBLs [n=11], MRSA [n=2]) on admission. Colonization rates were lower in patients admitted from the community (9/28; 32%) compared to those transferred from other healthcare facilities (4/9; 44%). All admitted patients who did not exhibit colonization at baseline and who were resident within the hospital for longer than 4 weeks (17/37; 46% of total patients) became colonised by an ESBL-producing Enterobacteriaceae species. No patients acquired MRSA during hospitalisation. Among ESBL Enterobacteriaceae, Escherichia coli (41/62; 66%) and K. pneumoniae [14/62; 23%]) predominated. Nineteen percent (7/37) of patients demised during their hospitalization. Both the Vitek system and Sensititre Gram Negative Xtra (GNFX2) MIC plates susceptibilities were similar for most antimicrobials, however there were discrepancies for tigecycline susceptibility profiles. A high number of isolates exhibited resistance to aminoglycosides and fluoroquinolones. Genes encoding for ESBLs (CTX-M-14, CTX-M-15, SHV-28, OXA-1, and OXY-2-9) were detected among ESBL Enterobacteriaceae. Two Enterobacteriaceae isolates with reduced carbapenem susceptibility did not contain carbapenemase-encoding genes. MLST revealed unique sequence types and genetic diversity among the K. pneumoniae isolates from hospitalised patients. However, the source and colonization routes of these isolates could not be determined, which requires further investigation. This study provides insight into the spectrum of bacterial pathogen colonisation in hospitalised TB patients and suggests a review of infection control programs and practices at the TB hospital