The emergence of multidrug-resistant Gram-positive bloodstream infections in India - a single center prospective cohort study

Nakka Vihari; Gopal Krishana Bohra; Ram Ratan Yadev; Deepak Kumar; Durga Shankar Meena; Vibhor Tak; Ankur Sharma; Vijaylaxmi Nag; Mahendra Kumar Garg

doi:10.18683/germs.2023.1389

The emergence of multidrug-resistant Gram-positive bloodstream infections in India - a single center prospective cohort study

Germs. 2023 Sep 30;13(3):229-237. doi: 10.18683/germs.2023.1389. eCollection 2023 Sep.

Authors

Nakka Vihari¹, Gopal Krishana Bohra², Ram Ratan Yadev³, Deepak Kumar¹, Durga Shankar Meena¹, Vibhor Tak⁴, Ankur Sharma⁵, Vijaylaxmi Nag⁴, Mahendra Kumar Garg⁶

Affiliations

¹ MD, Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India.
² MD, Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, 342005, India.
³ MS, Department of General Surgery, S.K. Medical College, Sikar, India.
⁴ MD, Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, India.
⁵ MD, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India.
⁶ DM, Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India.

Abstract

Introduction: Gram-positive bloodstream infections (BSIs) are an emerging health concern, especially in resource-limited settings. There is a paucity of data regarding the antimicrobial resistance (AMR) pattern of Gram-positive BSIs. The rise in multidrug-resistant infections further convoluted antibiotic selection. We aimed to assess the incidence, clinical and microbiological profile, antimicrobial resistance (AMR) and outcome in Gram-positive BSIs.

Methods: This was a single-center prospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with culture-proven Gram-positive BSIs were included. Data were collected on all patients' demography, risk factors, AMR and clinical outcome.

Results: A total of 210 clinically significant isolates were grown from July 2020 to December 2021. The incidence of Gram-positive BSIs was 29% (n=61); 55.9% of cases were healthcare-associated, while 44.1% were community-acquired. Coagulase-negative staphylococci (CoNS) were the major isolates (36.1%), followed by Enterococcus spp. (27.9%), methicillin-susceptible Staphylococcus aureus (MSSA) (18%) and methicillin-resistant Staphylococcus aureus (MRSA) (14.7%). The proportion of vancomycin and teicoplanin-resistant CoNS isolates was 13.6% and 19%. Among Enterococcus isolates, the proportion of vancomycin-resistant enterococci (VRE) and linezolid-resistant enterococci (LRE) were 11.8% and 5.9%. The overall mortality in Gram-positive BSIs was 42.6%. Older age, MRSA infection, septic shock, and high NLR were significantly associated with mortality. On the Cox regression model, age ≥65 years (HR: 2.5; 95%CI: 1.1-5.8; p=0.024) and MRSA infection (HR: 3.6; 95%CI: 1.5-8.5; p=0.021) were found as independent predictors of 30-day mortality.

Conclusions: This study found substantial mortality with Gram-positive BSIs, especially MRSA infections. Moreover, the emergence of VRE and LRE is also alarming. Active surveillance of AMR and evaluation of mortality predictors may help overcome the therapeutic challenges in managing BSIs.

Keywords: Bloodstream infections; Enterococcus; Gram-positive bacteria; Staphylococcus aureus; vancomycin.

GERMS.