Hospital associated infections — a missing piece in Kerala’s antimicrobial resistance puzzle

Going by the data from the Kerala Antimicrobial Resistance Surveillance Network’s Annual Report 2023, AMR is increasing in the coastal state.

ByDileep V Kumar

Published Aug 16, 2023 | 9:00 AMUpdatedAug 16, 2023 | 9:00 AM

Hospital-associated infections might be overlooked in Antimicrobial Resistance strategy

An uptick in hospital-associated infections (HAI) has triggered questions about whether healthcare institutions in the state of Kerala are becoming a hotbed of antimicrobial resistance (AMR).

A report on AMR, released by the state Health Department on 2 August, has set off concerns in this regard. Going by the data from the Kerala Antimicrobial Resistance Surveillance Network’s (KARS NET) Annual Report 2023, AMR is increasing in the state. And so is HAI.

It is feared that the state has waged a losing battle against drug resistance as it overlooked HAI in its AMR strategy.

What is hospital-associated infection (HAI)?

According to the World Health Organisation (WHO), HAI is an infection occurring in a patient during the process of care in a hospital or other healthcare facilities that was not present or incubating at the time of admission.

As HAI might result in prolonged hospital stays, misuse and overuse of antimicrobials (medicines used to prevent and treat infections) is also high.

Increased resistance of micro-organisms like bacteria, viruses, fungi, and parasites to the antimicrobials could thereby increase the risk of disease spread, severe illness, and even death.

According to the United States Centers for Disease Control and Prevention (CDC), HAIs comprise a range of infections like central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia.

Infections may also occur at surgery sites, known as surgical site infections.

Also Read: Why is IMA cautioning against use of antibiotics?

Reasons for concern

Trends of ESBL evidence from KARS NET over four years

Trends of ESBL evidence from KARS NET over four years. (Supplied)

As per the KARS NET Annual Report 2023, extended-spectrum beta-lactamases (ESBL) production as well as carbapenem resistance (CR) has been increasing over the years. It came to this conclusion after analysing the trend over the last four years, from 2018 to 2022.

ESBLs are enzymes produced by Enterobacterales, a large order of different types of bacteria (germs) that commonly cause infections both in healthcare settings, and in communities.

ESBLs can break down and destroy some commonly used antibiotics, including penicillin and cephalosporin, thereby making such drugs ineffective for treating infections.

The most worrying trend is the CR, as carbapenems — considered as last-resort antibiotics — are used for the treatment of infections caused by multidrug-resistant microbes.

Trends of Carbapenem resistance–evidence from KARS-NET over four years

Trends of Carbapenem resistance–evidence from KARS-NET over four years. (Supplied)

The report tracked CR against four groups of bacteria:

  • Acinetobacter (that can cause infections in the blood, urinary tract, and lungs, or wounds in other parts of the body)
  • E. coli (strains that can cause illnesses like urinary tract infections)
  • Klebsiella (causing HAI-like pneumonia, bloodstream infections, and meningitis)
  • Pseudomonas (causing infections in the blood, lungs, or other parts of the body after surgery)

It also traced the prevalence of Methicillin-resistant Staphylococcus aureus or MRSA (an infection in which Staphylococcus bacteria that causes a range of diseases including sepsis becomes resistant to Methicillin) and Vancomycin-resistant Enterococci or VRE (an infection in which Enterococci bacteria becomes resistant to Vancomycin) in the state from 2018 to 2022.

Trends of MRSA and VRE–evidence from KARS NET over four years

Trends of MRSA and VRE–evidence from KARS NET over four years. (Supplied)

As per the report, the apparent decrease in MRSA in 2021 may be attributed to the non-uniformity in data from some centres in the initial months of 2021, owing to the subsequent waves of the pandemic in the state and the majority of centres being Covid care centres. VRE rates have also increased over the last three years.

However, the report also cited a limitation as the data mostly represents tertiary care centres and it may not be representative of the community.

Also Read: Study finds prevalence of antibiotic resistance in rural Karnataka

Other findings

The KARS-NET report that covers the AMR data from 1 January to 31 December, 2022, was a result of information compiled from 23 surveillance laboratories spread across 11 districts in the state.

Data of patients checked for priority pathogens

Data of patients checked for priority pathogens. (Supplied)

The data from 27,604 patients were analysed. Of these, 51 percent (13,962) were female patients and 49 percent (13,443) were male patients.

Out of the 27,604 isolates, 49 percent (13,523) were in-patients (IPD), 35 percent (9,704) were out-patients (OPD), 13 percent (3,561) were patients admitted to the intensive care unit (ICU), and the remaining (816) of unknown origin.

As per the report, the most isolated pathogen from IPDs and OPDs was E. coli, followed by Klebsiella.

In IPD patients, it was 37 percent (5,004) and 26 percent (3,477), respectively. While in the case of OPD patients, it was 45 percent (4,360) and 22 percent (2,112). In ICU facilities, Klebsiella was the most isolated pathogen at 31 percent (1,102), followed by E. coli at 29 percent (1,019).

Antibiotic resistance profile of Escherichia coli

Antibiotic resistance profile of Escherichia coli. (Supplied)

The highest resistance to Carbapenem was observed in Klebsiella isolated from blood, that is 43 percent, compared to the other specimen types, while CR observed in E. coli isolates from blood was up to 10 percent.

The highlight of the KARS-NET Report was for the first-time network sites submitted AMR surveillance data of 41 Salmonella enterica serovar Typhi and Paratyphi (bacteria causing enteric fever).

It came out with the finding that such bacteria achieved low resistance to first-line antibiotics like ciprofloxacin, ampicillin, and chloramphenicol.

Also Read: India bans 14 fixed-dose combination medicines used for cough, infections

Healthcare institutions and community’s role 

Dr Aravind R, Convener of Kerala Antibiotic Resistance Strategic Action Plan’s (KARSAP) working committee, told South First that staff accountability and behavioural change are the prerequisites to fight AMR.

“Healthcare institutions, as well as the community, must give due importance to infection prevention and control (IPC),” said Dr Aravind.

Location wise distribution of isolates

Location-wise distribution of isolates. (Supplied)

Take the case of E. coli. These bacteria can cause disease when they make a toxin called Shiga toxin. But it can be prevented by practicing proper hygiene, especially good handwashing, said Dr Aravind.

“Washing fruits and vegetables well under running water, cooking meats thoroughly, avoiding cross-contamination and others are some steps that a common man can take to prevent E. coli,” he added.

He stated, “It can’t be presumed that ESBL occurs alone from healthcare facilities. There are cases of community-acquired ESBL infections also. But in the case of CR, the triggering factor could be HAI.”

Also Read: ICMR warns against the use of antibiotics for low-grade fever

‘Top priority to IPC in healthcare settings’

However, he stated that as KARSAP gives top priority to IPC in healthcare settings, the threat of HAI and resultant AMR could be effectively controlled.

“Under KARSAP, a slew of initiatives is being carried out. A plan is there to make all healthcare institutions accredited. Because the prevalence of patient safety culture is a major element of accreditation and IPC plays a major role in achieving the same,” said Dr Aravind.

Antibiotic resistance profile of Klebsiella species

Antibiotic resistance profile of Klebsiella species. (Supplied)

The convener also pointed out that the establishment of AMR committees at the block level will become a game-changer in the fight against antibiotic resistance.

It was on 2 August that the state government decided to form AMR committees at the block level, thus making Kerala the first state to do so.

A total of 191 block-level AMR committees came into being and are entrusted with the task of bolstering efforts for promoting antibiotic literacy.

It was in 2018 that KARSAP was launched to tackle the AMR problem of the state.

Meanwhile, an antibiogram, clinical data summarising the profile of various bacterial pathogens and their susceptibility to antibiotics that are meant to treat them, of the state released in 2021 shows that antibiotic resistance in bacteria that cause either community infections or HAI is on the rise when compared to the previous years.

Also Read: Reusable water bottle has 40k times more bacteria than toilet seat

How critical is HAI?

WHO, in its Global Report on Infection Prevention and Control, published on May 2022, highlights that microorganisms typically causing HAIs very frequently carry resistance patterns.

Antibiotic resistance profile of Salmonella enterica Typhi and Paratyphi

Antibiotic resistance profile of Salmonella enterica Typhi and Paratyphi. (Supplied)

It also underscores the importance of hand hygiene as it is “the most effective single measure for reducing the transmission of microorganisms and infection in health care settings”, whether “implemented as a stand-alone intervention or integrated into multifaceted interventions.”

Incidentally, the “crucial need to better understand the drivers of AMR” and “the importance of multimodal HAI prevention strategies that include IPC and antimicrobial stewardship efforts”, was highlighted in a study carried out in India.

The study that covered 26 tertiary-level hospitals was about healthcare-associated bloodstream and urinary tract infections. It was published in The Lancet in September 2022.

The study also found a high proportion of primary device-associated infections, thus supporting the rationale for prevention initiatives.