Risk Factors for Inappropriate Antimicrobial Therapy Among Patients with Hospital-Acquired Infection at Jimma Medical Center: A Prospective Observational Study

Figures & data

Figure 1 Patient flow chart of patients with hospital-acquired infection in JMC.

Table 1 Socio-Demographic Characteristics of Patients Diagnosed with HAIs in Medical, Surgical, and Gynecology/Obstetrics Wards of JMC

Characteristics		Frequency (%)
Sex	Male	117(39.0)
	Female	183(61.0)
Age (in years), mean ± SD		43.2 +19.9
Residency	Urban	144(48.0)
	Rural	156(52.0)
Marital status	Married	185(61.6)
	Single	82(27.3)
	Widowed	20(6.6)
	Divorced	13(4.3)
Educational status of the patient	Unable to read and write	31(10.3)
	1–8	149(49.7)
	9–12	104(34.7)
	>12	16(5.3)

Abbreviation: SD, standard deviation.

Table 2 Clinical Characteristics of Patients with HAIs in Medical, Surgical, and Gynecology/Obstetrics Wards of JMC

Characteristics		Frequency (%)
Reason for admission	For various surgical procedures and care*	122(40.7)
	Stroke	31(10.3)
	Heart failure	25(8.3)
	Asthma	19(6.3)
	Anemia	14(4.7)
	Kidney disease	14(4.7)
	Chronic obstructive pulmonary disease	12(4.0)
	Hypertensive crisis	11(3.7)
	Other lung diseases	10(3.3)
	Deep Vein Thrombosis	8(2.7)
	Epilepsy	6(2.0)
	Malignancy	7(2.3)
	Meningitis	6(2.0)
	Poorly controlled Diabetes Mellitus	6(2.0)
	Others	5(2.7)
Previous admission in the past 3 months for any reason		24(8.0)
Peripheral line inserted		299(99.7)
Catheterized		201(67.0)
Nasogastric tube inserted		62(20.7)
Mechanically ventilated		55(18.3)
Undergone surgery		122(40.7)
Types of HAI diagnosed	HAP	151(50.3%)
	UTI	45(15.0%)
	SSI	49(16.3%)
	BSI	41(13.7%)
	HAP + UTI	7(2.3%)
	HAP + SSI	3(1%)
	HAP + BSI	1
	UTI + SSI	3(1%)
Mean time to develop HAIs (Median)		5 days
Clinical presentation on the diagnosis of HAI	Fever	283(94.0)
	Cough	172(57.3)
	Tachypnea	167(55.7)
	Localized pain	155(51.7)
	Tachycardia	137(45.7)
	Urinary urgency/frequency	84(28.0)
	Discharge from the site of infection	60(20.0)
	Dysuria	45(15.0)
	Headache	42(14.0)
	Swelling at the site of infection	37(12.3)
Laboratory investigation on the diagnosis of HAIs	White blood cell count	12.3± 5.7×10^3 cells/μL
	Red blood cell count	3.9± 1.0×10^6 cells/μL
	Platelet count	263.7± 142.1×10^3 cells/μL
	Erythrocyte sedimentation rate (n=91)	63.9± 38.6 mm/hr

Note: *Cesarean section, surgery for traumatic brain injury, surgery for benign prostatic hyperplasia, thyroidectomy, and others.

Abbreviations: BSI, blood stream infection; HAP, hospital-acquired pneumonia; UTI, urinary tract infection; SSI, surgical site infection; μL, microliters; mm/hr, millimeters per hour.

Table 3 Culture and Sensitivity Pattern of Pathogen Identified from Patients with HAIs in Medical, Surgical, and Gynecology/Obstetrics Wards of JMC

Pathogen	Frequency	Antibiotics to Which Specific Pathogens are Sensitive and Resistant
		Sensitive to	Resistant to
Escherichia coli	4	Imipenem (3), meropenem (3), Gentamicin (1), amikacin (2), chloramphenicol (1)	Ampicillin (3), cotrimoxazole (2), nitrofurantoin (2), gentamicin (1), norfloxacin (1)
CONS (Coagulase-negative staphylococci)	4	Vancomycin (2), imipenem (2), Meropenem (2), nitrofurantoin (2), erythromycin (1)	Cloxacillin (4), doxycycline (4), Penicillin G (4), chloramphenicol (4), erythromycin (3), tetracycline (3)
Enterobacter	3	Nitrofurantoin (1), ampicillin (2) cotrimoxazole (2), gentamicin (2) ceftazidime (1), ceftriaxone (1) norfloxacin (2)	Chloramphenicol (3), ciprofloxacin, (3), cotrimoxazole (3), gentamicin (2), norfloxacin (2)
Klebsiella oxytoca	2	Ampicillin (1), cotrimoxazole (2), gentamicin (2), norfloxacin (2), Imipenem (2), meropenem (2)	Gentamicin (1), tetracycline (1), ciprofloxacin (1)
Citrobacter	2	Amikacin (1), imipenem (1), meropenem (1), nitrofurantoin (1), chloramphenicol (1), tetracycline (1), gentamicin (1)	Ampicillin (2), cloxacillin (2), doxycycline (2), erythromycin (2), penicillin G (2), cotrimoxazole (2)
Acinetobacter	2	Imipenem (1), meropenem (2), amikacin (1), amoxicillin/clavulanic acid (1)	Ampicillin (2), chloramphenicol (2), tetracycline (2), penicillin G (2), oxacillin (2)
Klebsiella pneumonia	1	Ceftazidime, ceftriaxone, cotrimoxazole, norfloxacin, gentamicin	Ampicillin, cloxacillin, doxycycline, erythromycin, oxacillin, penicillin G
Proteus mirabilis	1	Amikacin	Ampicillin, cotrimoxazole, nitrofurantoin, ceftriaxone
Streptococcus pneumoniae	1	Meropenem, imipenem, nitrofurantoin	Augmentin, amikacin, ceftriaxone cefuroxime, ciprofloxacin, norfloxacin, cotrimoxazole gentamicin
Pseudomonas aeruginosa	1	Ciprofloxacin	Oxacillin, penicillin G, nitrofurantoin
Enterobacter aerogenes	1	Imipenem, meropenem	Ceftriaxone, ampicillin, chloramphenicol, gentamicin, nitrofurantoin, doxycycline

Note: The number of times the isolated pathogen-resistant and sensitive to respective antibiotics.

Table 4 Medication Use Profile Among Patients with HAI in Medical, Surgical, and Gynecology/Obstetrics Wards of JMC

Variables			Frequency (%)
Antibiotics used for HAIs	Ceftriaxone		156(52.0)
	Metronidazole		156(52.0)
	Vancomycin		152(50.7)
	Ceftazidime		126(42.0)
	Cephalexin		33(11.0)
	Ciprofloxacin		16(5.3)
	Meropenem		15(5.0)
	Azithromycin		11(3.7)
	Gentamicin		9(3.0)
	Norfloxacin		6(2.0)
	Doxycycline		6(2.0)
	Ampicillin		5(1.7)
	Amoxicillin/clavulanic acid		2(0.7)
	Erythromycin		1(0.3)
Number of antibiotics prescribed per patient (mean ± SD)			2.6±1.0
Other medications used for comorbidities	Anti-pain		168(56.0)
	Anti-ulcer		103(34.3)
	Cardiovascular medications		85(28.3)
	Therapeutic iron		42(14.0)
	Steroids (dexamethasone, prednisolone, hydrocortisone)		41(13.7)
	Anti-diabetic medications (insulin and/or metformin)		33(11.0)
	Antiemetic’s (Metoclopramide)		33(11.0)
	Ant-seizure (diazepam and or phenytoin)		28(9.3)
	Antituberculosis		24(8.0)
	Antipsychotic/antidepressant (Fluoxetine, haloperidol, valproic acid).		10(3.3)
	Highly Active Antiretroviral Therapy		6(2.0)
	Anti-fungal (fluconazole)		1(0.3)
	Others	Mannitol	18(6.0)
		Vitamins /minerals	20(6.7)
		Statins	11(3.7)
		Warfarin	11(3.7)
		Heparin	31(10.3)
		Aspirin	9(3.0)

Abbreviation: SD, standard deviation.

Figure 2 Classification of AMT inappropriateness in patients with HAIs in medical, surgical, and Gynecology/Obstetrics wards of JMC.

Table 5 Bivariate and Multivariate Logistic Regression Analysis to Identify Factors Associated with Inappropriate AMT Among Patients with HAIs

Variable			Appropriateness of AMT		COR (95% CI)	P-value	AOR (95% CI)	P-value)
			Appropriate (n=72)	Inappropriate (n=228)
Admission wards	Internal medicine		26(36.1%)	140(61.4%)	3.26(1.71–6.19)	<0.001	-
	Surgical		20(27.8%)	45(19.7%)	1.36(0.66–2.79)	0.400	-
	Gynecology/obstetrics		26(36.1%)	43(18.9%)	1
Cardiac disease	Yes		10(13.9%)	73(32.0%)	2.92(1.41–6.02)	0.004	2.08(0.95–4.56)	0.067
	No		62(86.1%)	155(68.0%)	1		1
Pregnancy complication	Yes		18(25.0%)	28(12.3%)	0.42(0.22–0.82)	0.010	-
	No		54(75.0%)	200(87.7%)	1
Mechanical ventilation	Yes		5(6.9%)	50(21.9%)	3.76(1.43–9.84)	0.007	2.69(0.96–7.56)	0.059
	No		67(93.1%)	178(78.1%)	1		1
Culture done	Yes		11(15.3%)	21(9.2%)	0.56(0.25–1.23)	0.150	0.32(0.13–0.81)	0.016
	No		61(84.7%)	207(90.8%)	1		1
Undergone surgery?	Yes		45(62.5%)	77(33.8%)	0.31(0.18–0.53)	<0.001	-
	No		27(37.5%)	151(66.2%)	1
Analgesic (s) use	Yes		51(70.8%)	117(51.3%)	0.43 (0.25–0.77)	0.004	-
	No		21(29.2%)	111(48.7%)	1
Steroid use	Yes		3(4.2%)	38(16.7%)	4.60(1.38–15.38)	0.013	-
	No		69(95.8%)	190(83.3%)	1
Ceftriaxone use	Yes		62(87.5%)	172(75.4%)	0.44(0.21–0.94)	0.034	-
	No		9(12.5%)	56(24.6%)	1
Metronidazole use	Yes		54(75.0%)	102(44.7%)	0.27(0.14–0.48)	<0.001	0.25(0.13–0.49)	<0.001
	No		18(25.0%)	126(55.3%)	1		1
Cephalexin use	Yes		15(20.8%)	18(7.9%)	0.33(0.16–0.69)	0.003	-
	No		27(79.2%)	210(92.1%)	1
Vancomycin use	Yes		22(30.6%)	130(57.0%)	3.01(1.71–5.30)	<0.001	2.93(1.57–5.48)	0.001
	No		50(69.4%)	98(43.0%)	1		1
Ceftazidime use	Yes		20(27.8%)	106(46.5%	2.26(1.27–4.03)	0.006	-
	No		52(72.2%)	122(53.5%)	1

Abbreviations: AMT, antimicrobial therapy; AOR, adjusted odds ratio; COR, crude odds ratio; CI, confidence interval.