Evaluating the Prevalence and the Risk Factors of Gram-Negative Multi-Drug Resistant Bacteria in Eastern Saudi Arabia

Figures & data

Figure 1 Flowchart for study design including inclusion/exclusion criteria of isolates.

Table 1 Frequency of MDR GNB in Relation to Sociodemographic Features, and Risk Factors

	2017	2018	Total
	MDR-GNB n (%)	MDR-GNB n (%)	MDR-GNB n (%)
	540 (68.2)	429 (59.9)	969 (64.3)
Age groups
>10	84 (65.1)	63 (50.4)	147 (57.9)
10–19	31 (55.4)	25 (55.6)	56 (55.4)
20–29	137 (68.2)	74 (59.2)	211 (64.7)
30–39	63 (62.4)	61 (57.5)	124 (59.9)
40–49	49 (73.1)	26 (50)	75 (63)
50–59	27 (79.4)	30 (62.5)	57 (69.5)
60–69	59 (76.6)	52 (67.5)	111 (72.1)
70–79	47 (79.7)	39 (75)	86 (77.5)
80–89	32 (59.3)	45 (67.2)	77 (63.6)
≤90	11 (78.6)	14 (73.7)	25 (75.8)
Gender
Female	377 (68.1)	266 (56.6)	643 (62.8)
Male	163 (68.5)	163 (66.3)	326 (67.4)
Location
ICU	51 (67.1)	29 (63)	80 (65.6)
INP	145 (75.9)	151 (69.6)	296 (72.5)
OP	127 (68.3)	71 (55)	198 (62.9)
ER	217 (64)	178 (54.9)	395 (59.6)
Sample
Urine	338 (68.4)	255 (59)	593 (64)
Blood	23 (79.3)	13 (68.4)	36 (75)
Respiratory	37 (72.5)	29 (54.7)	66 (63.5)
Swab	127 (65.5)	113 (60.8)	240 (63.2)
Others	15 (62.5)	19 (73.1)	34 (68)
Gram-negative organisms
Acinetobacter spp.	24 (85.7)	8 (42.1)	32 (68.1)
Enterobacter spp.	29 (80.6)	35 (92.1)	64 (86.5)
Escherichia coli	328 (73.4)	225 (61.6)	553 (68.1)
Klebsiella pneumoniae	73 (61.3)	91 (60.7)	164 (61)
Proteus spp.	42 (67.7)	42 (77.8)	84 (72.4)
Pseudomonas aeruginosa	44 (44)	28 (31.1)	72 (37.9)
Risk factors
Central line (≥72 h)	21 (80.8)	8 (80)	29 (80.6)
Foley catheter (≥72 h)	71 (74)	56 (69.1)	127 (71.8)
Mechanical ventilator (≥72 h)	47 (81)	23 (69.7)	70 (76.9)
Post-operation (past 4 weeks)	44 (77.2)	33 (73.3)	77 (75.5)
History of admission in SFHD (past 6 months)	153 (80.1)	139 (66.5)	292 (64.3)

Figure 2 [The rate of antibiotics susceptibility among MDR-GNB isolates collected in 2017 AND 2018]. %Susceptibility rate=Number of susceptible isolates/Total number of isolates×100. Boxes in green, yellow and red color reflect susceptibility rate of: 90–100%, 70–89% and <70% respectively.

Abbreviations: AMIK, amikacin; AMP, ampicillin; AMC/CLAV, amoxicillin/clavulanic acid; CZO, cefazolin; FEB, cefepime; CAZ, ceftazidime; CRO, ceftriaxone; CXM, cefuroxime; CIP, ciprofloxacin; LEVO, levofloxacin; GENT, gentamicin; IMP, mipenem; MRP, meropenem; NFN, nitrofurantoin; TAZ, piperacillin/tazobactam; TRIMETH, trimethoprim.

Table 2 Descriptive Characteristics of MDR-GNB Over the Study Period in Relation to Patients' Sociodemographic Features and Health Indicators

	2017		2018		Total
	No. of GNB	MDR-GNB n (%)	No. of GNB	MDR-GNB n (%)	No. of GNB	MDR-GNB n (%)
	792	540 (100)	716	429 (100)	1508	969 (100)
Age groups	(X^2 = 17.899, df = 9, P value = 0.036)		(X^2 = 17.358, df = 9, P value = 0.043)		(X^2 = 25.193, df = 9, P value = 0.003)
>10	129	84 (15.6)	125	63 (14.7)	245	147 (15.2)
10–19	56	31 (5.7)	45	25 (5.8)	101	56 (5.8)
20–29	201	137 (25.4)	125	74 (17.2)	326	211 (21.8)
30–39	101	63 (11.7)	106	61 (14.2)	207	124 (12.8)
40–49	67	49 (9.1)	52	26 (6.1)	119	75 (7.7)
50–59	34	27 (5)	48	30 (7)	82	57 (5.9)
60–69	77	59 (10.9)	77	52 (12.1)	154	111 (11.5)
70–79	59	47 (8.7)	52	39 (9.1)	111	86 (8.9)
80–89	54	32 (5.9)	66	45 (10.5)	121	77 (7.9)
≤90	14	11 (2)	20	14 (3.3)	33	25 (2.6)
Gender	(X^2 = 0.015, df = 1, P value = 0.904)		(X^2 = 6.280, df = 1, P value = 0.012)		(X^2 = 2.979, df = 1, P value = 0.084)
Female	554	377 (69.8)	470	266 (62)	1024	643 (66.4)
Male	238	163 (30.2)	246	163 (38)	484	326 (33.6)
Location	(X^2 = 8.025, df = 3, P value = 0.045)		(X^2 = 13.255, df = 3, P value = 0.004)		(X^2 = 18.896, df = 3, P value = 0.000)
ICU	76	51 (9.4)	46	29 (6.8)	122	80 (8.3)
INP	191	145 (26.9)	217	151 (35.2)	408	296 (30.5)
OP	186	127 (23.5)	129	71 (16.6)	315	198 (20.4)
ER	339	217 (40.2)	324	178 (41.5)	663	395 (40.8)
Sample	(X^2 = 3.135, df = 4, P value = 0.536)		(X^2 = 3.240, df = 4, P value = 0.518)		(X^2 = 2.965, df = 4, P value = 0.564)
Urine	494	338 (62.6)	432	255 (59.4)	926	593 (61.2)
Blood	29	23 (4.3)	19	13 (3)	48	36 (3.7)
Respiratory	51	37 (6.9)	53	29 (6.8)	104	66 (6.8)
Sputum	12	8	13	3	25	11
Tracheal aspirate	38	28	36	23	74	51
Bronchial lavage and washing	1	1	3	2	4	3
Sinus aspirate	-	-	1	1	1	1
Swab	194	127 (23.5)	186	113 (26.3)	380	240 (24.8)
Anal	1	1	2	2	3	3
Ear	20	5	26	6	46	11
Endometrial	1	-	-	-	1	-
Eye	5	3	6	2	11	5
Genital	1	1	-	-	1	1
Groin	2	1	2	2	4	3
Placental	-	-	2	-	2	-
Pus	105	78	108	75	213	153
Skin	-	-	3	3	3	3
Throat	2	-	3	-	5	-
Vulval	2	-	-	-	2	-
Wound	55	38	34	23	89	61
Others	24	15 (2.8)	26	19 (4.4)	50	34 (3.5)
Bile Fluid	1	1	-	-	1	1
Catheter Tip	8	4	10	8	18	12
Peritoneal Fluid	1	1	1	1	2	2
Semen	3	1	-	-	3	1
Tissue	11	8	15	10	26	18
Gram-negative organisms	(X^2 = 41.596, df = 5, P value = 0.000)		(X^2 = 57.659, df = 5, P value = 0.000)		(X^2 = 83.573, df = 5, P value = 0.000)
Acinetobacter spp.	28	24 (4.4)	19	8 (1.9)	47	32 (3.3)
Enterobacter spp.	36	29 (5.4)	38	35 (8.2)	74	64 (6.6)
Escherichia coli	447	328 (60.7)	365	225 (52.4)	812	553 (57.1)
Klebsiella pneumoniae	119	73 (13.5)	150	91 (21.2)	269	164 (16.9)
Proteus spp.	62	42 (7.8)	54	42 (9.8)	116	84 (8.7)
Pseudomonas aeruginosa	100	44 (8.1)	90	28 (6.5)	190	72 (7.4)
Risk factors
Central line (≥72 h)	26	21	10	8	36	29
Foley catheter (≥72 h)	96	71	81	56	177	127
Mechanical ventilator (≥72 h)	58	47	33	23	91	70
Post-operation (past 4 weeks)	57	44	45	33	102	77
History of admission in SFHD (past 6 months)	191	153	209	139	400	292

Table 3 Logistic Regression Analysis of Risk Factors for MDR GNB

Risk Factors	Categories	Unadjusted				Adjusted^a				Adjusted^b
		OR	95% CI		P val.	OR	95% CI		P val.	OR	95% CI		P val.
			Lower	Upper			Lower	Upper			Lower	Upper
All samples
Age	Years	1.008	1.004	1.012	0.000	1.007	1.003	1.012	0.001	1.006	1.001	1.010	0.013
Gender	Female	Ref.
	Male	1.223	0.973	1.536	0.085	1.089	0.858	1.382	0.485	1.023	0.798	1.312	0.857
Central line (≥72 h)	No	Ref.
	Yes	2.345	1.020	5.389	0.045	2.167	0.936	5.016	0.071	2.521	1.028	6.182	0.043
Foley catheter (≥72 h)	No	Ref.
	Yes	1.475	1.044	2.084	0.028	1.156	0.792	1.686	0.453	1.066	0.702	1.621	0.764
Mechanical ventilator (≥72 h)	No	Ref.
	Yes	1.921	1.166	3.165	0.010	1.671	1.002	2.785	0.049	2.218	1.189	4.135	0.012
Post-operation (past 4 weeks)	No	Ref.
	Yes	1.775	1.116	2.823	0.015	1.595	0.996	2.554	0.052	1.430	0.887	2.306	0.143
History of admission in SFHD (past 6 months)	No	Ref.
	Yes	1.721	1.338	2.214	0.000	1.607	1.244	2.076	0.000	1.558	1.203	2.019	0.001
Samples	Urine	Ref.
	Blood	1.685	0.865	3.282	0.125	1.500	0.765	2.943	0.238	1.354	0.676	2.715	0.393
	Respiratory	0.975	0.640	1.486	0.907	0.742	0.473	1.163	0.193	0.606	0.368	0.999	0.050
	Swab	0.963	0.751	1.233	0.764	0.865	0.663	1.128	0.284	0.756	0.572	0.998	0.048
	Others	1.193	0.649	2.194	0.570	0.932	0.497	1.747	0.825	0.708	0.369	1.356	0.298
Location	ER	Ref.
	ICU	1.292	0.862	1.936	0.214	1.054	0.676	1.643	0.815
	INP	1.793	1.373	2.342	0.000	1.584	1.189	2.112	0.002
	OP	1.148	0.871	1.513	0.327	1.089	0.823	1.441	0.550
Specific samples
Central line (≥72 h)	Blood	1.667	0.306	9.080	0.555	2.725	0.412	18.041	0.299	2.773	0.261	29.447	0.398
Foley catheter (≥72 h)	Urine	1.343	0.708	2.547	0.367	1.009	0.505	2.015	0.981	0.976	0.458	2.080	0.950
Mechanical ventilator (≥72 h)	Respiratory	2.600	1.124	6.012	0.025	2.682	1.149	6.261	0.022	2.224	0.868	5.703	0.096
Post-operation (past 4 weeks)	Wound and pus swab	1.296	0.679	2.471	0.431	1.321	0.691	2.524	0.400	1.327	0.690	2.552	0.397

Notes: ^aAdjusted logistic regression (age and gender). ^bAdjusted logistic regression (age, gender, and location of sample collection).

Abbreviations: AMR, antimicrobial- resistance; E. coli, Escherichia coli; ER, emergency room; ESBL, extended-spectrum beta-lactamases; GNB, Gram-negative bacteria; HIS, hospital information system; ICU, intensive care unit; INP, inpatient; IRB, Institutional Review Board; K. pneumoniae, Klebsiella pneumoniae; LIS, laboratory information system; MDR, multidrug-resistant; MDR-GNB, multidrug-resistant Gram-negative bacteria; MDROs, multidrug-resistant organisms; NICU, neonatal intensive care unit; OB/GYN, obstetrics/gynecology; OP, outpatient; P. aeruginosa, Pseudomonas aeruginosa; PICU, pediatric intensive care unit; SFHD, Security Forces Hospital-Dammam.