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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 159-162

Microbiological profile of bloodstream infections in cancer patients


1 Department of Microbiology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
2 Department of Microbiology, SLN Medical College and Hospital, Koraput, Odisha, India

Date of Submission10-Feb-2020
Date of Acceptance20-May-2020
Date of Web Publication04-Mar-2022

Correspondence Address:
Swati Jain
142, Doctors' Enclave, Campus-3, IMS and SUM Hospital, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_11_20

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  Abstract 


Background: Bloodstream infections (BSIs) remain a major cause of mortality in patients with malignancies. Up to 17% of patients who develop a nosocomial BSI in the hospital have an underlying malignancy. Gram-negative bacilli are the predominant etiologic agents of BSI, and their multidrug resistance rate is increasingly being recognized. This study attempts to identify the likely causative agents and their antibiotic susceptibility profile of BSI in cancer patients. Methodology: We conducted a prospective study for a period of 1 year and analyzed the spectrum of BSI and their antimicrobial susceptibility profile in cancer patients. Blood samples were collected aseptically and inoculated in BacT/ALERT (BioMerieux) blood culture bottles. Identification and antimicrobial susceptibility testing of the isolates including their methicillin resistance and β-lactamase and carbapenemase production were done by Vitek-2 (BioMerieux) method. Results: Of a total of 250 cancer patients, 60 (24%) were found to have BSI. The most common underlying malignancy associated with BSI was of gastrointestinal system (45%) followed by acute myeloid leukemia (21.7%). Most of the isolates belonged to Gram-negative bacteria (53.3%). Coagulase-negative Staphylococcus was the most common organism isolated followed by Escherichia coli. Conclusion: The treatment of infections in patients with malignancy relies on the use of established guidelines along with the consideration of local epidemiological data. The poor activity of primary empirical agents and the emergence of multidrug-resistance is alarming.

Keywords: BacT/ALERT, bloodstream infection, cancer, multidrug resistant, Vitek-2


How to cite this article:
Kabi S, Swain B, Jain S. Microbiological profile of bloodstream infections in cancer patients. CHRISMED J Health Res 2021;8:159-62

How to cite this URL:
Kabi S, Swain B, Jain S. Microbiological profile of bloodstream infections in cancer patients. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:159-62. Available from: https://www.cjhr.org/text.asp?2021/8/3/159/339038




  Introduction Top


Cancer patients are more prone to different types of infections. Bloodstream infection (BSI) is a significant complication in these patients as it may delay the initiation of chemotherapy, prolong hospital stay, and increase health-care cost and also the prognosis such as morbidity and mortality.[1],[2] As per global estimates, cancer is a common comorbid condition associated with sepsis, reported approximately in 10%–17% cases of BSI.[3],[4] The overall mortality rate in patients with BSI and cancer is up to 40%, which is significantly higher than that in patients without cancer.[2],[5] Factors which increase the susceptibility of immunosuppressed cancer patients to infection include neutropenia, altered gut flora due to frequent antibiotic administration, and damage of epithelial surface by cytotoxic agents. Neutropenia, a major adverse effect of cytotoxic chemotherapy, can also be due to myelosuppression by malignant infiltration. Hence, cancer causes both direct and indirect effects on the patient's immune system.[6] The incidence of BSI in patients with hematological malignancy is higher than that in patients with solid tumors, but the reverse trend is noticed for case fatality rate.[7] A recent shift from Gram-positive to Gram-negative organisms has been documented in the etiology of BSI.[1] The emergence of multidrug resistant (MDR) bacteria, especially Enterobacteriaceae together with Pseudomonas species, exerts a major impact on the outcome of patients.[8] In addition, extensive prophylaxis with antifungals in hematologic patients has led to a shift in the fungal spectrum to more resistant strains.[9] The aim of this study is to identify the likely etiologic agents and their antimicrobial susceptibility profile in cancer patients with BSI.


  Methodology Top


The present study was carried out at IMS and SUM Hospital, Bhubaneswar, Odisha, India, over a period of 1 year (January 2019–December 2019). All hospitalized cancer patients (with or without neutropenia) admitted under medical/surgical oncology, clinical hematology, and pediatric oncology and undergoing anticancer therapy with suspected BSI were included in the study. Blood samples were collected aseptically, preferably before the commencement of antimicrobial therapy. In patients already receiving antibiotics, the timing of collection of blood samples was just before the next dose of antibiotic. The specimens were inoculated into the BacT/ALERT (Biomerieux, USA) blood culture bottles and incubated at 37°C for a maximum period of 7 days in BacT/ALERT 3D system and if there was no growth, the result was read as negative. From culture bottles which were flagged positive in the system, Gram stain was performed. If Gram-positive or Gram-negative bacteria were observed, blood was subcultured on Blood agar, MacConkey agar, and chocolate agar. If yeast cells were observed on staining, blood was subcultured on two Sabouraud's dextrose agar and blood agar plates and incubated at 37°C. Culture plates were examined for bacterial or fungal colonies after 24–48 hrs of incubation. Further identification and antimicrobial susceptibility testing (ABST) of the isolates were done by Vitek-2 (BioMerieux) with 0.5% McFarland suspension from the colonies using the identification card and ABST card as per Clinical and Laboratory Standards Institute guidelines and manufacturer's instructions.


  Results Top


Out of the 250 cancer patients with suspected BSI included in the study, only 60 (24%) were found to have BSI with a single type of pathogen. Maximum number of patients were in the middle age group, i.e., 41–60 years (32/60, 53.3%), and 56.6% (34/60) of the isolates were recovered from female patients. Thirty-seven patients had solid tumors and 23 were with hematological malignancies. The most frequent underlying malignancy associated with BSI was of gastrointestinal system (45%) followed by acute myeloid leukemia (AML) (21.7%) [Table 1].
Table 1: Distribution of cancer patients

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Gram-negative bacteria was more frequently (53.3%) isolated than the Gram-positive bacteria (36.7%). Candida was recovered in 10% of the isolates. Coagulase-negative staphylococcus (CoNS) was the most common organism isolated followed by Escherichia coli [Table 2].
Table 2: Distribution of microorganisms

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Gram-positive organisms were invariably susceptible toward linezolid, daptomycin, and vancomycin (100% each) and least susceptible to erythromycin (9%), as shown in [Graph 1]. Methicillin resistance was observed in 20% of Staphylococcus aureus isolates and 33.3% of CoNS isolates.



Gram-negative organisms of family Enterobacteriaceae were most susceptible toward amikacin (82.3%) and least susceptible toward ampicillin and cefuroxime (11.7% each), as shown in [Graph 2]. Out of 17 Gram-negative isolates, 7 were β-lactamase producers (41.2%).



Nonfermenting Gram-negative organisms were most susceptible toward amikacin and minocycline (60% each) and least susceptible toward ciprofloxacin and cefepime (13.3% each), as shown in [Graph 3]. Out of 15 nonfermenters, 6 were carbapenemase producers (40%).



Of the total candida species isolated (n = 6), all were susceptible to voriconazole, caspofungin, micafungin, amphotericin-B, and flucytosine, whereas only 66.7% of them were sensitive to fluconazole.


  Discussion Top


The prevalence of BSI in patients with cancer (with or without neutropenia) was found to be 24% in this study, which is well within the range (11%–38%) as reported earlier.[2],[10],[11] Middle age group people (53.3%) were most commonly affected in this study, with female patients (56.6%) outnumbering male patients. This pattern was similar to a study done by Islas-Munoz et al., in which around 60% of female patients were affected.[12] Of the total 60 malignancy cases, we had 37 cases with solid tumors mostly involving gastrointestinal system and 23 with hematological malignancies mainly the AML cases. This finding was consistent with a study by Horasan et al.[13] The organisms causing BSI in cancer have changed their pattern over time. Gram-negative organisms were the predominant causative agents in 1960–1970. Then, there was a shift toward Gram-positive organisms in the next two decades. Again, in the recent decades, Gram-negative organisms have been predominating as the causative agents of BSI in cancer. In our study, Gram-negative organisms (53.3%) were also the predominant causative agent. This finding is well correlated with other reports.[10],[12],[13],[14] The prevalence of methicillin-resistant S. aureus and methicillin-resistant staphylococci in our study was 20% and 33.3%, respectively, which is in concordance to a study by Prabhash et al.[15] Enterobacteriaceae-producing β-lactamases were identified in 41.2% of the isolates, which is similar to a study by Montassier et al.[2] This high prevalence of β-lactamases was attributed to the irrational use of β-lactams along with β-lactamase inhibitors, resulting in the emergence of resistant strains which promote the use of carbapenems. In our study, the organisms were mostly susceptible to amikacin (82.3%), followed by ertapenem and meropenem (76.5% each). Carbapenemase-producing nonfermenters were found to be 40% in this study, which is in concordance with a study by Karlowsky et al.[16] Six isolates were completely resistant to all the given antibiotics. Acinetobacter baumanii has emerged as the prominent MDR bacteria in intensive care units all over the world. In addition, their occurrence as a cause of BSI in malignancy can be disastrous. The reduced activity of carbapenems against nonfermenters is especially disturbing. As of now, colistin, tigecycline, and polymyxin are the reserved drugs and being used as alternative possible choices for treatment. Judicious and appropriate antibiotic must be used whenever indicated. It is a matter of time before these antibiotics are also exhausted.


  Conclusion Top


Emergence of MDR bacteria is an important health-care problem worldwide, more so, in patients with cancer. We should adapt antimicrobial use based on local epidemiological data which helps in maximizing the clinical outcome. Sound hospital infection control practices should be followed to reduce nosocomial transmission of infections.

Acknowledgment

We are grateful to S”O”A deemed to be university for their constant support and encouragement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marin M, Gudiol C, Ardanuy C, Garcia-Vidal C, Calvo M, Arnan M, et al. Blood stream infections in neutropenic patients with cancer: Differences between patients with haematological malignancies and solid tumours. J Infect 2014;69:417-23.  Back to cited text no. 1
    
2.
Montassier E, Batard E, Gastinne T, Potel G, de la Cochetiere MF. Recent changes in bacteremia in patients with cancer: A systematic review of epidemiology and antibiotic resistance. Eur J Clin Microbiol Infect Dis 2013;32:841-50.  Back to cited text no. 2
    
3.
Wisplinghoff H, Seifert H, Wenzel RP, Edmond MB. Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasms in hospitals in the United States. Clin Infect Dis 2003;36:1103-10.  Back to cited text no. 3
    
4.
Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003;348:1546-54.  Back to cited text no. 4
    
5.
Bos MM, Smeets LS, Dumay I, de Jonge E. Bloodstream infections in patients with or without cancer in a large community hospital. Infection 2013;41:949-58.  Back to cited text no. 5
    
6.
Staudinger T, Pene F. Current insights into severe sepsis in cancer patients. Rev Bras Ter Intensiva 2014;26:335-38.  Back to cited text no. 6
    
7.
Gudiol C, Aguado JM, Carratala J. Bloodstream infections in patients with solid tumors. Virulence 2016;7:298-308.  Back to cited text no. 7
    
8.
Tabah A, Koulenti D, Laupland K, Misset B, Valles J, de Carvalho FB, et al. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: The EUROBACT International Cohort Study. Intensive Care Med 2012;38:1930-45.  Back to cited text no. 8
    
9.
Lortholary O, Desnos-Ollivier M, Sitbon K, Fontanet A, Bretagne S, Dromer F, et al. Recent exposure to caspofungin or fluconazole influences the epidemiology of candidemia: A prospective multicenter study involving 2,441 patients. Antimicrob Agents Chemother 2011;55:532-8.  Back to cited text no. 9
    
10.
Obeng-Nkrumah N, Labi AK, Acquah ME, Donkor ES. Blood stream infections in patients with malignancies: Implications for antibiotic treatment in a Ghanaian tertiary setting. BMC Res Notes 2015;8:742.  Back to cited text no. 10
    
11.
Madani TA. Clinical infections and bloodstream isolates associated with fever in patients undergoing chemotherapy for acute myeloid leukemia. Infection 2000;28:367-73.  Back to cited text no. 11
    
12.
Islas-Munoz B, Volkow-Fernandez P, Ibanes-Gutierrez C, Villamar-Ramirez A, Vilar-Compte D, Corneju-Juarez P. Blood stream infections in cancer patients. Risk factors associated with mortality. Int J Infect Dis 2018;71:59-64.  Back to cited text no. 12
    
13.
Horasan ES, Ersoz G, Tombak A, Tiftik N, Kaya A. Bloodstream infections and mortality-related factors in febrile neutropenic cancer patients. Med Sci Monit 2011;17:CR304-9.  Back to cited text no. 13
    
14.
Morris PG, Hassan T, McNamara M, Hassan A, Wiig R, Grogan L, et al. Emergence of MRSA in positive blood cultures from patients with febrile neutropenia a cause for concern. Support Care Cancer 2008;16:1085-8.  Back to cited text no. 14
    
15.
Prabhash K, Medhekar A, Ghadyalpatil N, Noronha V, Biswas S, Kurkure P, et al. Blood stream infections in cancer patients: A single centre experience of isolates and sensitivity pattern. Indian J Cancer 2010;47:184-8.  Back to cited text no. 15
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16.
Karlowsky JA, Draghi DC, Jones ME, Thornsberry C, Friedland IR, Sahm DF. Surveillance for antimicrobial susceptibility among clinical isolates of Pseudomonas aeruginosa and Acinetobacter baumannii from hospitalized patients in the United States, 1998 to 2001. Antimicrob Agents Chemother 2003;47:1681-8.  Back to cited text no. 16
    



 
 
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