Bacterial Identification And Antibiotics Sensitivity Of Ventilator-Associated Pneumonia (VAP) Patients At RSD Dr. Soebandi Jember

Received: January, 19, 2021 Revised: March, 23, 2021 Available online: May 2021 Ventilator-Associated Pneumonia (VAP) is pneumonia in patients with a mechanical ventilator. The use of empirical antibiotics therapy to VAP patients based on bacterial identification and its antibiotics sensitivity. This study aims to determine bacterial identification and antibiotics sensitivity of VAP patients at RSD dr. Soebandi Jember. A descriptive observational study was conducted with a retrospective approach. The data were collected from the medical record of VAP patients from September to October 2019. All samples meet the inclusion and exclusion criteria. Data analysis utilized Microsoft Excel 2010. This paper had 15 VAP patients who conducted bacterial identification and its sensitivity to antibiotics. The most frequent bacteria that cause VAP was Acinetobacter baumannii. Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter aerogenes, Burkholderia cepacia, Pseudomonas fluorescens, Salmonella arizonae, and Escherichia coli also cause VAP. Antibiotics with the highest sensitivity to VAP-causing bacteria were amikacin, meropenem, and piperacillin-tazobactam. Meanwhile, the antibiotics that bacterial resistant were cefixime, cefotaxime, and ceftriaxone.


INTRODUCTION
Ventilator-associated pneumonia (VAP) is pneumonia in a ventilated patient on a ventilator for at least 48 hours (Dahlan, 2014). Its symptoms are fever, tachypnea, increased respiratory secretions, leukocytosis.
Other than that, its symptom also includes lung consolidation accompanied by new or changes in infiltrates on radiological examination (Hunter, 2006;(Mandell and Wunderink, 2015). Gadani's research showed that 37% of patients hospitalized in the Intensive Care Unit (ICU) became VAP (Gadani et al., 2010). Prolonged use of a ventilator leads to VAP risk, thereby increasing mortality from 5% to 65% (Schweiger et al., 2013) Several factors that influence VAP include the patient's age, length of use of a ventilator, patient consciousness level, comorbid disease, and antibiotic treatment (Wu et al., 2019) Several studies have reported bacterial resistance to antibiotics in humans, animals, and the environment García et al.,2020;Hoque et al., 2020). The negative impact of bacterial resistance in humans is that the infection does not recover by antibiotic therapy, more complication, a longer length of stay, higher cost of care, and increased patient mortality rate (Collignon, 2012;(Friedman et al., 2016     14. Acinetobacter baumannii.

DISCUSSION
The results of this study showed that VAP was more frequent in men than in women. This result is in line with Gadani et al., which reported that VAP was more frequent in men than women (Gadani et al., 2010).  (Kalil et al., 2016;Harris et al., 2017). In this study, eight Gram-negative bacteria species grew on bacterial culture. A study found Gram-negative bacteria caused 45-70% of VAP (Barbier et al., 2013). This paper showed that the most common bacteria that cause VAP was Acinetobacter baumannii (29%). Research reported that Acinetobacter baumannii was the cause of VAP in the ICU by 7.9% (Kalanuria et al., 2014). Acinetobacter baumannii is Gram negative, rod-shaped, and non-motile aerobic bacteria. It is often found in nosocomial pneumonia and immunosuppressed patients (Cilloniz, 2014). This bacteria has a particular target of moist tissue such as mucous membranes (Howard et al., 2012).
Klebsiella pneumonia, Enterobacter aerogenes, and Pseudomonas aeruginosa each bacteria were two samples (14%). Klebsiella pneumoniae and Enterobacter aerogenes are in the Enterobacteriaceae family that cause nosocomial pneumonia (Amer et al., 2018). Enterobacter aerogenes cause various nosocomial infections; one of them is VAP (Donenberg et al., 2015). Pseudomonas aeruginosa, in the form of rods and Gram-negative, can infect immune-compromised humans and become one of the pathogens that cause pneumonia in the ICU setting (Zander and Farver, 2018).
Pseudomonas fluorescens causes diseases in the respiratory tract and bacteremia in immunecompromised humans (Scales et al., 2014). In this paper, there were Escherichia coli and Salmonella arizonae; each bacteria were as many as two samples. They are Gram-negative, rod bacteria, and members of the Enterobacteriaceae family. Salmonella arizonae infection can occur in immunecompromised patients (Lee et al., 2016). Also, there was Burkholderia cepacia in one sample. However, these Gram-negative bacteria were reported to cause community-acquired pneumonia (Bayram et al.,

2011).
Antibiotics therapy empirically on VAP with the suspected cause of Gram-negative bacteria can use betalactam and non-beta-lactam antibiotics. Its antibiotics such as Fluoroquinolone, aminoglycosides, and polymixine (Kalil et al., 2016). The bacterial isolates were most sensitive to amikacin, meropenem, and piperacillin-tazobactam. 81% of the tested isolates were sensitive to amikacin, which is included in the aminoglycoside group. Aminoglycosides are therapy for infections caused by Gram-negative bacteria. It has a mechanism by inhibiting bacterial protein synthesis (Brunton et al., 2008). Some isolates were resistant to aminoglycoside. Aminoglycoside works through aminoglycoside modifying enzymes (AMEs) and ribosome target mutations (Garneau, 2016 (Hardman and Limbird, 2012). Piperacillin-tazobactam is stable against beta-lactamase and effective against Gram-positive and Gram-negative bacteria (Ito et al., 2010).
There were many bacteria from the Enterobacteriaceae family in this study. Most Enterobacteriaceae families are sensitive to cephalosporine and fluoroquinolone. Less than one percent of these bacteria had Extended-Spectrum Beta-Lactamase (ESBL) (Shindo et al., 2013). ESBL is an enzyme that can hydrolyze most of the penicillin class antibiotics. This paper showed that bacteria were resistant to the cephalosporin class, especially the third generation. The third generation of cephalosporin consists of cefixime, ceftriaxone, cefotaxime, and ceftazidime. The most common resistance mechanism to cephalosporins is the destruction of antibiotics through hydrolysis of the beta-lactam ring. The level of resistance to thirdgeneration cephalosporin in Enterobacteriaceae currently reached 10-70% (Ruppé et al., 2015). The production of beta-lactamase usually causes the resistance of Enterobacteriaceae to antibiotics. ESBL arises when there are mutations in genes encoding TEM-1, TEM-2, or SHV-1. Its mutations are new betalactamase capable of hydrolyzing third-generation cephalosporin and aztreonam (Paterson, 2006).

CONCLUSION
Acinetobacter baumannii is the most frequent VAP-causing bacteria at dr. Soebandi Hospital, Jember.