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Malaysian Journal of Medical Sciences
School of Medical Sciences, Universiti Sains Malaysia
ISSN: 1394-195X
Vol. 18, Num. 2, 2011, pp. 27-31
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Malaysian Journal of Medical Sciences, Vol. 18, No. 2, 2011, pp. 27-31
Original
Article
Microbiology of Lower Respiratory Tract Infections in Benin
City, Nigeria
Christopher Aye Egbe1, Casimir Ndiokwere1, Richard Omoregie1,2
1 Department of
Medical Microbiology, University of
Benin Teaching Hospital, PMB 1111,
Benin City, Edo State, Nigeria
2 School of
Medical Laboratory Science, University of Benin Teaching Hospital, PMB 1111, Benin City, Edo
State, Nigeria
Correspondence: Mr Christopher Aye Egbe MSc Medical Microbiology (Ambrose
Alli University) Department of Medical Microbiology University of Benin Teaching
Hospital PMB 1111, Benin City Edo State, Nigeria Tel: +2348055963431 Email: egbeaye@yahoo.com
Submitted: 2 Oct 2010
Accepted: 21 Dec 2010
Code Number: mj11018
Abstract
Background: Lower respiratory tract infections
are among the most common infectious diseases of humans worldwide and continue
to be a major cause of morbidity in Nigeria. This study focused on determining
the microbial agents of lower respiratory tract infections, the effect of age
and gender on its prevalence, and the susceptibility profile of bacterial
isolates.
Methods: Sputum specimens were collected from
1539 patients with symptoms of lower respiratory tract infections. The sputum
specimens were processed to recover microbial aetiologic agents and
susceptibility profiles of bacterial isolates were determined using standard
techniques.
Results: An overall prevalence of 18.91% of
lower respiratory tract infections was observed in this study. There is no
difference in the prevalence of lower respiratory tract infection between the
genders (P = 0.649). The
prevalence of lower respiratory tract infections increases significantly with
age (P < 0.001), with
patients 71 years and older having the highest prevalence. Klebsiella pneumoniae was
the most predominant isolate causing lower respiratory tract infection while Acinetobacter
species were the least predominant isolate. The fluoroquinolones, β-lactams,
and gentamicin showed moderate to
high activity.
Conclusion: Gender did not affect the
prevalence, but age did. β-lactams, fluoroquinolones, and gentamicin
were the most active antibacterial agents and, therefore, the drugs of choice
in treating lower respiratory tract infections in our setting.
Keywords:
aetiology, antibacterial agents, clinical microbiology, Nigeria,
prevalence, respiratory tract infections
Introduction
Lower respiratory tract infections (LRTIs) are
among the most common infectious diseases affecting humans worldwide (1).
They are important causes of morbidity and mortality for all age groups, and
each year approximately 7 million people die as a direct consequence of acute
and chronic respiratory infections (2). In Nigeria, LRTIs continue to be
the major cause of morbidity (3). Age, gender, and season are factors that
have been implicated to affect the prevalence of LRTIs (4).
The aetiologic agents of LRTIs vary
from area to area (2,5), so the susceptibility profile will also differ
between geographical locations. Knowing the local susceptibility profile is important,
as antimicrobial therapies for LRTIs are frequently empirical and presumptive (2).
Current knowledge of the organisms that cause LRTIs and their antibiotic
susceptibility profiles are therefore necessary for the prescription of appropriate
therapy. This study was conducted to determine the microbial agents of human
respiratory tract infections, the effect of age and gender on the prevalence of
LRTIs, and the susceptibility pattern of bacterial isolates.
Subjects and Methods
Study population
A retrospective laboratory record review was
undertaken. This study recruited a total of 1539 patients with symptoms of
LRTIs who visited the chest clinic of the University of Benin Teaching
Hospital, Benin City, Nigeria, between 1 February 2007 and 30 July 2010; 841
patients were men and 698, women. The age range of the patients was between 2
and 98 years. Exclusion criteria included antibiotic usage within 1 week prior
to clinic visit, positive for HIV, or sputum smear positive for acid-fast
bacilli. Verbal informed consent was obtained from each patient or their parents/guardians
(for children) prior to specimen collection. The Ethical Committee of
University of Benin Teaching Hospital approved this study.
Specimen collection and processing
Early morning sputum specimens, or for children, transtracheal
aspirates, were collected from each patient into wide-mouthed sterile
containers and transported to the laboratory. Films were made from the sputum
specimens and stained by Grams method. The presence of numerous pus cells
confirms true sputum and only such specimens were cultured. Each sputum sample
was inoculated on chocolate, blood, and MacConkey agar plates. The plates were
incubated at 37 0C for 2448 hours. Emergent colonies were
identified using standard methods (6). Susceptibility tests were performed
on significant bacterial isolates using the British Society for Antimicrobial
Chemotherapy (BSAC) standardized disc susceptibility testing method
(7).
Statistical analysis
The data obtained were analyzed with chi-square (χ2)
test using the INSTAT® statistical software (GraphPad Software Inc, San
Diego, CA, USA).
Results
A total of 291 (18.91%) out of 1539 sputum samples
yielded significant growth. There were no significant differences in the
prevalence of LRTIs (P = 0.649)
and mixed infections (P = 0.196)
between men and women (Table 1). The prevalence of LRTIs increased
significantly (P < 0.001)
with age, with the age group of 71 years and older having the highest
prevalence, 48.57% (Table 2). Generally, Klebsiella pneumoniae (30.16%) was the predominant isolate
recovered, followed by Haemophilus
influenzae (17.05%), Staphylococcus
aureus (15.41%), and Acinetobacter species
(0.66%). K. pneumoniae was also the
predominant isolate in both genders. S.
aureus was the second most predominant isolate in women, whereas H. influenzae was
the second most predominant isolate in men (Table 3). K. pneumoniae and Candida albicans were
isolated from 5 patients, making them the highest combination of mixed
infection, while the followings were isolated from 1 patient each: Proteus species and K. pneumoniae, K. pneumoniae and Enterobacter species, K.
pneumoniae and Providencia
species, Escherichia coli and C.
albicans, E. coli and Proteus
species, Citrobacter species and Alcaligenes
species, Citrobacter species and Proteus species, H. influenzae and C. albicans,
and H. influenzae and S. aureus.
Table 1: Effect of gender on the prevalence of lower respiratory tract
infections
Gender
|
No. tested
|
No. positive growth (%)
|
No. with mixed growth (%)
|
Male
|
841
|
163 (19.38)
|
5 (3.07)
|
Female
|
698
|
128 (18.34)
|
9 (7.03)
|
Total
|
1539
|
291 (18.91)
|
14 (4.81)
|
Gender versus positive growth: χ2= 0.207, P= 0.649
Gender
versus mixed growth: χ2= 1.670, P= 0.196
Table 2: Effect of age on the prevalence of lower respiratory tract
infections
Age (years)
|
Male
|
Female
|
Total
|
No. tested
|
No. positive growth (%)
|
No. tested
|
No. positive growth (%)
|
No. tested
|
No. positive growth (%)
|
110
|
38
|
5 (13.16)
|
34
|
9 (26.49)
|
72
|
14 (19.44)
|
1120
|
77
|
3 (3.90)
|
38
|
6 (15.79)
|
115
|
9 (7.88)
|
2130
|
233
|
43 (18.45)
|
220
|
26 (11.82)
|
453
|
69 (15.23)
|
3140
|
265
|
58 (21.89)
|
206
|
35 (16.99)
|
471
|
93 (19.75)
|
4150
|
88
|
27 (30.68)
|
82
|
14 (17.07)
|
170
|
41 (24.12)
|
5160
|
81
|
17 (20.99)
|
71
|
16 (22.54)
|
152
|
33 (21.71)
|
6170
|
41
|
4 (9.76)
|
30
|
11 (36.67)
|
71
|
15 (21.13)
|
> 71
|
18
|
6 (33.33)
|
17
|
11 (64.71)
|
35
|
17 (48.57)
|
Age versus positive growth: χ2= 37.484, P < 0.001
Table 3: Aetiologic agents in
lower respiratory tract infections
Organisms
|
Males (%)
|
Females (%)
|
Total (%)
|
Escherichia coli
|
6 (3.60)
|
7 (5.12)
|
13 (4.26)
|
Klebsiella pneumoniae
|
47 (27.98)
|
45 (32.85)
|
92 (30.16)
|
Citrobacter species
|
5 (2.98)
|
4 (2.92)
|
9 (2.95)
|
Enterobacter species
|
2 (1.19)
|
1 (0.73)
|
3 (0.98)
|
Proteus species
|
18 (10.71)
|
5 (3.65)
|
23 (7.54)
|
Providencia species
|
5 (2.98)
|
5 (3.65)
|
10 (3.29)
|
Acinetobacter species
|
1 (0.60)
|
1 (0.73)
|
2 (0.66)
|
Alcaligenes species
|
6 (3.60)
|
6 (4.38)
|
12 (3.93)
|
Pseudomonas aeruginosa
|
9 (5.36)
|
5 (3.65)
|
14 (4.59)
|
Haemophilus influenza
|
31 (18.45)
|
21 (15.33)
|
52 (17.05)
|
Staphylococcus aureus
|
24( 14.29)
|
23 (16.79)
|
47 (15.41)
|
Streptococcus pneumoniae
|
1 (0.60)
|
5 (3.65)
|
6 (1.97)
|
Candida albicans
|
13 (7.74)
|
9 (6.57)
|
22 (7.21)
|
Total
|
168 (55.08)
|
137 (44.92)
|
305 (100)
|
The susceptibility profile of bacterial isolates is
shown in Table 4. The fluoroquinolones (ofloxacin, ciprofloxacin), b-lactams (amoxicillin-clavulanate, cefuroxime,
cetazidime, ceftriaxone), and gentamicin showed moderate to high activity.
Sulfamethoxazole-trimetroprim, tetracycline, erythromycin, and cloxacillin
showed no activity against any bacterial isolates.
Table 4: Susceptibility profiles of bacterial agents of lower respiratory
tract infections
Organisms
|
Antibacterial agents (mg/disc)
|
OFX
(5)
|
CIP
(5)
|
CN
(10)
|
AUG
(30)
|
SXT
(25)
|
OB
(5)
|
TE
(10)
|
CXM
(30)
|
C
(10)
|
E
(5)
|
CRO
(30)
|
CAZ
(30)
|
Escherichia coli
(n = 13)
|
13
(100.0)
|
13
(100.0)
|
13
(100.0)
|
13
(100.0)
|
0
(0.0)
|
ND
|
0
(0.0)
|
11
(84.6)
|
0
(0.0)
|
ND
|
12
(92.3)
|
11
(84.6)
|
Klebsiella pneumonia
(n = 92)
|
88
(95.6)
|
86
(93.5)
|
79
(85.9)
|
86
(95.6)
|
0
(0.0)
|
ND
|
0
(0.0)
|
86
(93.5)
|
0
(0.0)
|
ND
|
84
(91.3)
|
81
(88.0)
|
Citrobacter species
(n = 9)
|
9
(100.0)
|
9
(100.0)
|
6
(66.7)
|
0
(0.0)
|
0
(0.0)
|
ND
|
0
(0.0)
|
9
(100.0)
|
0
(0.0)
|
ND
|
7
(77.8)
|
5
(55.6)
|
Enterobacter species
(n = 3)
|
3
(100.0)
|
3
(100.0)
|
0
(0.0)
|
0
(0.0)
|
0
(0.0)
|
ND
|
0
(0.0)
|
3
(100.0)
|
0
(0.0)
|
ND
|
3
(100.0)
|
3
(100.0)
|
Proteus species
(n = 23)
|
23
(100.0)
|
19
(82.6)
|
17
(73.9)
|
19
(82.6)
|
0
(0.0)
|
ND
|
0
(0.0)
|
19
(82.6)
|
0
(0.0)
|
ND
|
10
(43.5)
|
10
(43.5)
|
Providencia species
(n = 10)
|
10
(100.0)
|
8
(80.0)
|
6
(60.0)
|
10
(100.0)
|
0
(0.0)
|
ND
|
0
(0.0)
|
8
(80.0)
|
3
(30.0)
|
ND
|
6
(60.0)
|
6
(60.0)
|
Acinetobacter species
( n = 2)
|
2
(100.0)
|
2
(100.0)
|
1
(50.0)
|
10
(100.0)
|
0
(0.0)
|
ND
|
0
(0.0)
|
1
(50.0)
|
0
(0.0)
|
ND
|
1
(50.0)
|
0
(0.0)
|
Alcaligenes species
(n = 12)
|
10
(83.3)
|
8
(66.7)
|
7
(58.3)
|
10
(83.3)
|
0
(0.0)
|
ND
|
0
(0.0)
|
8
(66.7)
|
0
(0.0)
|
ND
|
8
(66.7)
|
7
(58.3)
|
Pseudomonas aeruginosa
(n = 14)
|
14
(100.0)
|
2
(85.7)
|
10
(71.4)
|
6
(42.9)
|
0
(0.0)
|
ND
|
0
(0.0)
|
0
(0.0)
|
0
(0.0)
|
ND
|
9
(64.3)
|
6
(42.9)
|
Haemophilus influenzae
(n = 52)
|
52
(100.0)
|
50
(96.2)
|
50
(96.2)
|
47
(90.3)
|
0
(0.0)
|
ND
|
0
(0.0)
|
45
(86.5)
|
0
(0.0)
|
ND
|
48
(92.3)
|
47
(90.4)
|
Staphylococcus aureus
(n = 47)
|
47
(100.0)
|
43
(91.45)
|
39
(83.0)
|
41
(67.2)
|
0
(0.0)
|
0
(0.0)
|
0
(0.0)
|
44
(93.6)
|
0
(0.0)
|
0
(0.0)
|
43
(91.5)
|
40
(85.1)
|
Streptococcus pneumoniae
(n = 6)
|
6
(100.0)
|
6
(100.0)
|
0
(0.0)
|
6
(100.0)
|
0
(0.0)
|
0
(0.0)
|
0
(0.0)
|
5
(83.3)
|
0
(0.0)
|
0
(0.0)
|
5
(83.3)
|
5
(83.3)
|
Data are expressed in number of susceptible isolates (percentage susceptibility).
Abbreviations: OFX = ofloxacin, CIP = ciprofloxacin, CN = gentamicin, AUG
= amoxycillin/clavulanate, SXT = cotrimoxazole, OB = cloxacillin, TE = tetracycline,
CXM = cefuroxime, ND = not done, C = chloramphenicol, E = erythromycin, CRO
= ceftriaxone, CAZ = ceftazidime.
Discussion
The aetiologic agents of LRTIs vary from area to
area, and the bacterial aetiology as well as their susceptibility pattern will
be useful in the management of this infection. This study focused on
determining the prevalence of microbial aetiology of LRTIs and their susceptibility
profile.
A total of 291 (18.91%) of the 1539 sputum specimens
yielded clinically significant pathogens. This prevalence is lower than the
figures in previous reports: 59.4% (2), 47.2% (3), and 27.0% (8). Among
children with diarrhea, prevalence of the infection varied with geographical
locations, regions within the same country, and even over time in the same
location and population (9). Indeed, the Ozyilmaz et al.s study (2) was
conducted in Turkey, the Egbagbe and Mordis study (3) was conducted in
University of Benin Teaching Hospital, Benin City, Nigeria, while the Okesola
and Iges study (8) was conducted in Ibadan in Nigeria.
Previous reports
had also indicated higher prevalence of LRTIs in women than in men (3,8).
However, in this study the prevalence of LRTIs did not differ significantly
between men and women. The prevalence of LRTIs was significantly higher in
patients 71 years and older. People within this age group may have lower
immunity due to age (10) or other ailments that may compromise the immune system,
which may explain the high prevalence observed in this study.
K.
pneumoniae was the most
predominant isolate recovered from patients with LRTIs. This is in agreement
with previous studies (3,8); however, another study (2) reported H. influenzae as the most prevalent. Acinetobacter species have been
associated with hospital-acquired pneumonia (1), but as our subjects were
outpatients, the Acinetobacter species
recovered in this study may be associated with community-acquired LRTIs. Further
investigation is required to verify this result, as many patients come to our
centre after visiting either public hospitals or primary and secondary care
hospitals. Other microbial agents recovered in this study have been reported to
be associated with LRTIs (13,8).
The susceptibility pattern of the bacterial
isolates revealed that b-lactams, gentamicin, and flouroquinolones were
very active against the bacterial isolates. This is surprising as sales of
antibiotics without prescriptions are rife in Nigeria (11,12). However, sulfamethoxazole-trimetroprim,
tetracycline, cloxacillin, and erythromycin were not active against any
bacterial isolate, while only 30% of Providencia
species were susceptible to chloramphenicol. This may indicate resistance
has evolved due to long-term use of these quite affordable antibacterial agents
in the community. The fluoroquinolones are contraindicated in children and
pregnant women, while ceftriaxone, ceftazidime, and cefuroxine are very
expensive. Gentamicin has toxic side effect in patients with renal impairment,
so amoxicillin/clavulanate appears to be the drug of choice, depending on the
bacterial isolates.
Conclusion
An overall prevalence of 18.91% of LRTIs was
observed in this study. Gender did not affect the prevalence of LRTIs. Patients
of 71 years and older have a significantly higher prevalence of LRTI compared
with other age groups. K. pneumoniae is the most predominant bacteria isolates. b-lactams,
fluoroquinolones, and gentamicin were the most active antibacterial agents.
This study highlights the aetiology of LRTIs and the bacteria susceptibility
profiles may be helpful for empiric therapy.
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