Infections and antimicrobial resistance in intensive care units in lower-middle income countries: a scoping review

Abstract

Background: Intensive care units (ICUs) in lower-middle income countries (LMICs) are suspected to constitute a special risk for patients of acquiring infection due to multiple antibiotic resistant organisms. The aim of this systematic scoping review was to present the data published on ICU-acquired infections and on antimicrobial resistance observed in ICUs in LMICs over a 13-year period. A systematic scoping review was conducted according to the PRISMA extension guideline for scoping reviews and registered in the Open Science Framework. Articles were sought that reported on ICU-acquired infection in LMICs between 2005 and 2018. Two reviewers parallelly reviewed 1961 titles and abstracts retrieved from five data banks, found 274 eligible and finally included 51. Most LMICs had not produced reports in Q1 or Q2 journals in this period, constituting a large gap in knowledge. However, from the reported evidence it is clear that the rate of ICU-acquired infections was comparable, albeit approximately 10% higher, in LMICs compared to high income countries. In contrast, ICU mortality was much higher in LMICs (33.6%) than in high income countries (< 20%). Multidrug-resistant Gram-negative species, especially Acinetobacter baumannii and Pseudomonas aeruginosa, and Klebsiella pneumoniae played a much more dominant role in LMIC ICUs than in those in high income countries. However, interventions to improve this situation have been shown to be feasible and effective, even cost-effective.

Conclusions: Compared to high income countries the burden of ICU-acquired infection is higher in LMICs, as is the level of antimicrobial resistance; the pathogen distribution is also different. However, there is evidence that interventions are feasible and may be quite effective in these settings. Protocol Registration The protocol was registered with Open Science Framework ( https://osf.io/c8vjk ).

Keywords: Acinetobacter; Bacterial drug resistance; Cross infection; Infection control; Intensive care units.

Fig. 1

Global Map highlighting lower-middle income countries (blue)

Fig. 2

Overview of study methodology

Fig. 3

Flowchart for literature search

Fig. 4

LMICs highlighted by number of studies reporting on Intensive Care Unit-associated infections in 2005–2018

Fig. 5

Distribution of ESKAPE pathogens causing ICU-acquired infection in LMICs and in West European countries. ESKAPE pathogens include Enterococcus spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli. Data from West European countries were extracted from reference [9]

Fig. 6

Distribution of ESKAPE pathogens causing Ventilator-Associated Pneumonia (VAP), Catheter-Associated Urinary Tract Infection (CAUTI) and Central Line-Associated Bloodstream Infection (CLABSI) in ICUs in lower-middle income countries, 2005–2018. ESKAPE pathogens include Enterococcus spp., Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Escherichia coli