Antibiotherapy during Bacterial Infection in Chronic Kidney Disease Patient Hospitalized in Nephrology of National Hospital Donka ()
1. Introduction
A bacterial infection is a proliferation resulting in cellular, tissu or general reactions, most often resulting in an inflammatory syndrome. It is the result of complex interaction between the body defense mechanism, the site and the bacteria [1] . Antibiotics are chemical or semi-synthetic substances produced by microorganisms, and have the power to oppose the multiplication of bacteria by destroying them or by inhibiting their multiplication [2] . The use of one or more antibiotic constitute antibiotherapy. Bacterial infection represents a major cause of morbidity and mortality (second cause after cardiovascular disease) in patients on chronic hemodialysis [3] .
All infections combined, the most frequently affected site are the urinary tract, respiratory system, skin and subcutaneous tissu. The germs most often responsible are gram-negative bacilli with Enterobacteriaceae (Escherichia coli, Klebsiella pneumonia…) then gram-positive cocci (Streptococcus pneumoniae, Staphylococcus aureus and Enterococcus) [4] .
The incidence of glomerulonephritis associated with bacterial infection in adults is estimated at 2 and 0.3 cases/100,000 person-years in developing and developed countries [5] . In Morocco, in a retrospective study carried out in 2012 at Al Ghassani provincial hospital in Fez, the prevalence of infection linked to central venous catheters in hemodialysis subjects was 1.23% with an average age of 46 years, after a catheter placement of 48 days [6] .
Research on infectious pathologies and antibiotic treatments has evolved rapidly, marked on the one hand by the emergence of new pathogen, on the other hand by the evolution of resistance to antibiotics despite the marketing of new molecule [7] . In Africa, 20% to 50% of antibiotic treatments are quantitatively or qualitatively inappropriate and this concerns both antibio-prophylaxis and curative antibiotic, whether or not there has been bacterial identification [8] . If the current trend continues, doctors could find themselves in the next few years, helpless in the face of certain infectious diseases [9] . The aim of the study was to identify the bacterial germ in our depatment and evaluate the bacterial sensitivity to antibiotic.
2. Methods
We did a descriptive study in 6 months from January 2 to June 30, 2019. We included all the patient hospitalized in the nephrology department who presented infectious signs, subjected to antibiotherapy. We determined the frequency of infections during the study period, socio-demographic parameters (age, sex, level of education) was evaluated; clinical parameters (length of hospitalization, signs of infection); laboratory parameters of the infection were full blood count, CRP; bacteriology (blood culture, cytobacteriological examination of urine with antibiogram), were studied. We researched prescribed antibiotics and assessed their effectiveness. This study was carried out under the supervision of the Nephrology department. All patients were informed of the benefit of this study and its confidentiality. We had verbal consent from patient or their caregivers during the study period.
3. Results
During the study period, we had 162 hospitalized patients 66 (41%) presented with an infectious syndrome from January 2 to June 30, 2019. The mean age of the patients was 45 ± 3.5 years. There was a male predominance 35 (53.03%) with a sex ratio (M/F) = 1.13. According to clinical parameters: the mean temperature was 38.28 (+/− 1.022)˚C, chills, sweat, dyspnea and meningeal syndrome. The functional signs were: pain, redness, induration, a purulent collection, urination burns, cough with sputum, diarrhea and earache. The mean duration of antibiotic therapy was 14 ± 7 days with extremes [3 to 21 day]. The biology was characterized by polynuclear neutrophilic leukocytosis in 37 (75.51%), an inflammatory syndrome with an elevated CRP in 37 patients with a mean of 24 ± 12 mg/L. The main infections were: infectious lung disease, urinary tract infection, salmonellosis, hemodialysis catheter infection, ENT infection. Cytological examination showed 27 (40%) positive culture including Gram negative Bacillus 5 (10.87%), Gram positive Bacillus 3 (6.52%). The main organisms isolated were: see Table 1.
We had a favorable outcome during antibiotic therapy in 50 (75.76%) and an unfavorable outcome in 16 (24.24%).
4. Discussion
Empirical treatment of a suspected bacterial infection should be done on the pathogen, the site of infection, the local antimicrobial resistance and according to the disease history of each patient. Antibiotic therapy should be adjusted according to the result of the antibiogram and the isolated germ. Antimicrobial resistance is recognized as a major public health problem. It is generally associated
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Table 1. Distribution by identified germ (N = 46).
with an overuse of antibiotics and makes it difficult to manage with empiric antibiotic therapy by clinicians, especially when there is antimicrobial resistance to the culture [10] . We have great difficulty in managing infections in our settings, especially when it comes to growing germs and waiting for the DST. Usually patients go to other services where the management of the infection has been poorly codified and the antibiotic therapy already started a long time ago, we receive them in the area of infection associated with end-stage renal failure. In this situation where the immune system is very weakened because of their uremic state, We encounter resistance associated with infections.
Urinary tract infection in renal failure is, from the outset, a complicated urinary tract infection requiring specific diagnostic and therapeutic management [11] . Urinary tract infection is often complicated and requires early and precise diagnosis and appropriate management. It can lead to general complications, such as urinary-onset sepsis [12] . Empiric antibiotic therapy has been the most widely used ciprofloxacin 500 mg until the results of the antibiogram and generally in case of resistance we use the carbapemes for 7 to 15 days until sterilization of the site of infection. Hemodialysis catheters are heavily used in our settings, given the delay in making arteriovenous fistula, chronic hemodialysis patients have catheters that are often infected. Double antibiotic therapy based on ceftriaxone 1 g combined with ciprofloxacin 500 mg was used until the antibiogram was obtained and then adapted according to the sensitivity of the germ. The management of ENT infections were generally done with empiric antibiotics containing aminoside for a treatment of 5 to 10 days, we had not encountered cases of resistance
The use of traditional antibiotics can be a huge source of antibiotic resistance. Infections are major risk factors for morbidity and mortality in chronic renal failure. Prevention occupies a very important place. This prevention must be centered on the prevention of nosocomial infections with regular disinfection of hospital services, the rigorous application of the prevention of infections in hemodialysis.
5. Conclusion
Antibiotics are regularly prescribed for bacterial infections in nephrology. Bacterial resistance represents a very high risk factor for mortality in CRF due to the associated comorbidities. The practitioner caring for patients with CRF must be familiar with the antimicrobial resistance encountered in order to be able to make the right choice of antibiotics. Bacterial culture should always be performed and then properly adapt the prescription. New antibiotics with low antimicrobial resistance must be adapted to our practices for better care of our patients.