The Impact of Health Seeking Behavior on Community-Acquired Multi-Drug Resistant Stool Colonization Among Hospitalized Febrile Illness Patients in Pune, India

Abstract

Background. Multi-drug resistant (MDR) infections are a major public health problem in India. Contact with outpatient care and the consumption of antibiotics in the community play important roles in the development of resistance. MDR pathogens that colonize the gastrointestinal tract can spread quickly in a hospital setting, causing costly and deadly infections. Methods. A prospective cohort was evaluated between 4 April 2015 and 8 August 2015 at Sassoon General Hospital in Pune, India. A standardized clinical history and perianal swab were collected on admission from hospitalized patients with a history of fever. Cultured bacteria grown in a media with ceftriaxone and vancomycin were considered multi-drug resistant. Those who confirmed seeing a provider or drug vendor for the same illness prior to admission were asked to participate in the supplemental survey of outpatient care. Results. Of the 219 patients enrolled, the median age was 11 years (IQR, 34-2) and 98 (45%) were women. 150 (68%) reported seeing a prior outpatient provider and agreed to be surveyed. Subjects saw a total of 278 providers (median, 2; range, 1-4), most often at government or private clinics (Figure 1). 51 (34%) patients reported visiting a non-allopathic provider or drug vendor without a prescription, while 52 (35%) were uncertain of their provider's qualifications. 40 (27%) patients were confirmed to have received antibiotics prior to admission, including 12 (8%) from non-allopathic providers and 9 (6%) from unknown clinics (Figure 2). 93 (62%) patients were unsure of whether they had received antibiotics. Of all 219 patients, 18 (8%) were found to be colonized by MDR bacteria. The quantity of providers seen and provider type were not associated with an admission finding of MDR colonization. Confirmed antibiotic use within the two weeks prior to admission was associated with MDR colonization in patients over 2 years of age (chi 2 = 4.54, p = 0.03). Conclusion. Both allopathic and non-allopathic providers see febrile illness patients and prescribe antibiotics in the community. Many patients are uncertain of the provider's qualification or their own consumption of antibiotics. Improved antibiotic stewardship and health literacy in the community are needed to reduce MDR colonization and their carriage into inpatient settings.