Infections Profile, Antimicrobial Use and Stewardship, And Predictors of Mortality in Critically Ill Indian Patients: Secondary Analysis of the Sepsis In India Prevalence Study (Pre-COVID-19) Data

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INTRODUCTION: Infections are a major concern in intensive care units (ICU) globally, contributing to significant morbidity, mortality and healthcare costs, with antimicrobial resistance further complicating care, particularly in low- and middle-income countries like India.(1–4) In India, comprehensive nationwide data on ICU infection and pathogen profile, antimicrobial prescribing and resistance pattern, and factors associated with mortality remain limited. OBJECTIVES: To describe hospital and ICU characteristics, pathogen and infection profiles, antibiotic prescribing and sensitivity patterns, antimicrobial stewardship capacity, and factors associated with mortality among ICU patients in India. MATERIALS AND METHODS: We conducted a pre-specified secondary analysis of the Sepsis in India Prevalence Study (SIPS)(5), a prospective, observational, cross-sectional study conducted in 35 adult ICUs (May–July 2019). The study obtained ethics approval with a waiver for consent. The SIPS included all adult patients (aged >18 years) present in the ICU on the study day. Outcomes were assessed at 30 days. Determinants of mortality were assessed using univariate and multivariable regression analyses conducted using generalized estimating equations and presented as prevalence ratios (PR) with 95% Confidence Intervals (CI). P values <0.05 were considered statistically significant. RESULTS: All 670 patients enrolled in SIPS were included. Most hospitals had ≥100 beds (32/35, 91.4%) and ICUs with 10–50 beds (27/32, 84.4%). About one-quarter of hospitals had three or less antimicrobial stewardship processes. Gram-negative pathogens such as Klebsiella spp. (62/157, 39.5%) and Escherichia coli (29/157, 18.5%) were predominant, with 5–10% non-susceptible to any tested antibiotic (Figure 1). Figure 1 Antibiotic sensitivity pattern in patients admitted to ICU. Commonly prescribed antibiotics included piperacillin-tazobactam (urinary tract and respiratory infections), meropenem (intra-abdominal infections) and ceftriaxone (central nervous system infections). Prescribed antibiotics primarily belonged to World Health Organisation (WHO) AWaRe “Watch” antibiotics (71.4%), with limited “Access” use (16.6%), a trend noted in both public and private hospitals. Multidrug resistance was noted in 30% of patients. Mortality risk was highest with sepsis during the current admission or within the prior three months (PR 2.04, 95% CI 1.11–3.77; p = 0.0223), followed by presence of ≥2 comorbidities (PR 1.45, 0.99–2.12; p = 0.0589). Increasing Sequential Organ Failure Assessment score also independently predicted mortality (PR per point 1.14, 1.10–1.18; p < 0.001). Other mortality predictors were multidrug-resistant infection and use of steroids/vasopressors or organ support (mechanical ventilation, Renal Replacement Therapy, Extracorporeal Membrane Oxygenation) (Table 1). Table 1 Univariate/multivariable regression analysis of factors associated with mortality in all patients. CONCLUSION: Management of infection in Indian ICUs is challenged by a predominance of resistant Gram-negative pathogens and limited use of WHO recommended “Access” antibiotics. Sepsis, high comorbidity burden, and severity of organ dysfunction are key mortality predictors in Indian ICU settings. This study offers important pre-COVID-19 baseline data on infections profile, antimicrobial resistance and stewardship practices in Indian ICUs, thus can be used to gauge how they have evolved since then.

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