International Journal of Science and Research (IJSR) ISSN: 2319-7064 ResearchGate Impact Factor (2018): 0.28 | SJIF (2019): 7.583 Volume 9 Issue 10, October 2020 www.ijsr.net Licensed Under Creative Commons Attribution CC BY Multi Drug Resistant Organism (MDRO) in Ventilator Associated Pneumonia (VAP) as a Cause of Morbidity and Mortality in Patients Post Obstetric Procedure: A Case Report I Gde Sastra Winata 1 , Vallery Giscard Delano Temmar 2 1, 2 Obstetric and Gynecology Department, Faculty of Medicine Udayana University, Sanglah Hospital, Bali-Indonesia Abstract: Ventilator Associated Pneumonia (VAP) is the most common form of nosocomial infection in intensive care units (ICU), especially in patients who use mechanical ventilation. The presence of VAP will increase mortality rate if pneumonia is caused by certain pathogens such as Multi Drug Resistant Organism (MDRO). This article reviews the case report of a 32-year-old woman with a diagnosis post-cesarean section day 4 and Suspected VAP with MDR risk. The patient was then treated in the ICU using a ventilator support because the patient had type I respiratory failure. There were three signs of systemic infection in patients, namely fever, tachycardia and leukocytosis. Aside of that, chest radiograph examination revealed infiltrates in the lung field. From the sputum culture results, there was growth of Acinetobacter Baumanii which is MDRO. In patients with MDRO or suspected MDRO, the recommended use of antibiotics is combination antibiotic regiments. Early recognition of MDRO in VAP can provide better management and prognosis, so that it can reduce morbidity and mortality in patients post obstetric procedure. Keywords: Ventilator associated pneumonia, multi drug resistant organism 1. Introduction Ventilator Associated Pneumonia (VAP) is the most common form of nosocomial infection in intensive care units (ICU), especially in patients who use mechanical ventilation. According to the American Thoracic Society in 2005, VAP is a lung infection that occurs after 48–72 hours of mechanical ventilator use. Ventilator Associated Pneumonia (VAP) is the second most common nosocomial infection at ICU with an incidence of 11.7 per 1000 treatments using a mechanical ventilator. The estimation of nosocomial pneumonia prevalence in ICU vary between 10-50%. According to the American Thoracic Society, the incidence of VAP in patients using mechanical ventilators ranges from 8 - 28%, but this figure can vary even up to 50%. The incidence rate of VAP itself will increase along with the use of mechanical ventilators' duration. It is estimated that the incidence rate will increase around 3% per day for the first 5 days, 2% during 6-10 days of use and 1% per day after day 10. VAP can increase mortality rates 2-10 times higher than patients without pneumonia. In Indonesia, deaths due to VAP in ICU at Cipto Mangunkusumo Hospital were reported as much as 57.2%. Based on research by Brahmani, et al the mortality rate in postoperative patients with mechanical ventilators at Sanglah Hospital Denpasar in 2015 had reached 71.5%. 1,2,3 The presence of VAP will increase mortality rate if pneumonia is caused by certain pathogens such as Multi Drug Resistant Organism (MDRO). MDRO is a microorganism, especially bacteria, that are resistant to one or more classes of antimicrobial agents. MDRO can be caused by several things, including improper dosage of antibiotics, improper diagnostic, and improper causative bacteria. Examples of pathogenic germs are A. baumanii, Pseudomonas aeruginosa and MRSA or in cases with secondary bacteremia. The MDRO incidence rate in VAP itself reaches 30-50% of all VAP incidents. 1,3,4 In patients with MDRO or suspected MDRO, the recommended use of antibiotics is combination antibiotic regiments. In MDR pathogens such as Pseudomonas aeruginosa, Klebsiella pneumonia and Acinetobacter sp, the preferred antibiotic regimen is Cephalosporin or Carbapenem or Beta-lactamase groups adjusted for the sensitivity results and combined with Fluoroquinolones. Whereas in MDR pathogens such as Methicillin Resistant Staphylococcus Aureus (MRSA), Aminoglycoside is the choice combined with Linesolid or Vancomysin. 1,3,4 The involvement of MDR pathogens in VAP events will increase both morbidity and mortality in VAP patients. The mortality of VAP patients ranges from 24-50% but in patients with MDRO the mortality rate can reach 76%. 5 2. Case Report 32-year-old woman referred from a private hospital in Denpasar with a diagnosis of post-cesarean section day 4 + post Hysterectomy due to placenta accreta + post urinary bladder rupture repair (21/04/20) + AKI prerenal dd/ renal phase polyuria + hypokalemia + Suspected VAP with MDR risk + Pulmonary edema due to AKI related. When the cesarean section was done, the patient experienced bleeding due to placenta accreta at the private hospital, thereafter during surgery was consulted to the Gynecologic Oncology division and a total abdominal hysterectomy was performed. During the operation, a urinary bladder was ruptured and repair was made. The patient was intensively treated at the ICU in the private hospital and underwent improved Paper ID: SR20909065123 DOI: 10.21275/SR20909065123 813