Epidemiological study of prevalence, determinants, and outcomes of infections in medical ICU at a tertiary care hospital in India

Antimicrobial Resistance Profile in ICU Patients Across India: A Multicenter, Retrospective, Observational Study

Background The pattern of antimicrobial resistance (AMR) changes with time and varies in countries and between hospitals within the same country. Physicians might thus benefit from information on regional resistance patterns of clinically significant bacterial isolates when deciding on the best empirical treatment. Numerous nosocomial infections are caused by multidrug-resistant (MDR) strains, notably methicillin-resistant Staphylococcus aureus (MRSA) strains, which are also linked to higher morbidity and death. Aim Evaluation of AMR profile in intensive care unit (ICU) patients of multiple tertiary care centers across India. Methods This was a multicenter, retrospective study based on electronic laboratory records of microbial isolates from clinical specimens from ICUs analyzed at microbiology laboratories of identified hospitals. Data of invasive sample records was collected from Microbiology labs of the identified hospitals within India and were aligned to WHO 5 Net standard reporting and as per Clinical & Laboratory Standards Institute (CLSI-2014) Guidelines for assessment. Data from 21556 samples were collected retrospectively from December 2021 to January 2010. Antibiotic susceptibility testing was done by using both the Kirby Baur disk diffusion method and the automated method (using the Vitek 2 compact system) as per CLSI (2014) guidelines. Results Of 21,556 enrolled patients, the majority (54.12%) were males and adults (62.07%). The median age was 58 years. Of 815 gram-positive bacteria reports, the commonest were S. aureus (552, 67.73%), Coagulase-negative Staphylococci (107, 13.13%), and Enterococcus spp. (105, 12.88%). For Coagulase-negative Staphylococci-positive samples, resistance was to penicillin (79, 73.83%), and erythromycin (73, 68.22%); and for S. aureus was to ciprofloxacin (361, 65.4%), and erythromycin (315,57.07%). Enterococcus spp. showed maximum resistance to erythromycin (73, 69.52%), followed by ampicillin, ciprofloxacin (68,64.76% each). Of 4,183 gram-negative bacteria reports, the commonest were Klebsiella pneumoniae (1,531, 36.6%), Escherichia coli (1,269, 30.34%), and Acinetobacter spp. (589, 14.08%), Pseudomonas aeruginosa (438, 14.08%), other Klebsiella spp. (174, 4.16%) and Enterobacter spp. (161, 3.85%). K. pneumoniae showed resistance to ciprofloxacin (1,001, 65.38%). E. coli showed resistance to ampicillin (918, 72.34%), and ciprofloxacin (798,62.88%); and Acinetobacter spp. to ceftazidime (525, 89.13%), and ciprofloxacin (507, 86.08%), while P. aeruginosa showed resistance to imipenem (234, 53.42%). Enterobacter spp. showed resistance to cefotaxime (129, 80.12%). MRSA samples showed resistance to phenoxymethylpenicillin (188, 35.54%) and benzylpenicillin (178, 33.46%). Conclusion Gram-negative bacteria were more common than gram-positive bacteria in causing antibiotic-resistant infections in ICU, with beta-lactams, fluoroquinolones, macrolides, and cephalosporins showing varied percentages of resistance. Fluoroquinolones, macrolides, and penicillin were noted to be highly resistant against gram-positive species. This indicates that evaluation based on MDR and antibiotic consumption patterns is imperative.

Sepsis, Management & Advances in Metabolomics

Though there have been developments in clinical care and management, early and accurate diagnosis and risk stratification are still bottlenecks in septic shock patients. Since septic shock is multifactorial with patient-specific underlying co-morbid conditions, early assessment of sepsis becomes challenging due to variable symptoms and clinical manifestations. Moreover, the treatment strategies are traditionally based on their progression and corresponding clinical symptoms, not personalized. The complex pathophysiology assures that a single biomarker cannot identify, stratify, and describe patients affected by septic shock. Traditional biomarkers like CRP, PCT, and cytokines are not sensitive and specific enough to be used entirely for a patient's diagnosis and prognosis. Thus, the need of the hour is a sensitive and specific biomarker after comprehensive analysis that may facilitate an early diagnosis, prognosis, and drug development. Integration of clinical data with metabolomics would provide means to understand the patient's condition, stratify patients better, and predict the clinical outcome.

Retrospective Analysis of Hospital Acquired Infection and Antibiotic Resistance in Coronary Care Unit (CCU), Adult, and Pediatric Cardiology Wards

BACKGROUND

Antibiotics resistance is an paramount threat affecting the whole world but nowhere situation is as gloomy as in India. No study till date regarding epidemiology of hospital acquired infections in coronary care units(CCU) and cardiology wards from India. From Indian perspective it is the first observational study to analyse microbiological profile and antibiotic resistance in CCU. The purpose of this observational study is to explore the epidemiology and importance of infections in CCU patients.

METHODOLOGY

After ethics committee approval, the records of all patients who were admitted in coronary care units, adult and pediatric cardiology wards surgery between January 2020 and December 2021 were reviewed retrospectively. The type of organism,source of infection ,age wise distribution and seasonal variability among patients who developed hospital acquired infection (HAI) were determined.

RESULTS

271 patients developed microbiologically documented HAI during from January 2020 to December 2021. Maximum number of organisms(78/271 28.78%) are isolated from urinary samples ,followed by blood stream(60/271 22.14%) and Endotracheal tube (54/271 19.92%). Acinetobacter baumanii (53/271, 19.5%) being the most common isolate among all the samples taken . Acinetobacter was the most frequent pathogens isolated in patients with LRTI and blood stream infection while E. coli was from urinary tract infection . In the adult population, infection with E. coli(24.6%) is the most common followed by Klebsiella pneumoniae (12.8%) and Acinetobacter baumanii (10.1%). In the pediatric population Acinetobacter baumanii (38.6%%) is the most common followed by Klebsiella pneumoniae (20.5%) and Methicillin Resistant Staphylococcus aureus, MRSA (6.8%). Commonly used antibiotics eg ciprofloxacin,ceftazidime and amikacin were found to be resistant against the top three isolates.

CONCLUSION

Urinary tract was the most common site of infection and Gram-negative bacilli, the most common pathogens in adult as well as pediatric population. Antibiotic resistance was maximum with commonly isolated microorganisms.

Eight year study on evolution of antimicrobial resistance in an antimicrobial-naïve trauma population

PURPOSE

Healthcare-associated infections (HAIs) are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Moreover, the burden of HAIs is higher in ICU admitted patients. Long term studies are beneficial to evolution pattern of AMR. Therefore, this study aimed to evaluate the evolution of AMR pattern over the years in one of the ICUs of a level 1 Trauma Center. This will enable us to modify the prescribing practices according to emerging resistance patterns.

METHODS

This study was conducted at one of the ICU of level-1 trauma center of tertiary care hospital. The study reports the findings of the AMR surveillance from January 2012 to December 2019. Standard definitions were used to define HAI (www.hais.com). The clinical records of the patients were maintained using ASHAIN indigenous software. Outbreak analysis was done by WHONET.

RESULTS

From 1st January 2012-31st December 2019, 4305 isolates were obtained from 1969 patients. Most frequent occurring organism were gram negatives among which A. baumannii was common followed by K. pneumoniae, and P. aeruginosa. Retrospective analysis showed 7 outbreaks/clusters during the study period and all the outbreaks occurred from October to December in each year. The increasing trend of AMR pattern emphasizes to strengthen infection control practices and sustained AMR surveillance.

Microorganism Spectrum and Its Sensitivity Pattern at Intensive Care Unit of a Secondary Care Teaching Hospital in Tangerang, Indonesia

BACKGROUND: Antimicrobial resistance is one of the world’s problems. It occurs due to misuse of antimicrobials in dealing with infectious diseases, making antimicrobial drugs less effective in treating infectious diseases. Antimicrobial sensitivity pattern is useful for directing clinicians in empirical therapy and preventing antimicrobial abuse so that resistance to antimicrobial drugs does not occur. AIM: This research is conducted to identify the microorganism spectrum and its sensitivity pattern at the intensive care unit (ICU) of a secondary care teaching hospital in Tangerang, Indonesia. METHODS: This study is a cross-sectional observational retrospective study done in the ICU of secondary care teaching hospital in Tangerang, Indonesia from January 2019to June 2020. This study used 1,341 isolated extracted from the ICU of a secondary care teaching hospital in the Tangerang database. All the samples would be analyzed using Microsoft Excel 2013 and Statistical Package for the Social Science 25 (SPSS 25) using ANOVA analysis. RESULTS: From 1,341 isolates, the most common microorganism found was Klebsiella pneumoniae 221(16%) and the most common specimen is sputum 905 (67,48%). Gram-negative bacteria had the highest sensitivity to amikacin 62% and imipenem 59%. Gram-positive bacteria had the highest sensitivity to tigecycline 98% and doxycycline 95%. While Candida spp. had the highest sensitivity to micafungin (96%) and voriconazole (97%). CONCLUSIONS: This study showed that the sensitivity of antimicrobials was no longer effective in treating infection. Therefore, the government and doctors must play an important role in socializing the correct way of using antimicrobial.

Epidemiology of sepsis and risk factors for mortality in intensive care unit: a hospital based prospective study in South India

OBJECTIVE

The present study was aimed at elucidating the epidemiology of sepsis, with a special emphasis on identifying the common bacterial aetiology, proportion of infections caused by multi-drug resistant (MDR) bacteria, and risk factors associated with 28-day mortality at a university hospital in South India.

METHODS

A prospective study was undertaken from January 2017 to March 2018. Adult patients with the diagnosis of sepsis requiring intensive care unit (ICU) care were recruited. Baseline clinical, epidemiological, and laboratory data were recorded, and their association with 28-day mortality was assessed using logistic regression models.

RESULTS

400 subjects with a qSOFA score ≥2 at the time of ICU admission were included in the study. The mean age was 55.7 ± 16.6 years, and 69% were males. The mean SOFA score at the time of admission was 9.9 ± 2.7. Bacterial aetiology of sepsis was established in 53.5% of cases and 24% were caused by MDR pathogens. Carbapenem resistance was observed in 37% of the Gram-negative isolates. Escherichia coli (34.1%) was the leading pathogen. Overall, the 28-day mortality in ICU was 40%. 38% died within 48 h of ICU admission. Hypertension and SOFA > 9, male gender, and baseline-creatinine values >2.4 mg/dl were risk factors for mortality.

CONCLUSIONS

Male gender, hypertension, SOFA > 9, and increased creatinine were identified as the predictors for mortality. Infectious aetiology remained undetected in nearly half of the cases using routine microbiology culture methods. Mortality within the first 48 h of admission to ICU is high and prompts the need for increasing awareness about early sepsis diagnosis in community health care settings.

Multidrug-resistant Acinetobacter baumannii infections: looming threat in the Indian clinical setting

INTRODUCTION

The recent increase in multidrug-resistant strains of A. baumannii has increased the incidences of ventilator-associated pneumoniae, catheter-associated urinary tract infections, and central line-associated blood stream infections, together increasing hospital stay, treatment cost, and mortality. Resistance genes blaOXA and blaNDM are dominant in India. Carbapenem-resistant A. baumannii (CRAB) International clone-2 (IC-2) are rising in India. High dependency on carbapenems and last-resort combination of tigecycline and polymyxins have aggravated outcomes. Despite nursing barriers, ward closure, environmental disinfections etc for detecting and controlling transmission, MDR isolates and CRAB nosocomial outbreaks continue. Treatment cost overruns by AMR adversely affect 80% of Indians without insurance cover.

AREA COVERED

This narrative review will cover epidemiology, resistance pattern, genetic diversity, device-related infection, cost, and mortality due to multidrug-resistant and CRAB in India. A comprehensive literature search in PubMed and Google Scholar using appropriate keywords at different time points yielded relevant articles.

EXPERT OPINION

It is challenging to enforce policies to control MDR A. baumannii in India. Government and hospitals should enforce stringent infection control measures, surveillance, and antimicrobial stewardship to prevent further spread and emergence of more virulent and resistant strains. Knowledge on antibiotic resistance mechanisms can help design novel antibiotics that can evade, resistance.

Therapeutic Options for the Treatment of Carbapenem-resistant Enterobacteriaceae Infections: Hope in the Times of Hype and Despair

How to cite this article: Ansari AS. Therapeutic Options for the Treatment of Carbapenem-resistant Enterobacteriaceae Infections: Hope in the Times of Hype and Despair. Indian J Crit Care Med 2021;25(7):752-753.

Microbial Distribution and Antibiotic Susceptibility of Lower Respiratory Tract Infections Patients From Pediatric Ward, Adult Respiratory Ward, and Respiratory Intensive Care Unit

Introduction

Lower respiratory tract infections (LRTIs) account for significant morbidity and mortality in patients admitted to hospitals worldwide, especially in children and elderly. The prevalent microorganisms and antibiotic susceptibility were investigated among LRTI patients from the pediatric ward, adult respiratory ward, and respiratory intensive care unit (RICU) in order to achieve more efficient treatment protocols and better recovery.

Methods

In this retrospective cross-sectional study (January 2016 to December 2019), 4,161 positive culture samples out of 18,798 different specimens (9,645 respiratory tract samples and 9,153 blood samples) from LRTI patients were analyzed for pathogen incidence and antibiotic sensitivity.

Results

Among the respiratory tract cultures, the frequency of Gram-negative bacterial strains was higher than Gram-positive bacterial strains. Pseudomonas aeruginosa was the dominant pathogen in both the adult respiratory ward (n = 156, 21.49%) and RICU (n = 975, 35.67%), whereas Staphylococcus aureus (n = 66, 19.19%) was the most common bacterium in the pediatric ward. Among the blood cultures, Gram-positive bacteria remained the major microorganisms involved in LRTIs, and the most frequent pathogen was Staphylococcus epidermidis (n = 59, 47.20%) in the pediatric ward and Staphylococcus aureus (n = 10, 21.8%) in adult respiratory ward. However, Gram-negative bacteria were the main pathogens in the RICU, of which Klebsiella pneumoniae (n = 51, 27.57%) is the most prevalent. Pseudomonas aeruginosa of LRTI patients remained highly susceptible (>70%) to routine antibiotics in pediatric ward. However, it only had high susceptibility to amikacin, tobramycin, gentamicin in both the adult respiratory ward and RICU and its antibiotic sensitivity to meropenem and imipenem was moderate in the adult respiratory ward and mild (<30%) in the RICU. Staphylococcus aureus isolated from LRTI patients was highly susceptible to linezolid, daptomycin, teicoplanin, vancomycin, tigecycline, rifampicin, and trimethoprim/sulfamethoxazole in all three wards, moderately susceptible to gentamicin in both the adult respiratory ward and RICU and to clindamycin, oxacillin, moxifloxacin only in the adult respiratory ward.

Conclusions

Microbial distribution and their patterns of antibiotic susceptibility revealed a high divergence among LRTI patients admitted to different wards in this hospital. Thus, different antibiotic therapies should be considered for distinct age groups.

Current Perspectives on Treatment of Gram-Positive Infections in India: What Is the Way Forward?

The emerging antimicrobial resistance leading to gram-positive infections (GPIs) is one of the major public health threats worldwide. GPIs caused by multidrug resistant bacteria can result in increased morbidity and mortality rates along with escalated treatment cost and hospitalisation stay. In India, GPIs, particularly methicillin-resistant Staphylococcus aureus (MRSA) prevalence among invasive S. aureus isolates, have been reported to increase exponentially from 29% in 2009 to 47% in 2014. Apart from MRSA, rising prevalence of vancomycin-resistant enterococci (VRE), which ranges from 1 to 9% in India, has raised concerns. Moreover, the overall mortality rate among patients with multidrug resistant GPIs in India is reported to be 10.8% and in ICU settings, the mortality rate is as high as 16%. Another challenge is the spectrum of adverse effects related to the safety and tolerability profile of the currently available drugs used against GPIs which further makes the management and treatment of these multidrug resistant organisms a complex task. Judicious prescription of antimicrobial agents, implementation of antibiotic stewardship programmes, and antibiotic policies in hospitals are essential to reduce the problem of drug-resistant infections in India. The most important step is development of newer antimicrobial agents with novel mechanisms of action and favourable pharmacokinetic profile. This review provides a synopsis about the current burden, treatment options, and the challenges faced by the clinicians in the management of GPIs such as MRSA, Quinolone-resistant Staphylococcus, VRE, and drug-resistant pneumococcus in India.

Study of Antibiotic Sensitivity and Resistance Pattern of Bacterial Isolates in Intensive Care Unit Setup of a Tertiary Care Hospital

Objective

To evaluate the antibiotic sensitivity and resistance pattern in an intensive care unit (ICU) setting of a tertiary care hospital.

Materials and methods

A cross-sectional, retrospective study was conducted for a period of 1 month in October 2017 on a total of 195 patients who were admitted to ICU of tertiary care hospital. The culture and sensitivity pattern of clinical isolates from blood, urine, sputum, endotracheal tube (ET) aspirate, catheter sites, and wound swabs were analyzed. Positive cultures were segregated and their antibiotic sensitivity testing was performed under the guidelines of clinical and laboratory standard institute (CLSI).

Results

Of the total 195 ICU admissions, cultures were sent for 167 cases. Of which 127 patients were culture positive and 40 cases were culture negative. Isolated bacteria were mostly gram-negative bacilli, of which Escherichia coli was (18.6%), Acinetobacter (14.5%), Klebsiella (11.6%), Pseudomonas (9.8%), and Proteus (1.74%). Among the gram-positive organisms, coagulase negative staphylococcus (CoNS) (15.6%) was most commonly isolated followed by Streptococcus (2.32%). Fungal growth was also seen in 26 (15.11%) samples. Samples that grew organisms were blood (n = 48), sputum (n = 17), urine (n = 39), ET aspirate (n = 40), pus (n = 11), catheter (n = 4), ear swab (n = 2), and stool (n = 1).

Conclusion

Gram-negative bacterial infections are increasing in ICUs, leading to inappropriate selection of antibiotics. Hence, antibiotic sensitivity and resistance pattern in a hospital setup has to be studied so as to guide the treating consultant to initiate empirical antibiotics in critical cases.

How to cite this article

Savanur SS, Gururaj H. Study of Antibiotic Sensitivity and Resistance Pattern of Bacterial Isolates in Intensive Care Unit Setup of a Tertiary Care Hospital. Indian J Crit Care Med 2019;23(12):547–555.

Evaluation of infection prevention and control policies, procedures, and practices: An ethnographic study

BACKGROUND

The intensive care unit (ICU) is considered the epicenter of infections, and patients in the ICU are at higher risk of infection because of their vulnerability, age, and lengthy hospitalization.

METHODS

The ethnographic design has been used to describe, examine, and evaluate the policies and procedures that are implemented to prevent and control hospital-acquired infections (HAIs) in the medical ICU in King Abdullah University Hospital. In-depth semi-structured interviews with 23 participants supported by nonparticipant observation and document analysis were carried out to collect triangulated data. The themes and subthemes were developed through a software package and hand-coding procedure.

RESULTS

Health care workers were aware but not fully engaged to prevent and control HAIs; nevertheless, they presented themselves as knowledgeable. Staff recognized the importance of involving family members and visitors. However, they had serious concern toward open visitation. The nurse to patient ratio was another challenge of infection prevention and control practices. The findings demonstrated that performing continuous prospective surveillance by highly qualified and trained staff can reduce the risk of endemic HAIs.

CONCLUSIONS

The study highlighted the importance of changing behaviors and practices of health care providers and visitors to improve adherence to infection prevention and control policies and practices.

Antibiotic Prescription, Organisms and its Resistance Pattern in Patients Admitted to Respiratory ICU with Respiratory Infection in Mysuru

Aim of Study:

Respiratory infections account for significant morbidity, mortality and expenses to patients getting admitted to ICU. Antibiotic resistance is a major worldwide concern in ICU, including India. It is important to know the antibiotic prescribing pattern in ICU, organisms and its resistance pattern as there is sparse data on Indian ICUs.

Materials and Methods:

We conducted a prospective study from August 2015 to February 2016. All patients getting admitted to RICU with respiratory infection who were treated with antibiotics were included into study. Demographic details, comorbidities, Clinco-pathological score (CPI) on day1 and 2 of admission, duration of ICU admission, number of antibiotics used, antibiotic prescription, antimicrobial resistance pattern of patients were collected using APRISE questionnaire.

Results:

During study period 352 patients were screened and 303 patients were included into study. Mean age was 56.05±16.37 and 190 (62.70%) were men. Most common diagnosis was Pneumonia (66%). Piperacillin-tazobactam was most common empirical antibiotic used. We found 60% resistance to piperacillin-tazobactam. Acinetobacter baumanii was the most common organism isolated (29.2%) and was highly resistant to Carbapenem (60%). Klebsiella pneumoniae was resistant to Amikacin (45%), piperacillin (55%) and Ceftazidime (50%).

Conclusion:

Piperacillin-tazobactam was the most common antibiotic prescribed to patients with respiratory infection admitted to ICU. More than half of patients (60%) had resistance to the empirical antibiotic used in our ICU, highlighting the need for antibiogram for each ICU. Thirty six percent of patient had prior antibiotic use and had mainly gram negative organisms with high resistance to commonly used antibiotics.

Antimicrobial Resistance Surveillance among Intensive Care Units of a Tertiary Care Hospital in Southern India

INTRODUCTION

Hospital Acquired Infections (HAIs) are the rising threat in the health care facilities across the globe. As most Intesive Care Unit (ICU) patients are frequently on broad spectrum antimicrobials, this induces selective antibiotic pressure which leads to development of Antimicrobial Resistance (AMR) among the microorganisms of ICUs.

AIM

To study the occurrence of different types of HAIs in patients admitted to various ICUs of JIPMER and the AMR pattern of the bacterial pathogens isolated from them.

MATERIALS AND METHODS

The record based retrospective data of culture reports of the patients admitted to all the ICUs of JIPMER during the period from April 2015 to March 2016 were collected. A total of 3,090 isolates were obtained from the clinical specimens of 1,244 patients. Data on various factors like demographic characters, type of ICU, infecting organism, site of infection, type of HAI's and AMR including co-resistance were collected and analysed using Microsoft Excel.

RESULTS

Most common culture positive clinical specimen received was tracheal aspirate (29.9%) followed by exudate (22.7%). Acinetobacter spp from tracheal aspirate and Pseudomonas spp from blood specimens were the most common organisms isolated; whereas Escherichia coli was the predominant organism found in urine, exudate and sterile fluid specimens. About 22.2% infections were HAIs, out of which pneumonia (6.24%) was the most common. Analysis of antimicrobial susceptibility pattern revealed that most of Gram-Negative Bacilli (GNB) was Multi Drug Resistant (MDR) i.e., resistant to three or more class of antibiotics such as cephalosporins, carbapenems, aminoglycosides, tetracyclines and fluoroquinolones. The prevalence of Methicillin- resistant Staphylococcus aureus (MRSA) and Vancomycin- resistant Enterococci (VRE) were found to be 40.6% and 11.9% respectively.

CONCLUSION

The increasing trend AMR among the hospital acquired pathogens such as MDR-GNBs, MRSA and VRE pose a great threat to HCWs as well as to the other critically ill patients of the ICUs. Study on AMR surveillance is the need of the hour as it helps the centers to generate local antibiogram which further helps in formulating the national data. It also guides the clinicians to choose appropriate empirical therapy and assist escalation and de-escalation wherever possible. Hence, such studies will be a stepping stone in establishing antimicrobial stewardship and regulate the antimicrobial use.

Epidemiology of Adult-population Sepsis in India: A Single Center 5 Year Experience

Background and Aims:

Sepsis is a major worldwide cause of morbidity and mortality. Most sepsis epidemiologic data are from the Western literature. Sparse data from India describe the epidemiology of infection rather than sepsis which is a host response to infection. This study describes the epidemiology of sepsis in the Intensive Care Unit (ICU) of an Indian tertiary care hospital.

Subjects and Methods:

A prospective study conducted between June 2006 and May 2011. All consecutively admitted patients during the 5 year study >=18 years of age were included and data obtained from hospital in-patient records. Variables measured were the incidence of severe sepsis, ICU, hospital, and 28-day mortality, the median length of ICU stay, median Acute Physiology and Chronic Health Evaluation II (APACHE II) score, infection site, and microbial profile.

Results:

There were 4711 admissions during the study with 282 (6.2%, 95% confidence interval 2.3, 13.1) admissions with severe sepsis. ICU mortality, hospital mortality, and 28-day mortality were 56%, 63.6%, and 62.8%, respectively. Predominant infection site was respiratory tract. The most common organisms were Gram-negative microbes. The most common microbe was Acinetobacter baumanni. Median APACHE II score on admission was 22 (interquartile range 16–28) and median length of ICU stay was 8 days. Severe sepsis attributable mortality was 85%.

Conclusion:

Severe sepsis is common in Indian ICUs and is mainly due to Gram-negative organisms. ICU mortality is high in this group and care is resource intensive due to increased length of stay.